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Eur J Cardiothorac Surg 1999;16:S69-S72
© 1999 Elsevier Science NL

Current results in off pump surgery

Department of Cardiac Surgery, University ‘G. D'Annunzio', c/o Ospedale San Camillo De Lellis, Via C. Forlanini, 50, 66100 Chieti, Italy

^* Corresponding author. Tel.: +39-871-358653; fax: +39-871-402239 (Email: calafiore{at}unich.it).

	Abstract

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

 
Objective: We reviewed our experience with myocardial revascularization without cardiopulmonary by-pass (CPB) to evaluate early- and mid-term results compared with those obtained using CPB. Methods: From May 21 1997 to November 1998, 747 patients had isolated myocardial revascularization, 480 without CPB (Group A) and 267 with CPB (Group B). Exposure of the target vessels was obtained with four slings (two passed through the transverse sinus and two behind the inferior vena cava) and four deep pericardial sutures on the mobile pericardium around the left atrium (Lima stitches). The number of anastomoses/patient (when two or more conduits were used) was higher in Group B (3.1±1.0 vs 2.6±0.7, P<0.001). More marginal branches were grafted in Group A (258 vs 239), but the percentage was higher in Group B (P<0.001). Crude and risk adjusted mortality was similar in both groups, as well as cerebrovascular accident (CVA) and acute myocardial infarction incidences. Patients in Group A woke earlier, had less inotropes, lower creatinkinase myocardial band (CK–MB) peak, lower bleeding and less transfusion, shorter Intensive Care Unit (ICU) and postoperative stay in hospital than patients in Group B. 266 anastomoses were checked; of these 98.5% were patent and 97.0% were patent and not restrictive. Conclusions: Myocardial revascularization without CPB can provide good early- and mid-term results in selected patients. Primary endpoints (death and acute myocardial infarction) were similarly independent from the technique used. Some of the secondary endpoints were favorable in Group A; however their importance is minor. Even if we feel that some high risk patients with severe comorbidities can benefit from CPB surgery; this aspect is difficult to demonstrate scientifically.

Key Words: Coronary revascularization • Beating heart surgery

	1. Introduction

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

 
Myocardial revascularization without cardiopulmonary bypass (CPB) is a procedure that is again becoming popular [1,2], as recently new instruments and advanced techniques of exposure allow surgeons to graft safely territories different from the anterior ones [3,4].

We herein report our experience in myocardial revascularization without CPB via median sternotomy to analyze the early- and mid-term results compared with patients who had myocardial revascularization with CPB.

	2. Materials and methods

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

 
From January 1992 to November 1998, 603 patients underwent myocardial revascularization without CPB via a median sternotomy. In the first part of our experience this procedure was reserved only for selected patients with high preoperative risk factors for CPB. Starting from May 21, 1997, better instruments were provided and a new exposure technique was used. During this period 480 procedures were performed without CPB; they represent the 64.3% of all patients that underwent isolated coronary revascularization via a median sternotomy. For a better analysis of our results, we compared these patients (Group A) with the patients that in the same period underwent myocardial revascularization using CPB (Group B). The preoperative data of these groups are shown in Table 1 .

2.2 Surgical technique
Anesthesia was induced and maintained as previously described [3]. The mammary arteries were harvested and skeletonized [5]; the remaining conduits were harvested and prepared as previously described [6,7]. A total of 2 mg/kg of heparin was administered. The target coronary vessels were explored and the surgical strategy confirmed. Four slings (length 50 cm, width 3 cm) were enrolled and passed, two through the transverse sinus (TS) and two behind the inferior vena cava (IVC) [3]. Four deep pericardial sutures were passed in the mobile posterior pericardium, at the level of the left superior and inferior pulmonary veins and between the latter one and the inferior vena cava (Ricardo Lima, personal communication). The maneuvers that allowed exposure of all the coronary vessels were previously reported [3]. The traction on the pericardial sutures allowed to reach a more vertical position of the heart and an easier access to the proximal portion of the coronary vessels in the lateral and inferoposterior walls.

