Repeat Open-Heart Surgery

Repeat Open-Heart Surgery Albert B. Iben, M.D., Edward J. Hurley, M.D., William W. Angell, M.D., and Norman E. Shumway, M.D. S econd open-heart operations will be performed with increasing frequency as experience in cardiac surgery grows. Progression of valvular or vessel disease, failure and fatigue of prosthetic materials, incomplete closure of septal defects, and technical errors comprise the etiology of repeat open-heart surgery. As soon after the first operation as difficulty is perceived, the reoperation must be planned. Failure to proceed early with corrective surgery is the leading cause of mortality in patients of this type. In a series of 768 consecutive intracardiac operations at the Stanford Medical Center, 40 patients underwent open-heart surgery for at least the second time; most of these 40 had been operated upon initially in this same clinic. Two patients had had two prior open procedures. There were 6 hospital or operative deaths. Not included in this report are patients who had had previous closed-heart operations. CASE MA TERIAL Among the 40 cases the aortic valve area by itself and in combination with the mitral valve accounted for 25 of the repeat open-heart procedures. The mitral valve alone was involved in 8 cases, and the second operation was required following ventricular septal defect closure in another 7. The reoperations were performed between twelve hours and eight years after the initial repair; data summarizing the histories of all 40 appears in Table 1. The earliest return to the operating room came in 2 instances of mediocystic disease of the aorta (Group I, Table 1). In both, difficulty with hemostasis was a serious problem. In 1, uncontrollable bleeding led to resection and replacement of the ascending aorta on cardiopulmonary bypass in a repeat operation after the aortic valve had been replaced at the first operation. This patient died two weeks later without regaining From the Division of Cardiovascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, Calif. Supported in part by U.S. Public Health Service Grant No. HE-08696. Presented at the Second Annual Meeting of The Society of Thoracic Surgeons, Denver, Colo., Jan. 24-26, 1966. 334 THE ANNALS OF THORACIC SURGERY

TABLE 1. SUMMARY OF CASE MATERIAL, 40 REPEAT OPEN-HEART OPERATIONS (listed in order of description in text) Group, Age, Sex Group I 1. 59, Mt 2. 30, M Group I1 1. 15, M 2. 51, M 3. 46, Mt 4. 64, M 5. 33, Mt 6. 51, M 7. 41, M 8. 42, M 9. 61, Mt 10. 68, F 11. 63, M 12. 58, M 13. 48, M 14. 58, F 15. 42, M - Original Surgery ; ascending aortoplasty Aortic & mitral valvuloplas- ties Aortic & mitral valvuloplasties Repeat Surgery Resection ascending aorta Aortic & mitral valve replace- ment Aortic & mitral valve replacement Aortic & mitral valve replacement Aortic & mitral valve replacement thospita1 or operative death. Interval Between Open-Heart Procedures 12 hr. 12 hr. 11 mo. 1 yr. 8 mo. 3 yr. 4 mo. 1 yr. 11 mo. 2 yr. 4 yr. 2 mo. 3 yr. 2 mo. 3 yr. 5 mo. 2 yr. 7 mo. 2 yr. 6 mo. 2 yr. 6 mo. 2 yr. 1 mo. 4 yr. 2 yr. 6 mo. 3 yr. 2 mo.

