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Eur J Cardiothorac Surg 1998;14:S38-S42
© 1998 Elsevier Science NL

Coronary artery bypass grafting without cardiopulmonary bypass – initial experience of 50 cases ¹

Stanisaw Wo^a,*, Ryszard Bachowski^a, Wojciech Ceglarek^a, Wojciech Domaradzki^a, Maciej Matuszewski^a, Ewa Kucewicz^b

^a 2nd Department of Cardiac Surgery, Silesian Medical School, ul. Zioowa 47, 40-635 Katowice, Poland
^b Department of Anaesthesiology, Silesian Medical School, ul. Zioowa 47, 40-635 Katowice, Poland

^* Corresponding author. Tel./fax.: +48 32 2526093.

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion References

 
This study was undertaken to assess our experience with the first 50 patients who underwent CABG without cardiopulmonary bypass. In seven patients left internal mammary artery to left anterior descending artery (LIMA-LAD) grafting was performed through a short left anterior thoracotomy. In 43 other patients median sternotomy was used. Primary CABG was performed in 48 patients; there were two reoperations. Eleven patients had unstable angina. Three patients had left ventricular ejection fraction (LVEF) equal to or lower than 25%. One patient had carcinoma of the right lung coexisting with unstable angina and underwent also right lower lobectomy. In each patient the clinical course, 12-lead ECG, transthoracic echocardiography and the serum levels of creatine kinase (CPK), alanine aminotransferase (ALAT), aspartate aminotransferase (AspAT) were assessed. The need for inotropic or intraaortic balloon counterpulsation (IABP) support and blood transfusion was also recorded. There were three deaths, all in the sternotomy group (6%). A patient with systemic lupus erythemetodes (SLE) died of postoperative MI due to graft thrombosis. Another patient who was found to have porcelain aorta and had LIMA-LAD grafting as a rescue procedure died of MI with low cardiac output. The third patient with unstable angina and ejection fraction of 30% developed postoperative MI with ventricular arrhythmia. One patient with LIMA-LAD graft in whom percutaneous translaminal coronary angioplasty (PTCA) had been abandoned because of coronary spasm developed acute myocardial ischaemia 5 h postoperatively. He had a vein graft placed to LAD in cardiopulmonary bypass, his further course was uneventful. Six patients had IABP support. Nine patients needed inotropic support. Ten patients received blood transfusion. Twelve-lead ECG did not show acute ischaemia or MI, apart from the above described cases. Echocardiographic check showed improved IVS contractility in three patients and better apex motion in one case. In the other survivors the echocardiografic findings were the same as before the procedure. ALAT and AspAT serum levels were normal in all the survivors, and the CPK levels did not exceed 200 IU/ml. One patient from the mini-thoracotomy group had recurrent angina 2 months after the procedure. His left internal mammary artery (LIMA) graft was occluded; we replaced it with a vein graft. All 47 survivors remain asymptomatic, with the mean follow-up time of 6 months. Coronary surgery without cardiopulmonary bypass seems a valuable alternative for high-risk patients.

Key Words: Coronary artery bypass • Cardiopulmonary bypass • Thoracotomy • Minimally invasive coronary surgery • Lung neoplasm

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion References

 
As in all other fields of surgery, cardiac surgeons look for less invasive techniques in order to limit the number of complications and shorten the hospital stay. This paper summarizes our experience with first 50 patients who had coronary artery surgery without cardiopulmonary bypass (CPB), seven of them through small thoracotomy. We will try to focus on some special clinical situations in which coronary artery bypass grafting (CABG) without CPB is especially useful and may reduce the operative risk [10].

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion References

 
From March 1996 to April 1997 50 patients underwent coronary bypass grafting without cardiopulmonary bypass. CABG without CPB accounted only for 4% of the total number of coronary operations performed in our department during that period of time. There were nine women and 41 men aged 42–62 years, the mean age was 54±7 years. The inclusion criteria were: one- or two-vessel disease in LAD and/or RCA that was not suitable for (another) angioplasty, did not require endarterectomy and the coronary anatomy allowed finding the appropriate part of the vessel and constructing the anastomosis on the beating and pumping heart. Informed consent was obtained in every patient who was qualified to have the procedure. In fact, only in three patients who had been scheduled for CABG without CPB the decision was changed after opening the chest and it was elected to go on bypass. The reason for that was intramyocardial LAD course in two cases, and a large diagonal branch that was worthwhile grafting but could not be visualized with the heart pumping, in one case. In one patient we had to use `emergency' CPB because of the myocardial ischaemia during the procedure: The patient was scheduled to have two grafts with the use of median sternotomy. First, left internal mammary artery to left anterior descending artery (LIMA-LAD) anastomosis was performed without problems. ST-elevations appeared on the monitor after the RCA was snared. That was accompanied by the systolic arterial pressure drop to 70 mmHg after the anastomosis to RCA was completed. We supported this patient with the use of CPB for 10 min. During that time, the ECG changes subsided and the patient went off bypass smoothly. Further course was uneventful.

Two special situations in which patients had three-vessel coronary artery disease are described further in the text.

Forty-eight patients had primary CABG; there were two reoperations. Eleven patients had unstable angina; four had previous percutaneous translaminal coronary angioplasty (PTCA), including one who had an emergency operation after LAD had been perforated with the guidewire, and three others whose mean delay to surgery was 9 months. Three patients had left ventricular ejection fraction equal or lower than 25%. All these three had proximal LAD and RCA disease, two had a positive dobutamine test (one had unstable angina). It was felt that the patients with very low EF could benefit from surgery in terms of myocardial contractility and, at the same time, avoid ischaemia-reperfusion injury caused by cardioplegic heart arrest. As far as other pathology is concerned, one patient had coexisting carcinoma of the right lung, another one had LGM at the stage of remission; one patient had LE; another one had chronic leukemia.

Seven patients had LIMA-LAD grafting through left anterior 10 cm thoracotomy. The operating procedure was as follows.

On the day of the operation the patient received oral beta- and calcium channel blockers to slow down the heart to approximately 60 beats per minute and provide additional protection against myocardial ischaemia. The patient was anaesthetized with the use of standard techniques and drugs (diazepam, metohexital, fentanyl). The pump was prepared and the perfusionist was present in the operating theatre. An incision (10 cm) was made in the fourth left intercostal space. The fourth costal cartilage was excised and the third rib was cut. The 6–10 cm left internal mammary artery (LIMA) pedicle was harvested under direct vision. The pericardium was incised. The patient received 5000-10 000 units of i.v. heparin, GTN infusion, 100 mg of i.v. lignocaine for additional prophylactics of ventricular arrhythmias. No i.v. beta-blockers were used. The anastomosis site was occluded and stabilized with the use of two 5/0 polypropylene sutures. In some patients mechanical ischaemic preconditioning was used. The anastomosis was constructed with the use of continuos 7/0 polypropylene suture. A 24 French drain was put to the pericardium or to the pleura and the pericardium, then the chest was closed. Heparin was not reversed with protamine unless the patient had significant bleeding with prolonged activated coagulation time. The patient was transferred to the ITU and extubated within 4 h after the operation (except in the patient who had reexploration for bleeding). Oral acetylsalicylic acid and subcutaneous low-molecular heparin were commenced.

In order to obtain blood packed cell volume lower or equal to 35%, in 28 patients 500 ml of blood were taken to the autotransfusion set.

Forty-three patients had one to three grafts through median sternotomy, the mean number of grafts was 1.5 per patient. The preparation of the patient and the postoperative care were as described above. LIMA was harvested in the usual manner. Saphenous vein grafts were usually placed first, but the strategy depended on the picture of coronary anatomy and collateral circulation. When one distal anastomosis was completed, the graft was immediately anastomosed to aorta. After that, LIMA was anastomosed to LAD. Twenty-five patients of this group had LIMA-LAD graft, 18 patients had a saphenous vein graft to LAD (unstable angina, low EF, redo procedures). Twenty-one patients had a vein graft to RCA and 11 a vein graft to the diagonal branch.

In each patient the clinical course, the 12-lead ECG before and 1 h, 1, 2, 4 and 7 days postoperatively, the left ventricular global and segmental contractility (transthoracic echocardiography) before and a week after the operation, serum levels of creatine kinase (CPK), alanine aminotransferase (ALAT) aspartate aminotransferase (AspAT) pre- and 1, 24 and 48 h postoperatively were assessed. The need for inotropic support and blood transfusion were also recorded. In six patients haemodynamic parameters were measured with the use of Swan–Ganz catheter, after the induction of anesthesia, after closing the chest and 12 h postoperatively.

There were two special clinical situations in which we decided to use CABG without CPB although full revascularization could not be achieved in this way.

A 59-year-old male, a chain smoker who had been treated for chronic bronchitis for several years, had a 7-cm tumor of the lower lobe of the right lung (bronchoscopy sample: carcinoma planoepitheliale) and unstable angina, on GTN infusion. Cardiac catheterization: LV ejection fraction of 40%; 85% left main stenosis and two 90% stenoses of proximal and middle portion of RCA. The patient was also treated with omeprazole because of a large duodenal ulcer (diagnosed while in the Cardiology Department). The operation was performed by median sternotomy. First, two saphenous vein grafts were done to LAD and RCA. Then, right lower lobectomy was performed.

