First cardiological or cardiosurgical reintervention for ischemic heart disease after primary coronary artery bypass grafting1

Abstract

Objective: To study the first reintervention for ischemic heart disease anytime after coronary artery bypass grafting (CABG) and the variables that drive its need or bias its occurrence. Reintervention is defined as an isolated or combined repeat surgical or cardiological procedure for ischemic heart disease. Methods: A consecutive series of 9600 CABG patients (1971–1992) were followed for up to 20 years (99.9% complete). A multivariable time-related analysis was performed. Results: The 1-, 10- and 15-year freedom from reintervention was 99, 89 and 72% respectively. A three-phase hazard function was identified. Patient variables influencing early freedom included anginal instability, completeness of revascularization and institutional variables. Late freedom was influenced importantly by demographic variables, cardiac and non-cardiac comorbidity and extensive arterial grafting. The 1-month and 10-year survival after reintervention was 95 and 73%. The 1- and 10-year freedom from angina after reintervention was 74 and 32%. Conclusion: Reinterventions for ischemic heart disease by interventional cardiology or surgery are rather infrequent in the first decade after CABG but nearly half the patients surviving their second decade undergo one. The increased reintervention rate, apparent after 1985 did not go parallel with improved late post-CABG survival. Older age and the presence of multiple arterial grafts seem to reduce but also to bias the event. The very good survival, only when return of angina is present, suggests a more restrictive differential therapy approach, certainly in the presence of a well functioning arterial graft to the antero-septal region and where the co-morbidity might induce a high reinterventional survival cost.