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Eur J Cardiothorac Surg 2001;19:239-244
© 2001 Elsevier Science NL

Off-pump coronary artery bypass surgery for critical left main stem disease: safety, efficacy and outcome

Bristol Heart Institute, University of Bristol, Bristol, UK

Received 5 September 2000; received in revised form 14 December 2000; accepted 27 December 2000.

Corresponding author. Bristol Heart Institute, Bristol Royal Infirmary, Bristol BS2 8HW, UK. Tel.: +44-117-928-3145; fax: +44-117-929-9737
e-mail: n.holloway-dee{at}bristol.ac.uk

	Abstract

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

 
Objectives: To determine whether patients with critical left main stem (LMS) coronary artery disease can undergo off-pump coronary artery bypass (OPCAB) surgery safely and successfully. Methods: From May 1996 to March 2000 data for patients with critical (50%) LMS stenosis who underwent conventional coronary artery bypass surgery with cardiopulmonary bypass (CCAB) or without (OPCAB) were collected prospectively using the Patient Analysis & Tracking System. A reusable pressure stabilizer, intra-coronary shunts and a single posterior pericardial stitch exposure technique were used in all OPCAB cases. Non-randomized, retrospective data analysis included demographic and preoperative risk factors, operative details, clinical outcome and early follow-up. Results: During the study period 387 patients with LMS stenosis underwent surgery (OPCAB n=75, CCAB n=312). Groups were similar in terms of preoperative and intraoperative variables although CCAB patients received significantly more grafts per patient (3.1±0.73 vs. 2.6±0.76, P0.001). Mortality was similar in both groups (OPCAB 1.3% vs. CCAB 2.6%). OPCAB patients when compared to CCAB patients had a lower requirement for postoperative inotropes (12.0% vs. 38.1%, P=0.0001), temporary postoperative pacing (2.7% vs. 10.1%, P=0.02), and blood product transfusion (6.7% vs. 31.4%, P<0.0001), a lower incidence of postoperative chest infection (0% vs. 6.7%, P=0.02) and a slightly reduced postoperative length of stay (7.9±5.46 vs. 8.3±5.11 days, P=0.01). At 24 months follow-up, CCAB and OPCAB actuarial survival was 94.1±1.7% and 97.7±2.3%, respectively. Conclusions: OPCAB surgery is safe and effective in patients with critical LMS disease.

Key Words: Left main stem disease • Off-pump coronary artery bypass surgery

	1. Introduction

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

 
The prognostic indications for coronary artery bypass surgery in the presence of critical left main stem (LMS) stenosis are well-established [1]. Medical therapy alone confers a poor survival advantage when compared to surgical revascularization [2,3] and percutaneous revascularization techniques for critical LMS stenosis are at present generally considered unsafe.

Recently, there has been renewed interest in the potential benefits of off-pump coronary artery bypass (OPCAB) surgery [4] with encouraging reports of clinical, angiographic and economic superiority when compared to conventional coronary artery bypass surgery using cardiopulmonary bypass (CCAB) [5–11]. Even more encouraging are the findings that high-risk and elderly patients benefit most from beating heart surgery in which cardiopulmonary bypass (CPB) is not used [12,13].

The presence of critical LMS disease has been considered a relative contraindication to OPCAB surgery. However, the development in exposure and stabilization techniques, the introduction of intra-coronary shunts, and an increasing understanding of the haemodynamic changes which occur during off-pump surgery should enable patients with critical LMS disease to undergo OPCAB surgery.

The present study aims to determine whether OPCAB surgery is a feasible and safe surgical technique in patients with critical LMS coronary artery disease.

	2. Patients and methods

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

 
2.1. Patient selection
The Bristol Cardiothoracic Centre is a tertiary referral centre and accepts patients referred with coronary artery disease from the Southwest region of the United Kingdom. Perioperative data of all patients operated on at our institution are prospectively and systematically collected in the Patient Analysis & Tracking Systems (PATS) (Dendrite Clinical Systems Ltd., London, UK). Between May 1996 and June 2000 a total of 1963 patients underwent coronary artery bypass surgery at our institute with an overall mortality of 1.4%. Three-hundred and eighty-seven patients with critical LMS stenosis (50% narrowing) were identified and of these 75 patients underwent OPCAB surgery. Individual senior surgeons decided whether to use OPCAB or CCAB techniques based upon their degree of proficiency with OPCAB surgery at the time of each procedure.

2.2. Anaesthesia and anticoagulation
A standard anaesthetic technique was used for all patients. This consisted of an oral premedication (20 mg temazepam) followed by total intravenous anaesthesia (3 mg kg^-1 h^-1 propofol). Neuromuscular blockade was achieved by administering pancuronium (0.15 mg kg^-1) or vecuronium (0.15 mg kg^-1). Intravenous heparin (300 IU kg^-1 with a target activated clotting time (ACT) of 480 s) was administered to the CCAB patients immediately prior to cannulation for CPB. OPCAB patients received 100 IU kg^-1 heparin prior to commencing the distal anastomoses with a target ACT of 250–350 s. Protamine sulphate was used to reverse the heparin effect at the completion of the surgical procedure [8,14,15].

2.3. Surgical procedures
2.3.1. CCAB group
CPB was instituted using an ascending aortic perfusion cannula, a single two-stage right atrial cannula and a non-pulsatile flow of 2.4 l min^-1 m^-2 as previously described [8,14,15].

2.3.2. OPCAB group
All OPCAB procedures were performed through a median sternotomy incision using techniques similar to those recently described [16,17]. Briefly, a single 0-silk suture, which had been passed through a large (12x70 cm) gauze swab, was inserted into the posterior pericardium midway between the inferior vena cava and the left inferior pulmonary vein. The gauze swab was then securely snared into position on the pericardium. This retraction stitch enabled anterior displacement of the cardiac apex and better visualization of the target coronary arteries during the distal anastomoses. A reusable stabilizer incorporating a footplate (Abbey Surgical Limited, Mitcham, Surrey, UK) was used during the construction of the anastomoses. To further assist good exposure of the inferior and obtuse marginal surfaces of the heart the patient was placed in a gentle right decubitus Trendelenburg position. Following exposure and stabilization of the target vessel, the coronary artery was opened and a suitably-sized intra-coronary shunt was inserted into the lumen (Flothru Biovascular Inc., St. Paul, MN) following temporary proximal occlusion of the coronary with a snare.

2.4. Clinical data collection, monitoring and definitions
Clinical outcome data from non-randomized patents with critical LMS disease were prospectively inserted into the PATS system and retrospectively analyzed. Operative mortality was defined as any death that occurred within 30 days of operation. ST segment changes and arrhythmias were detected and recorded as previously reported.[16]. Clinical diagnostic criteria for perioperative myocardial infarction (MI), low cardiac output syndrome and respiratory tract infection were as defined previously [8]. Ventilatory failure was defined by the requirement for mechanical ventilation of more than 48 h. Derangements of the coagulation profile were treated using a specific diagnosis-directed therapy where bleeding was excessive (150 ml h^-1 over two consecutive hours). Elevation of ACT of more than 30 s when compared to baseline was treated with an additional dose of protamine. Values of pro-thrombin time (PT), activated partial pro-thrombin time (aPTT) and international normalised ratio (INR) of more than 1.5 times control suggested clotting factor deficiency and were corrected by infusion of fresh frozen plasma. A platelet (PLT) count of less than 80 000 µl^-1 was an indication for a PLT transfusion. A haematocrit of 24% was corrected by transfusion of packed red blood cells (RBC). Postoperative blood loss was measured as the total chest tube drainage starting immediately after closure of the chest in the operating theatre.

Follow-up was performed by recording data at subsequent office visits and by mailing known survivors at 6 monthly intervals.

