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{"project":"testtesttest","denotations":[{"id":"T48","span":{"begin":2437,"end":2441},"obj":"Body_part"},{"id":"T49","span":{"begin":3643,"end":3648},"obj":"Body_part"}],"attributes":[{"id":"A48","pred":"uberon_id","subj":"T48","obj":"http://purl.obolibrary.org/obo/UBERON_8480049"},{"id":"A49","pred":"uberon_id","subj":"T49","obj":"http://purl.obolibrary.org/obo/UBERON_0000948"},{"id":"A50","pred":"uberon_id","subj":"T49","obj":"http://purl.obolibrary.org/obo/UBERON_0007100"},{"id":"A51","pred":"uberon_id","subj":"T49","obj":"http://purl.obolibrary.org/obo/UBERON_0015228"},{"id":"A52","pred":"uberon_id","subj":"T49","obj":"http://purl.obolibrary.org/obo/UBERON_0015230"}],"text":"DISCUSSION\nOnly few studies have reported on the use of OPCAB technique for redo coronary surgery [1, 6, 16–19]. The largest report in 617 patients from Japan focuses on in-hospital outcome only with no late survival and suggests that redo-OPCAB surgery is associated with lower 30 days mortality (3.5 vs 7%) and less complications (11 vs 21.5%) compared to redo-CABG [1]. Other studies from North America and India have reported on redo-OPCAB, although in small cohorts [1, 7, 17, 18, 20, 21].\nOur unmatched analysis suggests that redo-OPCAB is associated with reduced composite end-point and similar 10-year survival when compared with redo-CABG. In this analysis, the effect size of redo-OPCAB appears marked for mortality and need for IABP that were 3 times more common in the redo-CABG group. Our propensity score-Matched Analysis A (any cardiac procedure as primary operation) showed no differences in early composite end-point (21 vs 15%) and 10-year survival (65.1 vs 60.8%) between redo-CABG and redo-OPCAB, respectively. Conversely, the propensity score-Matched Analysis B (isolated coronary surgery as primary operation) showed a reduction in the early composite end-point by \u003e50% (19 vs 8%), with marked difference in mortality (5 times lower—5 vs 0%, P = 0.13) and severe LCO needing IABP (4.5 times lower—11 vs 2%, P = 0.02), both favouring redo-OPCAB; 10-year survival was similar to redo-CABG (71.6% vs 71.7%), respectively.\nThe 30-day mortality for redo-OPCAB in Matched Analysis B was lower than that reported in the Japanese study (1.1% vs 3.5%). This difference could reflect differences in risk profile. However, in both studies redo-OPCAB was associated with lower mortality than redo-CABG. This is confirmed by others. Sabik et al. reported the outcome of 4518 redo-CABG reoperations [2] with mortality at 4.3% for first redo, 5.1% for second redo and 6.4% for third redo or more. Similar results were reported by Ghanta et al. in 72 322 redo-CABG procedures from the STS database [3].\nOur study and the report by Dohi et al. [1] also suggest less postoperative complications following redo-OPCAB. Others have reported more complications following redo-OPCAB than our study, although still less than the rate observed for the redo-CABG groups. Morris et al. [22] reported 41.3% of postoperative complications after redo-CABG vs 25% after redo-OPCAB (P \u003c0.01), in keeping with the outcome of a small UK study [23].\nShin and colleagues [18] reported postoperative complication rates of 64.2% vs 33.3% (P = 0.08) between redo-CABG and redo-OPCAB, respectively. These findings could explain a tendency for the shorter hospital stay observed with redo-OPCAB in our study, which was 0.6, 0.75 and 1.3 days shorter for the unmatched, Matched B and Matched A analyses, respectively. This is in keeping with the reports by others [1, 18, 20, 22].\nThe two propensity score-matched analyses of this study suggested that redo-OPCAB may be more effective when used for redo patients who have undergone isolated coronary surgery as their primary operation. This is highlighted by the rates of early composite end-point, which was 8% vs 15% for the redo-OPCAB groups for Matched Analysis B vs Matched Analysis A, respectively (Table 4). This finding was not observed for redo-CABG cohorts when using a similar comparative approach.\nAn important finding of the current study is that in terms of the 10-year survival redo-OPCAB is as effective as conventional redo-CABG across all the 3 analyses undertaken. This finding is reassuring when considering the technical complexity involved in undertaking coronary anastomoses on the beating heart within the context of a redo cardiac procedure. This finding is in keeping with the long-term outcome of our previous BHACAS trial reporting on long-term graft patency and survival following primary OPCAB surgery [14].\nOur propensity score-Matched Analysis B showed similar 1- and 5-year survival between groups at 97.6 vs 95.2% and 87.5 vs 88.9% for redo-OPCAB vs redo-CABG, respectively. This finding is similar or better than that reported by others following redo coronary surgery. Usta et al. [19] reported in a small study a 3-year survival rate of 81 ± 12vs 63 ± 9% in redo-OPCAB vs redo-CABG. Tugtekin et al. [21] reported in another small study a 3-year survival rate of 83.8 vs 88.6% for redo-CABG vs redo-OPCAB. In a further small study with 43 patients in each group, actuarial survival at 5-year was 87 ± 5.5% for redo-CABG and 95 ± 3.2% for redo-OPCAB (P = 0.17) [23].\nCompleteness of coronary revascularization has been associated with long-term outcome [17, 21, 24]. Some evidence suggests that this may be a limit for OPCAB surgery [25], with a retrospective analyse suggesting that OPCAB is an independent predictor of incomplete revascularization [17, 20, 21, 24]. Our study showed similar completeness of revascularization between groups in the unmatched analysis but better results in the redo-CABG group in Matched Analysis A. In Matched Analysis B, completeness of revascularization favoured only slightly redo-CABG surgery (71 vs 68%; P = 0.60), although the number of grafts needed was reduced in the redo-OPCAB group (21 ± 0.8 vs 2.4 ± 0.8; P = 0.03) reflecting the baseline difference in number of diseased vessels. This finding might reflect a tendency to perform redo-OPCAB in patients with reduced number of diseased coronaries as suggested by others [22], but this speculation cannot be confirmed in our study.\nThe ESC/EACTS guidelines suggest that in view of the higher risk of procedural mortality with redo-CABG and the similar long-term outcome, percutaneous coronary intervention is the preferred revascularization strategy in CABG patients requiring redo revascularization [26]. The findings of our Matched Analysis B suggests an overall in-hospital mortality of 2.5% (0% for redo-OPCAB) and 1-, 5-, and 10-year survival rates of 96, 88 and 71.6%, respectively. These remarkable results question the rationale of treating these patients with percutaneous coronary intervention stenting [5] and call for a more in-depth evaluation of the available evidence.\n\nLimitations\nThere are several limitations to this study. It is a retrospective single-centre analysis in a limited cohort. The allocation of patients to the study group was by surgeon’s expertise, and this might have led to undetected difference in risk profile between groups. The study is from an Institution with historical high interest and expertise in OPCAB surgery, and this might limit the applicability of the findings to Institutions with less interest and proficiency in OPCAB surgery. The study included a patient cohort treated over a long time period, hence with possible confounding factors due to changes in clinical practice overtime. Finally, the evaluation of long-term impact of redo-OPCAB surgery was limited to all-cause mortality as no data were available on cardiac-related mortality or late graft patency."}

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