The coronary arteries were occluded before the anastomoses [3]. The left anterior descending (LAD) and the main right coronary artery (RCA) were occluded proximally and distally the anastomotic site, whereas the other branches only proximally. An O₂ blower made the operative field dry at the moment of the anastomosis.

The coronary vessels were stabilized using the MV system (CardioThoracic System, Cuppertino, CA, USA).

Once exposure and stabilization were obtained, the target coronary vessel was incised and the anastomosis was performed as previously described [3]. Blood loss during the procedure was reinfused, when necessary, using a cell saver (DIDECO, Mirandola, Modena, Italy). Protamine was reversed 0.5:1 and the wound closed in the usual fashion.

2.3 Postoperative course
The patients were admitted in the ICU, where they remained until extubation and clinical stabilization; intravenous diltiazem was infused. The patients were transferred to the ward generally on the same day of the operation or in the first postoperative day; diltiazem (60 mg three times a day) was given orally and continued for 4 weeks. In the morning of the first postoperative day all the infusion lines were removed, as well as the drainage tubes and the patients were mobilized. If the patient agreed, control angiography was performed before discharging or a few days or a few weeks later. One month postoperatively all the patients were seen in the outpatient clinic, with the result of a stress test performed without medical treatment.

In order to stratify properly the risk factors for each group with regard to early mortality and prediction of cerebrovascular accidents (CVAs), the risk factors for early death derived by the New York State data base for 1995 was used (Table 2 ) as well as the nomogram proposed by Newman et al. [8]

	3. Results

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

 
The population of the groups was not completely homogeneous: more redo patients were present in Group B, while the mean age in Group A was statistically higher. The operative and postoperative data are shown in Tables 3 and 4 , respectively. More arteries in the circumflex territory were grafted in Group A, but, as a percentage, more patients in Group B had a marginal graft. Mortality and CVAs were not statistically different between the two groups. Awakening, bleeding, number of transfused patients and use of inotropes were lower in Group A; postoperative ICU and in hospital stay were also significantly lower in this group. Angiographic evaluation of 266 anastomoses was obtained: according to the gradation proposed by Fitzgibbon et al. [9], 98.1% of them were found patent (grade A or B), and 97.0% patent and not restrictive (grade A). This percentage was respectively, 100 and 98.9% for the LAD and 98.6% and 96.4% for the marginal grafts.

View larger version (13K): [in this window] [in a new window]   Fig. 1. Survival of Group A (((() and Group B (- - - - - - - - -).

View larger version (15K): [in this window] [in a new window]   Fig. 2. Event free survival of Group A and Group B.

	4. Discussion

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

 
Myocardial revascularization without CPB is a surgical strategy that is again becoming popular. The rationale is that the great majority of the coronary vessels to be grafted are in epicardial position. However, in the past the surgical technique was not well defined and often related to the skill of the individual surgeon. The advent of stabilizers and new exposure techniques allowed not only to overcome the difficulties in performing a safe anastomosis but also in grafting the vessels in the lateral wall.

However, in our hands a significant number of patients could not be revascularized without CPB because of technical or hemodynamic factors. Moreover, the real benefit for the patients has still to be clearly demonstrated. In our experience the primary end points (death, incidence of myocardial infarction) are similar in both groups. Even if there is evidence that some factors related to a better cardiac outcome (lower incidence of inotropes and lower CK–MB peaks) are prevalent in Group A, their importance is questionable in the long-term outcome.

Some of the secondary end points (awaking time, bleeding, transfused patients, ICU stay, postoperative in hospital stay) are undoubtedly favorable for the patients operated on without CPB; however, their importance for early outcome is minor. In fact, many of the techniques developed for surgery without CPB (different anesthesiological protocols, ICU discharge in the same day, reduced postoperative in hospital stay) are now applied also to the patients operated on with CPB, with excellent results. The difference between groups, even if statistically significant, is 0.7 h for awaking time, 6.8 h for ICU stay and 1 day for postoperative in hospital stay. It is likely that in the near future these figures will have a tendency to equalization. Bleeding is significantly less in Group A, as well as the incidence of transfused patients; this aspect will likely remain similar, as in the patients operated on without CPB coagulation disorders will be always lacking.

