title: The impact of symptom severity on cardiac reoperative risk: early referral and reoperation is warranted.
abstract: BACKGROUND
  Operative mortality is comparatively higher for coronary artery bypass grafting (CABG) or valve reoperations. Studies of reoperative risk have focussed on surgical techniques. We sought to determine the risk and predictors of poor outcome in current practice, and the influence of preoperative symptoms.
  
  
  METHODS
  For every redo patient (n=289), we selected the best-matched pair of patients who underwent a primary operation (n=578) between 1998 and 2006. Matching variables were age, gender, left ventricular ejection fraction (LVEF) and type of operation. Poor outcome was defined as operative mortality or major morbidity.
  
  
  RESULTS
  Median age was 68 (interquartile range 62-73) years and 28% were female for both groups. Severe symptoms and cardiac morbidity dominated the presentation of redo patients. CABG (53%), valve repair/replacement (34%) and combined CABG and valve (12%) were performed with overall operative mortality of 6.6% (median additive EuroScore 7.0) for redo versus 1.6% (median additive EuroScore 4.0) for primary groups (p<.0001). Whereas no significant difference was observed between primary (1.6%) and redo CABG (3.9%, p=.19), valve reoperations had higher operative mortality (9.6% vs 1.5%, p<.0001). Major complications occurred more frequently after redo valve compared to primary valve operations (28% vs 14%, p=.001). Reoperation (odds ratio [OR] 1.26, 95% confidence interval [CI] 0.66-2.42, p=.48) was not a predictor of major adverse event after CABG or valve surgery. Determinants of poor outcome after valve reoperations were New York Heart Association class III/IV (OR 6.86, 95% CI 2.29-12.11, p=.03), duration of extracorporeal circulation (OR 1.17, 95% CI 1.02-1.35, p=.03) and mitral valve replacement (OR 4.07, 95% CI 1.83-36.01, p=.04). The predictors of major adverse events after redo CABG were congestive heart failure (OR 1.85, 95% CI 1.04-8.98, p=.006) chronic obstructive pulmonary disease (OR 17.5, 95% CI 1.87-35.21, p=.05) and interval from prior surgery (OR 1.37, 95% CI 1.09-1.92, p=.01).
  
  
  CONCLUSIONS
  In the current era, redo CABG is nearly as safe as the primary operation. A valve reoperation, on the contrary, is higher risk due, partly, to severe symptoms at presentation. Patients should be referred and operated on early before they develop severe symptoms.
authors: Cardiothoracic Centre, Castle Hill Hospital, Cottingham, East Yorkshire, United Kingdom. dngaage@yahoo.com
authors: Dumbor L
authors: DL
authors: Ngaage
authors: Michael E
authors: ME
authors: Cowen
authors: Steve
authors: S
authors: Griffin
authors: Levant
authors: L
authors: Guvendik
authors: Alexander R
authors: AR
authors: Cale
mesh_terms: D000368:Aged; D001026:Coronary Artery Bypass / Q000379:methods / Q000401:mortality*; D003327:Coronary Disease / Q000150:complications / Q000401:mortality / Q000601:surgery*; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D012017:Referral and Consultation; D012086:Reoperation / Q000401:mortality; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome