Izhar, Uzi

Background —Patients who have had previous CABG may subsequently develop significant mitral valve (MV) dysfunction that requires surgical intervention. Methods and Results —We reviewed 80 consecutive patients who had had previous CABG and who underwent MV surgery between January 1972 and March 1997. Forty-seven (59%) had initial CABG elsewhere, and 5 had had previous CABG twice. The mean interval between the previous CABG and the MV surgery was 6.3 years (range, 4.4 months to −17 years). At least 15 patients had grade 1/4 to 2/4 mitral regurgitation at initial CABG. The study group included 59 men and 21 women, with a mean study group age of 65.5 years. Ninety-four percent had symptoms of congestive heart failure, 60% had angina, 96% were in NYHA class III to IV, and 37% had an ejection fraction (EF) <50%. Origin of the MV disease was ischemic in 33 patients, myxomatous in 19, combined ischemic and myxomatous in 16, rheumatic in 5, infective in 3, and unknown in 4. MV repair was performed in 46 patients (58%) and MV replacement (MVR) in 34. Concomitant repeat CABG was performed in 38 (48%) patients. In-hospital mortality was 7 of 80 (8.8%); no early death occurred among patients with myxomatous disease. EF <50% was the only significant predictor of early mortality. Overall 1-, 5-, and 10-year survival was 83.8%, 55.6%, and 34.4% respectively. Predictors of late cardiac death were preoperative NYHA class IV ( P =0.0006), urgent or emergency operation ( P <0.0001), use of intra-aortic balloon pump ( P =0.002), and EF <50% ( P =0.01). Seven patients had an additional reoperation: 4 received CABG, 2 MVR, and 2 MV repair. Conclusions —Ischemic, myxomatous, rheumatic, or infective MV dysfunction may develop subsequently after CABG. MVR or MV repair after previous CABG is associated with an acceptably low operative risk and good relief of symptoms. Left ventricular function is strongly correlated with both hospital and late mortality. Surgery should be done before LV dysfunction develops.

Background Coarctation of the aorta is commonly associated with recoarctation or additional cardiovascular disorders that require intervention. The best surgical approach in such patients is uncertain. Ascending-to-descending aortic bypass graft via the posterior pericardium (CoA bypass) allows simultaneous intracardiac repair or an alternative approach for the patient with complex coarctation. Methods and Results Between 1985 and 2000, 18 patients (13 males and 5 females, mean age 43±13 years) with coarctation of the aorta underwent CoA bypass through median sternotomy. Before operation, average New York Heart Association class was II (range I to IV), and 15 patients (83%) had systemic hypertension. One or more previous cardiovascular operations had been performed in 12 patients (67%); 10 patients had ≥1 prior coarctation repair. Two patients had prior noncoarctation cardiovascular surgery. Concomitant procedures performed in 14 patients (78%) included the following: aortic valve replacement in 9; coronary artery bypass surgery in 3; mitral valve repair in 2; and septal myectomy, mitral valve replacement, aortoplasty, subaortic stenosis resection, ventricular septal defect closure, and ascending aorta replacement in 1 patient each. All patients survived the operation and were alive with patent CoA bypass at a mean follow-up of 45 months. No graft-related complications occurred, and there were no instances of stroke or paraplegia. Systolic blood pressure fell from 159 mm Hg before surgery to 125 mm Hg after surgery. Conclusions CoA bypass via median sternotomy can be performed with low morbidity and mortality. Although management must be individualized, extra-anatomic CoA bypass via the posterior pericardium is an excellent single-stage approach for patients with complex coarctation or recoarctation and concomitant cardiovascular disorders.