Reoperative CABG using left thoracotomy: A tailored strategy

Background. Reoperative coronary artery bypass grafting (CABG) through a le ft thoracotomy is a challenging operation with no one dominant approach. We developed a tailored strategy for this difficult group of patients, integr ating the currently available newer technologies for each patient indicatio n. Methods. Between October 1991 and October 1999, 50 consecutive patients und erwent reoperative CABG through a left thoracotomy. Age was 65 +/- 9 years, 40 (80%) were men, and preoperative ejection fraction was 40 +/- 13. In 36 patients (72%) the left internal mammary artery had been placed to the lef t anterior descending coronary artery during the primary CABG and in 25 of 36 patients (70%) this left internal mammary artery-left anterior descendin g coronary artery graft was patent. The mean duration from previous CABG wa s 8.0 +/- 4.8 years. Three approaches were used: (1) conventional cardiopul monary bypass using fibrillatory or circulatory arrest (n = 33, 66%); (2) H eartport endoaortic balloon occlusion (n = 4, 8%); and (3) off-pump beating heart techniques (n = 13, 26%). Results. The off-pump CABG technique was used in the majority of recent pat ients and 1 (7.7%) had to be converted to cardiopulmonary bypass due to hem odynamic instability. When cardiopulmonary bypass was used its duration was 122 +/- 59 minutes and mean temperature on bypass was 24 degrees +/- 6 deg reesC. In the 4 patients in whom the Heartport system was used, the median endoaortic occlusion duration was 49 minutes. Patients received an average of 1.4 grafts/patient. In 60 of 70 patients (89%) distal anastomoses were p erformed to an anterolateral coronary target. There were 3 of 50 (6%) opera tive deaths, 2 in the conventional group and 1 in the endoaortic balloon oc clusion group. The mean length of stay in the 47 survivors was 7.8 +/- 3.9 days (median, 7 days). Conclusions. Reoperative CABG by left thoracotomy remains a challenging ope ration. Several techniques, including off-pump CABG, conventional cardiopul monary bypass, circulatory arrest, and endoaortic balloon occlusion, should be in the surgeon's armamentarium to allow a tailored approach for each op eration based on patient indications. (Ann Thorac Surg 2001;71:196-200) (C) 2001 by The Society of Thoracic Surgeons.