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Bypass Surgery Re-operation

Bruce Lytle , M.D.

Questions and Answers about Bypass Surgery Re-operation - Video Transcript

Video by Bruce Lytle , MD

Chairman, Department of Thoracic and Cardiovascular Surgery

Specialties: Coronary artery disease, arterial bypass grafting, valvular heart diseases, coronary reoperations, diseases of the thoracic aorta, idiopathic hypertrophic subaortic stenosis, and laser transmyocardial revascularization surgery.

Hello, I'm Dr. Bruce Lytle from the Cleveland Clinic Foundation. When we talk to people about bypass surgery one subject that comes up a lot is the issue of a re-operation for coronary artery disease. It often starts when we're talking about having a first operation and someone asks, “Well now doesn't this operation only last for 10 or 15 years and then you have to get it done again?”. Fundamentally the answer to that question is usually no, but as with most things, it’s a bit more complicated than that. It is true that coronary bypass surgery by itself does not stop someone from developing atherosclerosis in either of their native coronary arteries or particularly of saphenous vein grafts. So, the likelihood of someone having further problems in the future is related to coronary risk factors such as smoking, an unhealthy diet, lack of exercise, and things that we do not have a lot of control over such as diabetes, or hyperlipidemia.

Fortunately, today we understand a lot more about controlling atherosclerosis risk factors; sometimes with lifestyle changes and sometimes with drugs or diet. The instance of needing a second operation is decreasing. Another thing that we now know that decreases the likelihood of needing a second operation is how the first operation is done. We now know that the more internal mammary artery graphs that we use at a first operation the less likely someone is to need a second operation. That is because internal mammary artery graphs are much more resistant to atherosclerosis, what is commonly known as hardening of the arteries, then saphenous vein-type bypass graphs.

When the issue does arise about needing a second operation (coronary reoperation), there are a couple of very important points. The first point is whether a second operation is really needed or not. There are alternatives to needing a second operation, such as enhancing someone's medical treatment and interventional procedures such as stenting for some limited obstructions in vessels. In general, re-operations are done only when people have reasonably severe problems and severe obstructions in their arteries or graphs which put them at a lot of risk. Making a decision about whether or not a second operation is in someone's interest is not a trivial decision. People should be very comfortable about getting more than one opinion about whether or not a coronary re-operation is in someone's interest.

When re-operations are needed, they are different than first time operations. First of all, coronary reoperations are carried out in patients that are usually older and their disease has gotten worse, therefore, they are difficult operations to do. It has taken us a long time, but finally at the Cleveland Clinic Foundation we have been able to establish the situation where the risk of having a second operation is approximately equal to that of having a first operation. That has not been an easy accomplishment and we certainly would not try to tell anybody that it means there is no risk associated with re-operations. It is very important to have a coronary re-operation done in a setting where people have a lot of experience with this type of an issue.

The risk of coronary re-operations short term is low. Long term outcomes are relatively good, although not quite as good as for patients undergoing a first operation. Part of the reason for that is that during a re-operation we usually make people a little less perfect then we do during a first operation. Unfortunately, one of the risks of getting older is that we become a little less perfect, at least in terms of our health, with the passage of time. From a patient’s stand point the important thing to understand about having a re-operation is that:

  1. It can be done
  2. It can be done relatively safely, in experienced hands
  3. It is important to be certain that it is the best treatment for you and it’s important to seek a second opinion if you have any doubts about that.
  4. Finally, it’s important to have coronary re-operations done in a setting where people have a lot of experience.

Thank you very much.

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Reviewed: 04/11

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