~ TABLE 1 (Continued) Group, Age, Sex Original Surgery Group I1 (Continued) 16. 50, M 17. 50, F Group I11 1. 25, M 2. 57, Mt 3. 51, M 4. 51, M 5. 62, M 6. 24, M Group IV 1. 58, F 2. 60, F 3. 58, F 4. 64, F 5. 42, F Aortic & mitral valvuloplas- ties Aortic & mitral valvuloplasties (mediocystic disease) (bacterial endocarditis) Mitral commissurotomy Mitral commissurotomy Mitral commissurotomy Mitral commissurotomy Mitral commissurotomy Interval Between Open-Heart Repeat Surgery Procedures Aortic & tricuspid valve re- placement 1. Mitral valve replacement 2. Aortic & tricuspid valve replacement Closure of leak about prosthesis Closure of leak about prosthesis Closure of leak about prosthesis Closure of leak about prosthesis Closure of leak about prosthesis Removal & replacement of aortic prosthesis Mitral valve replacement Mitral valve replacement Mitral valve replacement Mitral valve replacement Aortic & mitral valve replacement 2 yr. 2 yr. 1 mo. 1 yr. 7 mo. 5 mo. 6 mo. 1 yr. 1 mo. 11 mo. 3 mo. 2% mo. 2 yr. 7 mo. 1 yr. 6 mo. 1 yr. 2 mo. 1 yr. 5 mo. 1 yr.

Group V 1. 42, M Mitral valve replacement 2. 60, F Mitral valve replacement Group VI 1. 45, F Repair of acyanotic tetralogy of Fallot 2. 11, F 3. 11, F Closure of ventricular septal defect Repair of tetralogy of Fallot 4. 7, M Repair of tetralogy of Fallot 5. 12, M 6. 5, M Closure of ventricular septal defect Repair of tetralogy of Fallot 7. 3% Mt Closure of ventricular septal defect Group VII 1. 62, M Mitral valve replacement?hospital or operative death. Closure of leak about pros- thesis Removal & replacement of mitral prosthesis 1. Closure of residual ventricular septal defect 2. Excision of subvalvular aortic stenosis & aortic valve replacement Tricuspid annuloplasty Closure of residual ventricular septal defect Closure of residual ventricular septal defect Closure of residual ventricular septal defect Repair of ventricular aneurysm Closure of residual ventricular septal defect 4 mo. 3 mo. 1 yr. 6 yr. 3 mo. 8 yr. 2 yr- 2 yr. 4 mo. 1 yr. 9 mo. 1 yr. 6 mo. 2 yr. 10 mo. 4 mo.

IBEN, HURLEY, ANGELL, AND SHUMWAY consciousness. The duration of cerebral anoxia was prolonged due to the sudden exsanguination, but the heart recovered despite numerous episodes of arrest. Acute aortic insufficiency after valvuloplasty for leaflet prolapse was responsible for reoperation in the other patient, and aortic valve substitution was performed in the repeat operation within the first twelve hours. The patient recovered fully and is now well and active. As both cases were reoperated upon a few hours after the first procedure, their repeat operations tested well the facilities for emergency cardiopulmonary bypass. Forty-four of the original 768 cardiac surgery patients had both debridement and commissurotomy performed on the aortic valve either separately or in conjunction with mitral repair. Seventeen returned for further surgery (Group 11, Table 1). Eleven of the 17 originally had had aortic repair and returned for aortic replacement; 2 others required mitral substitution as well. Two of the 4 who had had combined aortic and mitral repair returned for replacement in both areas. Another patient required substitution of the aortic and tricuspid valves, while the fourth had the mitral valve replaced at a second operation and the aortic and tricuspid valves at a third. In almost all instances of progression of aortic disease, the process was calcified aortic stenosis and the valve was bicuspid in nature, possibly congenital in origin. Three patients died following the second procedure. Six times in 166 aortic valve replacements insufficiency developed around the prosthesis (Group 111, Table 1). Symptoms and signs of insufficiency appeared early, and repeat surgery was carried out within 2% to 13 months. The average interval was 6% months. One patient with mediocystic disease of the aorta had corrective surgery within 3 months when it was found that one-third of the prosthetic ring of the largest Starr-Edwards aortic valve had pulled away from the annulus. The shortest interval between operations in this group was in a 24-yearold male who had an aortic valve replacement following endocarditis. The initial operation was done as soon as blood cultures had cleared. Much of the annulus was weak and fragmented, holding sutures poorly and predisposing to leakage about the valve upholstery. At the second procedure, a new prosthesis was inserted, and the course was uneventful. One patient in this group died postoperatively. Open mitral commissurotomy in 5 patients was followed by mitral replacement in 4 and aortic and mitral substitution in 1 (Group IV, Table 1). The average time between operations was 18 months. Following mitral valve substitution in 146 of the original 768 cases, insufficiency appeared in 2 (Group V, Table 1). In 1 patient there was true leakage about the ring. In the other, a 60-year-old female, a thick fibrin clot was densely adherent to all metallic portions of the cage and ring of the Starr-Edwards prosthesis, making it impossible for the ball 338 THE ANNALS OF THORACIC SURGERY