A 55-year-old male patient with unstable angina who was originally scheduled to have three vein grafts in CPB. After opening the chest the ascending aorta was found to be heavily calcified: cannulation or anastomosing the grafts to the aorta were impossible. It was decided to perform LIMA-LAD without CPB grafting as a rescue procedure – in hope that at least the RCA stenosis could be suitable for angioplasty. Intraaortic balloon counterpulsation (IABP) was inserted during the operation.

Also, the case of a 52-year-old woman with disease in LAD and RCA who had unstable angina with left ventricular ejection fraction below 20% deserves a short description. The IABP was inserted electively before the operation. Vein grafts were placed to LAD and RCA. Amrinone and dopamine were administered for postoperative inotropic support. IABP was removed 12 h postoperatively.

Altogether, two patients had IAPB support perioperatively. Four further patients had the balloon inserted postoperatively due to myocardial infarction (MI) or myocardial ischaemia.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion References

 
Full myocardial revascularization was achieved in all patients except in the two above mentioned cases. The mortality and morbidity is shown in Table 1 .

There were three hospital deaths in the sternotomy group (6%). A female patient with two-vessel coronary artery disease and lupus erythematodes who had grafts to LAD, D and RCA developed MI due to the thrombosis of all three grafts and died on the first postoperative day. The patient with porcelain aorta needed prolonged inotropic support postoperatively, developed MI and died of low cardiac output 8 days postoperatively. Another 45-year-old patient with unstable angina, who had subendocardial MI 2 weeks before the procedure and EF of 30%, developed perioperative MI with ventricular arrhythmias and died 16 h after the operation. Other early complications were a patient who had LIMA-LAD graft through median sternotomy, in whom PTCA had been abandoned because of coronary spasm, developed acute myocardial ischaemia 5 h postoperatively despite adequate arterial blood pressure, central venous pressure and the therapy with i.v. GTN and nifedipine infusion. A vein graft was placed to LAD in CPB. IABP was inserted. The ECG changes subsided, the patient did not have perioperative MI, his further course was uncomplicated. One patient from mini-thoracotomy group needed wound reexploration for bleeding. Another patient of that group had a bleeding duodenal ulcer postoperatively that required transfusion of 2 units of blood.

The patient who had simultaneous CABG and lobectomy developed respiratory failure on the third postoperative and required reintubation and mechanical ventilation for 4 days. His further course was uneventful and he is free of any symptoms after a 9-month follow-up.

Nine patients needed postoperative inotropic support with dopamine, epinephrine, amrinone. Ten patients required the transfusion of 1–4 units of blood. Twelve-lead ECG did not show any acute ischaemia or MI, apart from the above described cases. Echocardiographic check in 47 survivors showed improved contractility of interventricular septum in three patients and improved contractility of the apex in one case. In the other patients the echocardiografic findings were the same as before the procedure. ALAT and AspAT serum levels were normal in all the survivors, and the CPK levels were not higher than 200 IU/ml which can be attributed to LIMA harvesting. Mean cardiac index in the patients who had Swan–Ganz catheter was 1.93±0.37 l/min per m² after the induction of anesthesia, 2.2±0.35 l/min/m² after closing the chest and 2.6±0.5 l/min per m² 12 h after the operation. The observed changes were not statistically significant.

The 47 patients were discharged from the hospital on the 4th–15th postoperative day. One patient who underwent LIMA-LAD grafting through mini-thoracotomy had recurrent angina 2 months after the procedure. On cardiac catheterization there was no distal LIMA filling. The patient was reoperated on through median sternotomy. LIMA graft was occluded, probably due to the pedicle tension, and was replaced with a vein graft – without CPB. Further course was uncomplicated.

These 47 patients have been followed up for 1–14 months (mean follow-up 6 months). They are free of angina and have negative stress test results.

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion References

 
The first operations, a milestone in the history of coronary artery surgery, were done without cardiopulmonary bypass. One can recall the names of D.C. Sabiston (1962) and W.I. Kolesov (1967) [12]. Then with the development of the techniques of cardiopulmonary bypass and myocardial preservation during cardioplegic heart arrest, the method was abandoned. Recently, however, good results of CABG without CPB, as well as MIDCAB procedures performed on a large series of patients with low mortality were reported by F. Benetti [3–5], E. Buffolo [7], A. Calafiore [8], P. Corso [3]and R. Landreneau [14], to mention only a few.

