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REOPERATIVE CARDIAC SURGERY: A MULTIDISCIPLINARY APPROACH Michelle Capdeville, M.D. Associate Professor Cleveland Clinic Lerner College of Medicine Program Director, Cardiothoracic Anesthesia Fellowship The Cleveland Clinic Foundation GOALS AND OBJECTIVES 1. To understand the factors that make cardiac reoperations distinctly different from primary operations. 2. To appreciate how the risk of cardiac reoperations has changed over the past 25 years. 3. To discuss the technical advances and improvements in myocardial preservation strategies that have reduced the risk of cardiac reoperations. 4. To understand the pathophysiology of vein graft atherosclerosis and its relevance to patient outcomes and management. 5. To illusrate novel techniques using a multidisciplinary approach to the management of patients presenting for cardiac reoperations. INTRODUCTION Cardiac reoperations are complex procedures that are performed in a very unique patient population. These operations have become increasingly prevalent in cardiac surgical practice and are distinctly different from first-time operations. Unfortunately, little detail about cardiac reoperations is presented in textbooks geared towards the cardiac anesthesiologist, with the general teaching being limited to placement of large intravascular access and having checked blood in the operating room in anticipation of catastrophic hemorrhage. THE CHANGING FACE OF CARDIAC SURGERY After the first coronary revascularization procedures were performed in the 1960’s, it became clear by the 1970’s that many of these patients would be presenting for a second operation. Indications for reoperation have changed over the past several decades, with early graft failure becoming a lesser problem. The use of arterial conduits such as the internal mammary and radial arteries has extended the time interval between operations. Coronary artery bypass operations have declined in volume, due in large part to a high prevalence of percutaneous interventions. Regular use of antiplatelet agents and lipid lowering agents may also contribute to this decline. What was once referred to as a “routine CABG” is almost considered an aberrancy today, since typical CABG patients present with a history of multiple PCI with stents and decreased cardiac reserve. In fact, many of today’s “routine CABG” patients would not have been considered surgical candidates 25 years ago. Coronary reoperations have increased in frequency (though this trend is changing), with approximately 8% of all CABG cases in the United States being repeat operations. REOPERATIONS AND PERIOPERATIVE RISK
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Despite increased surgical experience and improved perfusion strategies, cardiac reoperations are associated with an increased risk of death, perioperative myocardial infarction, low output syndrome, increased need for inotropic and intra-aortic balloon pump support, increased transfusion rate, increased postoperative organ dysfunction, increased incidence of arrhythmias,
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