Repeat Open-Heart Surgery to seat properly during systole. The valve was replaced and satisfactory function ensued. Reoperation was performed within 4 and 3 months, respectively. Spencer recently described a similar patient [61. Ventricular septal defect repairs produced a group of repeat operations extending up to eight years following the initial surgery (Group VI, Table 1). One patient in this category required two procedures for acyanotic tetralogy of Fallot and a third for a procedure consisting of aortic replacement, resection of subaortic stenosis, and closure of a still residual ventricular septal defect. Another patient required tricuspid annuloplasty almost eight years after closure of the septal defect. In all but 1 of the remaining cases, a residual ventricular septal defect was closed on the second operation. Following repair of a tetralogy of Fallot, a right ventricular aneurysm developed in 1 case and was resected eighteen months later. The only death occurred as a result of aortic valve injury during closure of a ventricular septal defect in a small child with pulmonary hypertension. A single case comprises Group VII (see Table 1). Replacement of the aortic valve was done 4 months following mitral valve substitution. Minimal aortic insufficiency was noted at the first surgery, and its severity was magnified by a competent mitral valve. PROCEDURE FOR REPEAT OPERATION The median sternotomy was used in all cases. When a previous lateral approach has been employed, the intact anterior pericardium allows for easy performance of the sternal split. In most instances, however, sternotomy has been used on the initial entry, and no attempt was made to close the pericardium. This leaves the aorta and right ventricle in close proximity to the undersurface of the sternum, which makes the reoperation incision somewhat hazardous even when care is exercised. It is the policy now to prime the heart-lung machine before the incision is begun. Even if the right ventricle or aorta is entered, the patient can be connected to extracorporeal circulation before irreversible brain injury results from hypoxia. After the sternum is approached through the skin and subcutaneous tissues, the wires of the earlier sternal closure are bared and removed. The electric bone saw is used for cutting the outer table along the line of healed bone. After dividing the upper midline abdominal musculature, the inner table of bone is divided from below upward, using a blunt cutting instrument such as a slightly curved Mayo scissors. With the scissor points visualized, the bone and adhesions are divided anterior to the ventricle and aorta. In order to avoid traction injury to the right ventricle, the self-retaining retractor is not used until the anterior chest wall is freed from the heart.