2.5. Postoperative management
At the end of surgery, patients were transferred to the intensive care unit (ICU). The lungs were ventilated with 60% oxygen using volume-controlled ventilation and a tidal volume of 10 ml kg^-1 with 5 cm H₂O of positive end-expiratory pressure (PEEP). Adjustments in FiO₂ and respiratory rate were made according to routine blood gas analysis, in order to maintain PaO₂ between 80 and 100 mmHg, and PaCO₂ between 35 and 40 mmHg. Forced air warming was used until a stable nasopharyngeal temperature of 37°C had been reached. Patients were extubated as soon as they met the following criteria: haemodynamic stability, no excessive bleeding (80 ml h^-1), normothermia, and consciousness with adequate pain control. Fluid management postoperatively consisted of 5% dextrose infused at 1 ml kg^-1 h^-1 with additional Gelofusine or blood to maintain normovolaemia and haematocrit greater than 24%. Potassium and magnesium deficiency was promptly treated as necessary to maintain an electrolyte balance within the normal range [8].

2.6. Statistical analysis
Statistical analyses were performed using the Stat-View statistical software package (SAS Institute Inc, Cary, NC). Continuous variables are presented as the mean±standard deviation and categorical variables are presented as either absolute numbers or percentages. Data were checked for normality prior to statistical analysis. Categorical variables were analyzed using either the ²-test or Fisher's exact test. Normally distributed continuous variables were compared using the unpaired t-test and the Mann–Whitney U-test was used for those variables that were not normally distributed. Postoperative actuarial survival was analyzed using the Kaplan–Meier method and differences in survival were compared using the log-rank (Mantel–Cox) test. Differences between study groups were considered statistically significant when P0.05.

	3. Results

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

 
The distribution of patients operated on with the OPCAB and CCAB techniques during the study period is presented in Fig. 1a.

View larger version (19K): [in this window] [in a new window]   Fig. 1. (a) Patients with critical LMS disease operated on with the OPCAB or CCAB technique during the study period May 1996 to March 2000. (b) Actuarial cumulative survival.

In-hospital mortality was comparable between groups and consisted of one (1.3%) death in the OPCAB group and eight (2.6%) deaths in the CCAB group. With regard to the effect of both techniques on the occurrence of myocardial complications, two (2.7%) OPCAB patients suffered a perioperative myocardial infarct compared with nine (2.9%) patients in the CCAB group. Similar results were observed in the incidence of ST segment changes 1 mV. However, the overall inotropic requirement was significantly higher in the CCAB group as was the requirement for postoperative temporary pacing (Table 3).

There was no difference in total blood loss in the two groups. Transfusion requirements, however, were significantly lower in the OPCAB group compared to the CCAB group (Table 3). Only five (6.7%) OPCAB patients required a red cell transfusion compared to 80 (25.6%) CCAB patients and this represented a nearly four-fold difference. No OPCAB patients received either platelets or fresh frozen plasma, compared with 15 (4.8%) CCAB patients requiring a postoperative platelet transfusion and three (1%) requiring fresh frozen plasma.

There were minimal differences between the two groups in the periods of ventilatory support required, and ICU and HDU length of stay. Total postoperative hospitalization was significantly shorter in the OPCAB group (Table 3).

At 24 months follow-up actuarial survival was 94.1±1.7% and 97.7±2.3% in the CCAB and OPCAB groups, respectively (P=0.36) (Fig. 1b).

	4. Discussion

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

 
OPCAB surgery although first described more than 30 years ago [18] was subsequently abandoned following the development of CPB. The deleterious effects of CPB, however, have prompted a renewed interest in beating heart coronary revascularization and OPCAB surgery has been shown to confer significant advantages in terms of morbidity and cost when compared to conventional coronary artery bypass grafts (CABG) [8–11]. Moreover, evidence is now emerging to suggest that both elderly and high-risk patients may benefit preferentially from OPCAB procedures [12,13].

