Anesthesia and heart reoperations
The number of reoperations for heart disease in the Cleveland Clinic has been steadily increasing and currently comprises 4.5% of total myocardial revascularizations. Because of progressive disease and potential technical difficulties, reoperations usually have higher mortality and morbidity rates than the first operations (Table). This report summarizes our experience during the past decade in the management of anesthesia for patients undergoing these reoperations.
Reoperative revascularization is indicated for one or more of the following: progressive coronary atherosclerosis, graft failure, incomplete previous revascularization, Vineberg implants, and graft atherosclerosis.1
The incidence of left ventricular impairment and preoperative angina is also high. Loop et al2 reviewed our experience in 500 patients; 25.6% had New York Heart Association Class II angina, 46.4% had Class III angina, and 26.8% had Class IV angina.2 Ventricular hypokinesis or akinesis was detected in 29% of the patients, and 18% had poor ventricular contractility. Because of the severity of symptoms, an intraaortic balloon pump was required to support circulation in about 5% of the patients, either preoperatively or postoperatively.
Valve replacement is indicated when there is deterioration of the valve after the initial aortic or mitral valve replacement, previous commissurotomy, endocarditis that is resistant to treatment, prosthetic dysfunction, perivalvular leak, and valve thrombosis. Not infrequently, these patients require emergency surgery, since sudden valve dysfunction or severe perivalvular leak can predispose to congestive heart failure or even acute pulmonary edema.3
The management of these patients necessitates every effort to maintain the myocardial oxygen demand ratio, starting in the preoperative period . . .