IBEN, HURLEY, ANGELL, AND SHUMWAY All adhesions about the heart are divided for total control and to permit local cooling [4, 51 in cases where the aorta has to be occluded. Dissection is extended to the points of great vessel control. Another area of danger during dissection is in the angle of junction between the inferior vena cava and the right atrium, as dense adhesions and a friable myocardium in this region can result in inadvertent entry to the heart. If posterior adhesions cannot be divided easily, their dissection is postponed until partial cardiopulmonary bypass decreases the heart size and makes its displacement of less hernodynamic consequence. When the patient is on total cardiopulmonary bypass, the appropriate repair is carried out. The aortic valve is approached through the line of the previous anterior curvilinear aortotomy. The mitral valve, as before, is exposed through a left atriotomy done anterior to the confluence of right pulmonary veins. Right ventriculotomies are made in the scar of the previous procedure. OPERATIVE DEATHS The patient in Group I who required early resection of the ascending aorta died of the complications of prolonged hypotension some 14 days after operation. In Group 11, in which aortic valve repair was followed by reoperation for valve replacement, there were 3 deaths: 1 at surgery, another within 72 hours of surgery, and the third some two weeks after aortic replacement. Repeat surgery was delayed in the first patient until heart failure with electrolyte derangement led to cardiac arrest with resuscitation early in the morning of the day of surgery. The operation was performed after his condition had improved only slightly and with the patient in renal shutdown and in the process of peritoneal dialysis. The second hospital death in this group occurred in a patient whose recurrent aortic stenosis had produced massive left ventricular hypertrophy. Thirty-six hours following aortic valve replacement recurrent bouts of ventricular fibrillation developed which were uncontrolled. The third patient expired following two weeks of coma, the result of central nervous system anoxia that began when a dissecting aneurysm was entered during sternotomy. Bypass was initiated within 12 minutes and aortic replacement was effected, but the brain insult was irreversible. There was one death in Group 111, in which insufficiency presented around an aortic valve prosthesis. Again, failure to reoperate on this individual early and a degree of coronary artery disease caused the unfavorable outcome. The single remaining death was the result of aortic insufficiency developing as a complication of the closure of a ventricular septa1 defect in a 3%-year-old child with severe pulmonary hypertension. 340 THE ANNALS OF THORACIC SURGERY

Repeat Open-Heart Szirgcry To summarize, there were 6 hospital or operative deaths among the 40 cases of repeat operations (an overall mortality of 15%). Surgery had been delayed beyond the optimum time in 4 of the 6 patients who died. DISC USSIOlV Regardless of how carefully each open-heart procedure is planned, a residual group will appear requiring repeat surgery, especially when acquired valvular lesions are concerned. Often these repeat patients must be operated upon when they are more severely ill than they were before the initial procedures. A mortality rate of 15% results, in our experience. This rate is relatively high compared with 2 deaths among 60 patients having multiple valve replacement during the same period of time at the Stanford Medical Center; it reflects well the increased risk a second open-heart operation carries. The greatest morbidity and mortality resides in cases of mitral valve disease, especially mitral stenosis. It is here where left ventricular reserve is decreased by the small ventricular size and involvement of the myocardium by old rheumatic disease. It may be that a less than perfect aortic valve will increase the morbidity if not recognized and replaced. It is in such instances that we deviate from our usual sequence of combined valve replacement and replace the aortic valve after the mitral valve substitution [ 11. Symptomatic patients should be reoperated upon as soon as persistent disease is noted in order to avoid increased risk. The problem should be located and plans made to correct it before signs and symptoms become severe. Of 44 patients who had aortic valvuloplasties, 17 returned for replacement of at least the aortic valve. However, many patients who underwent aortic valvular debridement are continuing to do well up to five years postoperatively. This procedure is used now only in the most ideal situation where the valve is clearly tricuspid and each commissure can be opened to the annulus without significant insufficiency. Leakage about prosthetic devices points out the need of meticulous suture techniques and proper sizing of the valvular annulus. The one case of clotting of a mitral prosthesis suggests the need for careful maintenance of anticoagulation. Patients with aortic valve prostheses appear to carry less risk of embolic phenomena, but every patient with a mitral valve prosthesis must be protected against clotting by anticoagulants and restoration of normal sinus rhythm whenever possible. Starr-Edwards prostheses were used in all cases of replacement. Mackenzie et al. 121 and March et al. [3] described the difficulties following ventricular septal defect closures. Their experience agrees to some extent with our own. The liberal use of the Teflon patch for closure of ventricular septal defects has led in recent years to the disappearance of residual septal defects.