Do these methods carry enough benefit for the patient, or are they just a fashionable technical variation with still uncertain distant results?

If there is any clear answer, it probably depends on the patient – and on the surgeon. We can probably say that for an average coronary patient with good left ventricle and no additional diseases the early operative mortality and morbidity are already so low that it is difficult to make them lower, and we should keep in mind the issue of late patency of grafts anastomosed on the beating heart. Early discharge of those patients is the most apparent advantage [1, 14].

Things change if the patient is likely to have complications of CPB (malignancies, severe renal insufficiency [3], severe blood coagulopathy, pregnancy [18]), cardioplegic heart arrest (very low left ventricular ejection fraction [19], unstable angina or recent myocardial infarction [3, 4]), aortic cannulation and cross-clamping (severe atheromatosis of the ascending aorta [3, 13, 16, 17]). In our material presented above, we had examples for most of these categories.

Avoiding the use of CPB in the patient with co-existing lung carcinoma seems important because the patients who had combined CABG in CPB and lung tissue resection for cancer die more often because of the neoplasm than because of the coronary heart disease [6]. The early mortality of 6% is usually reported [6, 11], due to coronary heart disease and respiratory insufficiency, but two-thirds of the late deaths are caused by the recurrent cancer with survival rate of about 40% within 5 years [6]. CPB is known to diminish both types of immune response and accelerate the spread of neoplasms. It would be interesting to see if long-term survival of these patients is improved by avoiding the use of CPB. However, we have not found any late results of simultaneous CABG without CPB and lung resection in the literature.

All our three patients with low left ventricular ejection fraction made a successful recovery with low inotropic support and no complications. Data from other, more extensive reports, confirm that high-risk patients benefit from coronary surgery without CPB, with extremely low early mortality of 2–3.5%; even if they do not have full revascularization [4, 7, 20]. Also, it has been shown by Akins et al. [2]and also by our results that CABG without CPB preserves or improves the interventricular septum motion; in patients who had CABG in CPB abnormal septum motion is often found [2].

The patient with calcified aorta died; if we had known about the porcelain aorta, we could have used left thoracotomy and anastomose the grafts to his left subclavian artery [16]. Or perhaps we should have harvested both internal thoracic arteries and the radial artery and use LIMA-LAD, radial artery to OM, connected to LIMA, and RIMA to RCA in femoral cardiopulmonary bypass with left ventricular vent, without clamping the aorta [17].

No need for blood transfusion in 80% of our patients was an important advantage [4]as the transfusion still carries the risk of viral infection.

Avoiding the use of CPB can also save at least $650 per patient – as this is the approximate cost of CPB materials.

The answer to our question about the possible advantages and drawbacks of CABG without CPB certainly depends also on the surgeon, because the anastomosis on the beating heart requires a lot of technical skill and experience – and it is not a technique for everyone.

At the end, a few words of comment on LIMA-LAD grafting through left mini-thoracotomy. As we understand it, the term `minimally invasive' CABG corresponds rather with avoiding the use of CPB, heart arrest and aortic clamping than with the site and length of the incision. However, we have to admit that mini-thoracotomy causes less pain and allows faster recovery. In the recent report of Acuff et al. [1]the patient could be discharged home even 48 h after surgery.

From a technical point of view, in our modest experience, the length of the harvested LIMA pedicle and the topographic relation between LIMA and LAD are very important. In our opinion, LIMA graft occlusion in one of our patients was caused by too much tension on the pedicle. Thoracoscopic harvest [1]may be superior to that under direct vision as it enables dividing of all the LIMA branches. Also, using polypropylene snares to stabilize and occlude the anastomosis site may induce wall injury and explain graft dysfunctions: using mechanical stabilizers is certainly a better option.

Thirty years after it was originally used by Kolesov in 1967 [12], LIMA-LAD graft has certainly become the `gold standard' in coronary surgery [9]. Its good long-term patency reaching even 97% after 10 years, and better survival of the patients with the arterial graft are widely known [15]. Will MIDCAB or `no CPB' techniques be able to maintain these good results? That is the basic question.

	5. Conclusion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion References

 
In our early results, CABG without CPB offers a valuable alternative in high-risk patients with the stenoses of LAD and RCA: they can benefit from surgical revascularization, avoiding the side effects of CPB, aortic cross-clamping, cardioplegic heart arrest, blood transfusion. However, anastomoses on the beating heart are more demanding from a technical point of view. Will their long-term patency be similar to the patency of grafts performed with the use of cardioplegia? We are going to answer this question after a longer follow-up of our patients.