The renewed interest in OPCAB surgery is due, in part, to recent technical advances as well as the appreciation that it is possible to adequately expose the coronary arteries and so achieve complete myocardial revascularization [16,17]. In particular, the use of stabilizers to steady the heart and intra-coronary shunts to permit continued myocardial perfusion during construction of the distal anastomoses (both routinely used at our institution) have contributed to the increasing acceptance of OPCAB techniques. Initial concerns regarding the inaccessibility of the circumflex and obtuse marginal vessels have proven unfounded.

However, the presence of critical LMS disease has been considered a relative contraindication to OPCAB surgery due to concerns over the well-demonstrated haemodynamic changes that occur during displacement of the heart [19]. Recently, however, two groups have reported encouraging preliminary data with OPCAB for patients with LMS stenosis [20,21].

The results of the present study suggest that myocardial revascularization in the presence of critical LMS stenosis can be safely and effectively achieved using OPCAB techniques. We observed lower rates of morbidity in the OPCAB patients compared to CCAB patients. In particular, OPCAB patients required less postoperative inotropic support, less temporary pacing, lower postoperative transfusion requirements and had a reduced incidence of postoperative chest infections compared to the CCAB group. The reduced requirement for blood transfusions in the OPCAB patients, despite similar total postoperative blood loss, may be due to greater haemodilution and/or increased intraoperative blood loss which would be expected in the CCAB patients. The relatively small sample size in the present study remains a limiting factor preventing a detailed analysis of the various subgroups and it is possible that with further experience these differences will become more apparent.

One further limitation to the present study is that it is a non-randomized, retrospective study comparing outcome in patients undergoing either OPCAB or CCAB procedures. However, all of the procedures were conducted within a single institute in similar numbers by senior surgeons during an identical time period and the data were collected prospectively. Additionally, comparison of preoperative demographic and risk factors demonstrated that the two cohorts were well-matched.

There was a statistically significant difference in the numbers of grafts performed in the two groups. Thus, CCAB patients received on average 0.5 more grafts per patient when compared to the OPCAB patients. This difference is unlikely to be due to ‘incomplete revascularization’ in the OPCAB patients for two reasons. First, OPCAB patients had significantly less extensive coronary artery disease compared to the CCAB patients (when extent was measured by the number of coronary vessels with 50% stenosis) and, second, the OPCAB group received proportionately less grafts to the circumflex region when compared with the CCAB group (70.7% vs. 86.2%, respectively). This is likely to be a reflection of our growing experience with the technique of OPCAB surgery in critical LMS stenosis (Fig. 1). In the early phase of our experience it is likely that patients with technically difficult circumflex branches requiring grafts were considered more suitable for CCAB rather than OPCAB surgery. The decision towards an OPCAB or CCAB procedure was made at the time of surgery and was based upon the preference of the individual senior surgeon according to his degree of proficiency with the OPCAB technique. The number of patients with LMS stenosis undergoing OPCAB surgery in our institute was relatively low in 1996 (2.0% of the total) but increased to 57.6% in the first quarter of 2000 reflecting our increasing experience in this procedure.

Our current strategy is to perform all coronary artery bypass grafts using OPCAB surgery unless compelled to do otherwise by electrical or haemodynamic instability. The degree of LMS stenosis, the presence of concomitant right coronary artery disease or the presence of impaired left ventricular function are not considered contraindications to OPCAB. The grafting strategy is the same as for any OPCAB case where the LAD is grafted first and the circumflex last.

In summary, the results of this study suggest that patients with critical LMS stenosis can safely undergo myocardial revascularization using OPCAB techniques and that both early and intermediate results compare very favourably to those obtained using conventional coronary artery bypass techniques.

	References

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

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mark Yeatman Massimo Caputo Franco Ciulli Gianni D. Angelini Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yeatman, M. Articles by Angelini, G. D. Search for Related Content PubMed PubMed Citation Articles by Yeatman, M. Articles by Angelini, G. D. Related Collections Minimally invasive surgery