IBEN, HURLEY, ANGELL, AND SHUMWAY SUMMARY Among 40 patients having multiple open-heart procedures, 38 had two and 2 patients had three open-heart operations. Although this represents a high-risk group of patients, a combined hospital and operative mortality rate of 15% was attained. Nine patients were in the seventh decade of life. Decision to operate early is of great importance in seeking a lower mortality. Four of the 6 hospital deaths were related to procrastination. Previous open-heart procedures do not preclude successful accomplishment of a second operation, if the appropriate anatomical considerations are observed. REFERENCES 1. Iben, A. B., Hurley, E. J., and Shumway, N. E. Surgery for combined lesions of the aortic and mitral valves. Amer. J. Surg. 110:262, 1965. 2. Mackenzie, J. W., Sloan, H., Morris, J. D., and Stern, A. The problem of second open cardiotomies. J. Thorac. Cardiov. Surg. 44: 544, 1962. 3. March, H. W., Gerbode, F., and Hultgren, H. N. The reopened ventricular septal defect. Circulation 24:256, 1961. 4. Shumway, N. E., and Lower, R. R. Tropical cardiac hypothermia for extended periods of anoxic arrest. Surg. Forum 10:563, 1960. 5. Shumway, N. E., Lower, R. R., and Stofer, R. C. Selective hypothermia of the heart in anoxic cardiac arrest. Surg. Gynec. Obstet. 109:750, 1959. 6. Spencer, F. C., Trinkle, J. K., and Reeves, J. T. Successful replacement of a thrombosed mitral ball-valve prosthesis. J.A.M.A. 1954: 191, 1965. DISCUSSION DR. JOHANN L. EHRENHAFT (Iowa City, Iowa): It is always an agonizing experience for a surgeon to decide upon reoperation in patients who had previous open-cardiac procedures. All these patients present surgical failures of one type or another which need to be and can be corrected in most instances. Reoperation may not be necessary in all patients, but this decision must depend upon complete reevaluation of each patient and the proper timing for the procedure. The number of patients Dr. Iben presented is the same as we have in our series. In 770 heart operations using extracorporeal circulation, reoperation was necessary in 9 instances. This is only one-fourth the number reported by Dr. Iben needing reoperation. The reason for this difference might be that 'in our series the number of patients with valvular disease needing valve replacement were fewer and there were more patients with various congenital lesions. The patients who needed reoperation in our series had the following lesions: tetralogy of Fallot, 2 patients; interventricular septal defect, 1 patient; subaortic stenosis, 3 patients; and congenital calcific aortic stenosis, 1 patient. One other patient, now a 12-year-old boy, had two reoperations for congenital aortic insufficiency; in the first, at age 8, a Muller-Littlefield valve was inserted. This valve stiffened, and the patient developed subacute bacterial endocarditis. The valve was replaced after one and one-half years with a Magovern aortic prosthesis. It functioned well for about one year. Due to dislodgment and recurrent aortic insufficiency, this prosthesis was replaced with a Starr-Edwards prosthesis with ultimate complete recovery of the patient. The only fatality in our reoperated patients was 1 with a previous tetralogy of Fallot. This patient developed aortic insufficiency several years after the initial 342 THE ANNALS OF THORACIC SURGERY

