Reoperative Cardiac Surgery

History

Patients undergoing reoperative cardiac surgery are generally older, have more comorbidity, and more advanced cardiovascular disease than patients undergoing first-time surgery. The decision to operate usually depends on correlating a precise account of the nature, timing, and severity of symptoms with the findings from diagnostic studies and balancing the benefits of intervention against the incremental risk of mortality and morbidity posed by reoperation. Additionally, the medical history should establish details of all prior cardiovascular procedures, including date and type of PCI; any previous cardiac surgery, including incisions; history of difficult intubation or adverse reaction to anesthesia, respiratory failure, or tracheostomy; coagulopathy and blood transfusions; and postoperative sepsis and organ dysfunction. Although the balance of risks generally favors continuing antiplatelet medication until surgery in non-reoperative patients, this may not be the case in patients scheduled for reoperative surgery, who will be at greater risk of postoperative coagulopathy and bleeding. It may be appropriate to admit patients preoperatively to discontinue oral anticoagulation and transition to a shorter-acting regimen, such as a heparin infusion.

Clinical Examination

One of the most important risk factors for poor outcomes is frailty. Although this is not well defined, and consequently is not included in most risk models, it is a relatively easy, albeit subjective, judgment often made by looking at a patient. Physical examination of all patients referred for cardiac surgery includes a careful inspection of the entire chest and abdomen. Patients may omit to mention distant cardiac and thoracic surgery procedures, and these may become evident only from incisions, which can be inframammary, posterior thoracotomy, or axillary. All incisions, including conduit harvest sites, pacemaker or defibrillator insertion sites, and potential sites of peripheral cannulation for cardiopulmonary bypass (CPB) in upper and lower extremities, should be assessed for signs of distant or recent infection, poor healing, and vascular complications such as stenosis or aneurysm formation. Evaluation of the airway includes inspection of the suprasternal notch and trachea for evidence of prior tracheostomy.

Imaging

With the exception of young adult patients without risk factors for acquired or congenital coronary artery disease, all patients should have recent cardiac catheterization, including coronary angiography, to assess the patency and anatomy of native vessels and any CABG. In young patients, computed tomographic (CT) coronary angiography usually provides sufficient information about coronary anatomy. Coronary angiograms should be reviewed to determine whether grafts are close or even adherent to the sternum.

Noncontrast computed tomography provides helpful visualization of calcification and aneurysmal segments along the entire arterial tree from aortic root to femoral vessels that may dictate choice of cannulation site. The presence of large amounts of prosthetic material indicates potentially severe adhesions. Intravenous contrast may be employed in CT angiography to demonstrate the course of bypass grafts more clearly; contrast is required to assess patency, and it provides detailed information on the presence of peripheral vascular disease, which is particularly relevant if peripheral arterial cannulation is planned or the patient is likely to need an intraaortic balloon pump.

Echocardiography is necessary to quantify right and left ventricular function, the presence of pulmonary hypertension, and the nature and grade of any valvular dysfunction. Transesophageal echocardiography (TEE) is particularly valuable in the detailed assessment of prosthetic valve endocarditis and failed valve repair or if transthoracic echocardiographic windows are poor.