Third and fourth operations for myocardial ischemia: Short-term results and long-term survival

Adrian W. Pick, Charles J. Mullany, Thomas A. Orszulak, Richard C. Daly, Hartzell V Schaff

Research output: Contribution to journalArticle

8 Citations (Scopus)

Abstract

Background: An increasing number of patients having at least two operations for myocardial ischemia are now presenting for a third or fourth procedure. We report the Mayo Clinic experience with repeated reoperative surgery for coronary artery disease. Methods and Results: We have evaluated 67 consecutive patients (54 men, 13 women) during a 14-year period (1978 to 1992). The mean age at the third procedure (n=63) was 63.4 years and at the fourth procedure (n=4) was 70.6 years. Clinical indications for surgery were unstable angina in 29 patients (43%), New York Heart Association class III angina in 36 (54%), non-Q wave acute myocardial infarction in 1, and acute pulmonary edema in 1. Urgent or emergency surgery was undertaken in 17 patients (25%). All patients had triple-vessel disease, and 20 (30%) had left main coronary artery stenosis >50%. The mean ejection fraction in 56 patients was 0.56±0.11. Occlusion or significant stenoses of preexisting saphenous grafts were thought to be the major cause of recurrent ischemia in 64 patients (96%). Only 14 patients (21%) had received previous arterial grafts. An average of 2.4 grafts was placed, and a new internal mammary artery was used on 47 occasions. Eight patients (11.9%) died. Three patients required a left ventricular assist device, and one of them survived. There were 21 late deaths: 8 were cardiac and 5 were likely to be cardiac. Five-year and 10- year survival in all patients was 75.6%±5.3% and 47.9%±7.7%, respectively. Freedom from further intervention for hospital survivors at 5 and 10 years was 88.4±4.5 and 72.3±8.5%, respectively. Of the 38 patients still alive at last follow-up, 29 (76%) were considered to be in New York Heart Association functional class I or II. On univariate analysis, use of an intra-aortic balloon pump, prolonged bypass time, left main coronary artery stenosis >50%, and a surgeon's impression of angiographic inoperability correlated with increased risk of early mortality. Conclusion: We conclude that in a select group of patients, repeated reoperative surgery, despite an increased mortality, can result in good long-term survival and significant improvement in clinical status.

Original languageEnglish (US)
JournalCirculation
Volume96
Issue number9 SUPPL.
StatePublished - Nov 4 1997

Fingerprint

Myocardial Ischemia
Survival
Coronary Stenosis
Transplants
Heart-Assist Devices
Mammary Arteries
Mortality
Unstable Angina
Pulmonary Edema
Survivors
Coronary Artery Disease
Pathologic Constriction
Emergencies
Ischemia
Myocardial Infarction

Keywords

  • Angina
  • Coronary artery surgery
  • Reoperations

ASJC Scopus subject areas

  • Physiology
  • Cardiology and Cardiovascular Medicine

Cite this

Pick, A. W., Mullany, C. J., Orszulak, T. A., Daly, R. C., & Schaff, H. V. (1997). Third and fourth operations for myocardial ischemia: Short-term results and long-term survival. Circulation, 96(9 SUPPL.).

Third and fourth operations for myocardial ischemia : Short-term results and long-term survival. / Pick, Adrian W.; Mullany, Charles J.; Orszulak, Thomas A.; Daly, Richard C.; Schaff, Hartzell V.

In: Circulation, Vol. 96, No. 9 SUPPL., 04.11.1997.

Research output: Contribution to journalArticle

Pick, AW, Mullany, CJ, Orszulak, TA, Daly, RC & Schaff, HV 1997, 'Third and fourth operations for myocardial ischemia: Short-term results and long-term survival', Circulation, vol. 96, no. 9 SUPPL..
Pick, Adrian W. ; Mullany, Charles J. ; Orszulak, Thomas A. ; Daly, Richard C. ; Schaff, Hartzell V. / Third and fourth operations for myocardial ischemia : Short-term results and long-term survival. In: Circulation. 1997 ; Vol. 96, No. 9 SUPPL.
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abstract = "Background: An increasing number of patients having at least two operations for myocardial ischemia are now presenting for a third or fourth procedure. We report the Mayo Clinic experience with repeated reoperative surgery for coronary artery disease. Methods and Results: We have evaluated 67 consecutive patients (54 men, 13 women) during a 14-year period (1978 to 1992). The mean age at the third procedure (n=63) was 63.4 years and at the fourth procedure (n=4) was 70.6 years. Clinical indications for surgery were unstable angina in 29 patients (43{\%}), New York Heart Association class III angina in 36 (54{\%}), non-Q wave acute myocardial infarction in 1, and acute pulmonary edema in 1. Urgent or emergency surgery was undertaken in 17 patients (25{\%}). All patients had triple-vessel disease, and 20 (30{\%}) had left main coronary artery stenosis >50{\%}. The mean ejection fraction in 56 patients was 0.56±0.11. Occlusion or significant stenoses of preexisting saphenous grafts were thought to be the major cause of recurrent ischemia in 64 patients (96{\%}). Only 14 patients (21{\%}) had received previous arterial grafts. An average of 2.4 grafts was placed, and a new internal mammary artery was used on 47 occasions. Eight patients (11.9{\%}) died. Three patients required a left ventricular assist device, and one of them survived. There were 21 late deaths: 8 were cardiac and 5 were likely to be cardiac. Five-year and 10- year survival in all patients was 75.6{\%}±5.3{\%} and 47.9{\%}±7.7{\%}, respectively. Freedom from further intervention for hospital survivors at 5 and 10 years was 88.4±4.5 and 72.3±8.5{\%}, respectively. Of the 38 patients still alive at last follow-up, 29 (76{\%}) were considered to be in New York Heart Association functional class I or II. On univariate analysis, use of an intra-aortic balloon pump, prolonged bypass time, left main coronary artery stenosis >50{\%}, and a surgeon's impression of angiographic inoperability correlated with increased risk of early mortality. Conclusion: We conclude that in a select group of patients, repeated reoperative surgery, despite an increased mortality, can result in good long-term survival and significant improvement in clinical status.",
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