Crude mortality was not different and the risk adjusted mortality was similar. The CVA incidence was also similar, even if a statistically significant reduction in comparison with the expected incidence was shown by our data.

The great benefit from myocardial revascularization without CPB could be in the subgroup of high risk patients for the presence of severe comorbidities. This is our feeling, however this aspect is very difficult to demonstrate scientifically.

In conclusion, we think that myocardial revascularization without CPB is a safe technique that can give good results in the mid-term, provided a good anastomosis could be done. This strategy is not clearly superior to conventional techniques, even if our data allows us suppose that the incidence of CVA could be reduced in patients operated on without CPB. Moreover it is likely that selected subgroups of patients with high risk factors can benefit from it. A longer follow-up is necessary to demonstrate its validity in the long-term using the current techniques.

	Footnotes

 
Presented at the 2nd MITSIG International Symposium: Controversies in Cardiothoracic Surgery, Hong Kong, November 20–21, 1998.

	References

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

 

1. Buffolo E, Silva de Andrade JC, Rodrigues Branco JN, Teles CA, Aguiar LF, Gomes WJ. Coronary artery bypass surgery without cardiopulmonary bypass. Ann Thorac Surg 1996;61:63-66.[Abstract/Free Full Text]
2. Bergsland J, Hasnan S, Lewin AN, Bhayana J, Lajos TZ, Salerno TA. Coronary artery bypass grafting without cardiopulmonary bypass – an attractive alternative in high risk patients. Eur J Cardiothorac Surg 1997;11:876-880.[Abstract]
3. Calafiore AM, Teodori G, Di Giammarco G, Vitolla G, Maddestra N, Paloscia L, Zimarino M, Mazzei V. Multiple arterial conduits without cardiopulmonary bypass. Early angiographic results. Ann Thorac Surg 199967:450-456.
4. Jansen EW, Borst C, Lahpor JR, Gründeman PF, Eefting FD, Nierich A, Robles de Medina EO, Bredée JJ. Coronary artery bypass grafting without cardiopulmonary bypass using the octopus method: results in the first one hundred patients. J Thorac Cardiovasc Surg 1998;116:60-67.[Abstract/Free Full Text]
5. Calafiore AM, Vitolla G, Fino C, Di Giammarco G, Marchesani F, Teodori G, D'Addario G, Mazzei V. Bilateral internal mammary artery grafting: pedicled versus skeletonized. Mid-term results. Ann Thorac Surg 1999(in press).
6. Calafiore AM, Di Giammarco G, Luciani N, Maddestra N, Di Nardo E, Angelini R. Composite arterial conduits for a wider arterial myocardial revascularization. Ann Thorac Surg 1994;58:185-190.[Abstract]
7. Calafiore AM, Di Giammarco G. Complete revascularization with three or more arterial conduits. Semin Thorac Cardiovasc Surg 1996;8:15-23.[Medline]
8. Newman MF, Wolman R, Kanchuger M, Marschall K, Mora-Mangano C, Roach G, Smith LR, Aggarwal A, Nussmeier N, Herskowitz A, Mangano DT. Multicenter preoperative stroke risk index for patients undergoing coronary artery bypass graft surgery. Multicenter Study of Perioperative Ischemia (McSPI) Research Group. Circulation 1996;94(Suppl II):74-80.
9. Fitzgibbon GM, Kafka HP, Leach AJ. Coronary bypass graft fate and patient outcome: angiographic follow up of 5065 grafts related to survival and reoperation in 1388 patient during 25 years. J Am Coll Cardiol 1996;28:616-626.[Abstract]

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