J Thorac Cardiovasc Surg 2006;132:209-210
© 2006 The American Association for Thoracic Surgery
Redo coronary bypass grafting: Role of arterial grafts and time interval
Omer Ashraf, MBBS
Aga Khan University, Karachi, Pakistan
To the Editor:
I read with interest the article by Sabik and colleagues wherein they present their experience with reoperations in bypass surgery.
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Although the authors have conducted an extensive temporal analysis, some important concerns remain in reference to the implications drawn from this report.
An important factor left unaddressed in this study was the mean time for reoperation. The time between primary and secondary bypass grafting is a determinant not just of reoperation outcome but also of the risk factors and patient characteristics deeming reoperative therapy.
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Therefore it is important to keep in consideration that the risk factors for reoperation shown in this report may not have uniform applicability and may differ for patients undergoing their second bypass at varying times from their first surgery. The patency of arterial and venous bypass conduits similarly is likely to have individual alterations at different points in time from the first operation, illustrating the efficacy of arterial grafts in reducing reoperation rate only beyond a certain time interval from the primary procedure.
The authors in this report, in cognizance with certain trials in the past, advocate extensive use of arterial revascularization to decrease reoperation rate on basis of their findings. However, some amount of conflict prevails on this issue, with a number of studies advocating no additional benefit of using more than a single arterial graft.
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In fact the reason that authors were unable to document high reoperation rates among patients with multiple arterial grafts may be owing to the notion that such patients are more likely to undergo percutaneous angioplastic intervention rather than a second bypass procedure. It is arguable, thus, that broad use of arterial grafting would prevent future myocardial ischemia in these patients. Even if a small extra degree of reoperative risk was conferred by avoiding use of more than 1 arterial graft, there remains little overall clinical justification for overuse of multiple arterial grafts, bringing into view one of Dr Sabik's own recent reports that reoperation procedures pose little extra patient hazards today.
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References
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- Sabik 3rd JF, Blackstone EH, Gillinov AM, Banbury MK, Smedira NG, Lytle BW. Influence of patient characteristics and arterial grafts on freedom from coronary reoperation. J Thorac Cardiovasc Surg 2006;131:90-98(Epub 2005 Dec 5).[Abstract/Free Full Text]
- Christenson JT, Simonet F, Schmuziger M. The impact of a short interval (> or = 1 year) between primary and reoperative coronary artery bypass grafting procedures. Cardiovasc Surg 1996;4:801-807.[Medline]
- Sergeant PT, Blackstone EH, Meyns BP. Does arterial revascularization decrease the risk of infarction after coronary artery bypass grafting?. Ann Thorac Surg 1998;66:1-10(discussion 10-1).[Abstract/Free Full Text]
- Kawasuji M, Sakakibara N, Fujii S, Yasuda T, Watanabe Y. Coronary artery bypass surgery with arterial grafts in familial hypercholesterolemia. J Thorac Cardiovasc Surg 2000;119:1008-1013(discussion 1013-4).[Abstract/Free Full Text]
- Sabik 3rd JF, Blackstone EH, Houghtaling PL, Walts PA, Lytle BW. Is reoperation still a risk factor in coronary artery bypass surgery?. Ann Thorac Surg 2005;80:1719-1727.[Abstract/Free Full Text]
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