	Footnotes

 
¹ Presented at the World Congress on Minimally Invasive Cardiac Surgery, Paris, May 30–31, 1997.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion References

 

1. Acuff TE, Landreneau RJ, Griffith BP, Mack MJ. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;61:135-137.[Abstract/Free Full Text]
2. Akins CW, Boucher CA, Pohot GM. Preservation of interventricular septal function in patients having coronary artery bypass grafts without cardiopulmonary bypass. Am Heart J 1984;107:304-309.[Medline]
3. Benetti FJ, Mariani MA, Ballester C. Direct coronary surgery without cardiopulmonary bypass in acute myocardial infarction. J Cardiovasc Surg (Torino) 1996;37:391-395.[Medline]
4. Benetti FJ, Naselli D, Wood M, Geffner L. Direct myocardial revascularization without extracorporeal circulation. Chest 1991;100:312-316.[Abstract/Free Full Text]
5. Benetti FJ, Mariani MA, Sani G, Boonstra PW, Grandjean JG, Giomarelli P, Toscano M. Video-assisted minimally invasive coronary operations without cardiopulmonary bypass: a multicenter study. J Thorac Cardiovasc Surg 1996;112:1478-1484.[Abstract/Free Full Text]
6. Brutel de la Rivicre A, Knaepen P, Van Swieten H, Vanderschueren R, Ernst J, Van den Bosch J. Concomitant open heart surgery and pulmonary resection for lung cancer. Eur J Cardiothorac Surg 1995;9:310-313.[Abstract]
7. Buffolo E, de Andrade JCS, Branco JNR, Teles CA, Aguiar LF, Gomes WJ. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1996;61:63-66.[Abstract/Free Full Text]
8. Calafiore AM, Giammarco GD, Teodori G, Bosco G, D'Annunzio E, Barsotti A, Maddestra N, Paloscia L, Vitolla G, Sciarra A, Fino C, Contini M. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-1663.[Abstract/Free Full Text]
9. Corso PC. Cardiopulmonary bypass and coronary artery bypass graft. Are the risks necessary?. Chest 1991;100:298-299.[Free Full Text]
10. Fanning WJ, Kakos GS, Williams TE. Reoperative coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1993;55:486-489.[Abstract]
11. Johnson JA, Landreneau RJ, Boley TM, Haggerty SP, Hattler B, Curtis JJ, Hazelrigg SR. Shoud pulmonary lesions be resected at the time of open heart surgery?. Am Surg 1996;62:300-303.[Medline]
12. Kolesow WI. Mammary artery–coronary artery anastomosis as method of treatment for angina pectoris. J Thorac Cardiovasc Surg 1967;54:535-544.[Medline]
13. Laborde F, Abdelmequid I, Piwnica A. Aortocoronary bypass without extracorporeal circulation: why and when?. Eur J Cardiothorac Surg 1989;3:152-155.[Abstract]
14. Landreneau RJ, Mack MJ, Magovern JA, Acuff TA, Benckart DH, Sakert TA, Fetterman LS, Griffith BP. `Keyhole' coronary artery bypass surgery. Ann Surg 1996;224:453-459.[Medline]
15. Loop FD, Lytle BW, Cosgrove DM. Influence of the internal mammary artery graft of 10 year survival and other cardiac events. N Engl J Med 1986;314:1-6.[Abstract]
16. Mizumoto T, Hiraiwa T, Kinoshita T, Fujii H. Left thoracotomy for coronary artery bypass grafting without cardiopulmonary bypass in a patient with porcelain aorta. Nippon Kyobu Geka Gakkai Zasshi 1997;45:161-164.[Medline]
17. Olearchyk AS. Calcified ascending aorta and coronary artery disease. Ann Thorac Surg 1995;59:1013-1015.[Abstract/Free Full Text]
18. Silberman S, Fink D, Berko RS, Mendzelevski B, Bitran D. Coronary artery bypass surgery during pregnancy. Eur J Cardiothorac Surg 1996;10:925-926.[Abstract]
19. Sternik L, Moshkovitz Y, Hod H, Mohr R. Comparison of myocardial revascularization without cardiopulmonary bypass to standard open heart technique in patients with left ventricular dysfunction. Eur J Cardiothorac Surg 1997;11:123-128.[Abstract]
20. Tashiro T, Todo K, Haruta Y, Yasunaga H, Tachikawa Y. Coronary artery bypass grafting without cardiopulmonary bypass for high-risk patients. Cardiovasc Surg 1996;4:207-211.[Medline]

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