Repeat Open-Heart Surgery repair, necessitating an aortic valve replacement. Death was due to cardiac arrhythmias in the immediate postoperative period. I would like to emphasize that reoperation is necessary after procedures considered failures or ones that did not completely correct the existing lesions. The stakes are definitely higher and the operative and postoperative problems more complex in reoperation. Nevertheless, one should never deny a patient the chance of complete recovery because the problems to achieve this aim are more difficult. The attitude must be an aggressive one, and it often will bring satisfactory results. DR. JAMES W. MACKENZIE (Columbia, Mo.): I would like to thank Dr. Iben and his coauthors for their usual lucid presentation and to support their thesis that previous open-heart surgery does not preclude a successful second operation. In 1962 we reported a series of 22 second open-heart operations carried out at the University of Michigan with Dr. Sloan and Dr. Morris. In this group, which included only congenital lesions, there were 5 deaths. Since then we have continued to apply an aggressive surgical approach to reoperation in patients with acquired heart disease who have obvious hemodynamic difficulty. There are a few problems we have encountered that I suppose are rather pedestrian but might merit some discussion. In terms of local adhesions, it would seem to us that about one year following operation is probably the worst time to schedule reoperation. This is obviously just a clinical impression. We have, when option was available, tried to use a separate surgical field, particularly in valvular replacement. This is quite often possible and probably desirable, not so much because the dissection is difficult but because the postoperative pulmonary problems are often greater when the same field is reentered. I would emphasize, as the authors have here, and as Dr. McGoon has previously, that complete freeing of the heart is probably necessary, both for control of air and also for the possible necessity of defibrillation. In terms of the dissection of the heart from the surrounding adhesions, known to most of you, I am sure, is the need for sharp dissection. The tendency to carry out blunt dissection frequently results, unfortunately, in dissection in the fat along the coronary vessels; sometimes severe injury to the major coronary vessels or heart occurs. Cannulation of the ascending aorta, as recommended by Dr. DeWall and others, avoids the occasional problem of perfusion through damaged femoral vessels. DR. PETER AILEN (Vancouver, B.C., Canada): I would like to augment Dr. Iben s remarks on reoperation in open-heart surgery, specifically by dwelling on those patients with recurrent aortic valve disease. With increasing frequency, cardiac surgeons are seeing a return of patients who have survived palliative surgery of the aortic valve. At the time of reoperation one finds dense, widespread calcification into the aortic root and along the gnarled, deformed aortic cusps. There is an almost irresistible urge to remove every bit of calcium, regardless of the consequences. Indeed, as a result of this singleness of purpose, many of us have found ourselves in the undesirable position of having button-holed the root of the aorta, or even worse, of partially separating the aorta from its attachment to the left ventricle. I would make the point that one must resist this temptation, and excise the calcium flush with the aorta only, thereby leaving the base of the aorta undamaged. Under these circumstances extremely accurate and deep placement of sutures into the friable aortic root will insure firm anchorage of the valve pros thesis. DR. IBEN: We wish to thank the discussants for their remarks. It was our hope in preparing this paper that we would have discussion such as this, and that in sharing some of these problems we could to some extent dispel the feeling of loneliness that we have developed as a result of the lack of such reports in the literature over the years. In answer to some points made by Dr. Mackenzie concerning the time of VOL. 2, NO. 3, MAY, 1966 343

IBEN, HURLEY, ANGELL, AND SHUMWAY reoperation in relation to the number of adhesions encountered, this has not been a problem in our series. We have always proceeded at a time when we felt it was necessary to act on a particular situation. The adhesions at any given time vary in individual patients. In closing, I would like to say that we frequently find consolation in having a living patient upon whom to perform a second operation. We are, however, perplexed by the 15% mortality rate in this group, which runs higher than the mortality rate we have had in our primary series, in which we have been fortunate to have had a 12% rate in mitral operations, a 5% rate in aortic operations, and an overall mortality rate of 7.3%. NOTICE FROM THE SOCIETY OF THORACIC SURGEONS Abstracts for papers to be presented at the 1967 Annual Meeting of The Society of Thoracic Surgeons are now being accepted. The meeting is to be held in Kansas City, Missouri, on January 23-25. The deadline for receipts of abstracts is September 15, 1966. An original and six copies should be submitted to Francis X. Byron, M.D., Secretary, The Society of Thoracic Surgeons, City of Hope Medical Center, Duarte, California. Abstracts must summarize an original contribution and must not exceed 200 words in length. Abstracts received after the deadline or exceeding 200 words will not be considered. The program committee reserves the right to select papers for either 15- or 10-minute forum-type presentations. Essayists are reminded that the complete manuscript must be submitted in duplicate either to the editor of The Annals of Thoracic Surgery before the meeting or to the secretary of the Society at the meeting, immediately prior to presentation. FRANCIS X. BYRON, M.D. Secretary 344 THE ANNALS OF THORACIC SURGERY