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Eur J Cardiothorac Surg 2001;19:245-248
© 2001 Elsevier Science NL

Outcome of non-elective coronary artery bypass grafting without cardio-pulmonary bypass

David Varghese, Magdi H. Yacoub, Richard Trimlett, Mohamed Amrani

Department of Cardiothoracic Surgery, Harefield Hospital, London, UK

Received 24 July 2000; received in revised form 27 November 2000; accepted 30 December 2000.

Corresponding author. Harefield Hospital, Hill End Road, Middlesex, UB9 6JH, UK. Tel.: +44-1895-828550; fax: +44-1895-828992
e-mail: mr.amrani{at}rbh.nthames.nhs.uk


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 References
 
Objectives: There is limited experience in the use of beating heart coronary artery bypass grafting (CABG) in emergency and urgent cases. The aim of this study was to retrospectively assess the safety and efficacy of this technique when used in a non-elective setting. Methods: We retrospectively reviewed all urgent and emergency cases of coronary artery bypass grafting performed without cardiopulmonary bypass (CPB) from July 1999 to February 2000. There were 35 patients in total. The mean age was 64.8±11.9. Twenty-six (74.3%) patients had Canadian Cardiovascular Society grade 4 angina. Twenty-six patients (74.3%) had triple vessel disease. Eleven patients (31.4%) were on preoperative IV nitrates and nine patients (25.7%) had a preoperative IABP (intra aortic balloon pump). Three patients (8.6%) had suffered a preoperative cardiac arrest during coronary angiography. Other associated significant risk factors were smoking (60%), hypertension (40%), hypercholesterolemia (57.1%) and previous Q wave myocardial infarction (31.4%). Results: Twenty-two patients (62.9%) were classified as being urgent and 13 patients (37.1%) were classified as emergencies. The mean number of anastomoses performed were 2.8±0.8 (range 1–4) with 68.6% of patients under going triple or quadruple vessel grafting. All patients (100%) received at least one arterial graft. There was no conversion to cardiopulmonary bypass. The main postoperative complications were – supraventricular arrhythmias eight (22.9%), low cardiac output seven (20%) and postoperative HF/dialysis two (5.7%). The median postoperative intensive care unit (ICU) stay was 27.5 h. The mean postoperative hospital stay was 8.3±3.1 days.One patient died (2.9%) at the eighth day after surgery due to postoperative myocardial infarction, multi-organ failure secondary to the septicaemia and ventricular arrest. Conclusion: Non-elective CABG without CPB is feasible and safe with modern cardiac stabilization devices.

Key Words: Coronary artery bypass grafting • Off pump • Non-elective


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 References
 
Coronary artery bypass grafting (CABG) without the use of cardioplegia and cardiopulmonary bypass (CPB) with their attendant risks [1] is now an accepted method of myocardial revascularization [2]. The advent of modern cardiac tissue stabilization devices has enabled cardiac surgeons to accurately construct anastomosis on the beating heart [3]. About 20% of all CABG are now are performed on the beating heart [4] and it is becoming increasingly popular because of the theoretical advantages over CPB and its cost containment [5].

However, there are very few studies that show its effectiveness in a non-elective setting. The aim of this study was to review the outcome of all the urgent and emergency CABG procedures performed without CPB.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 References
 
2.1. Study variables and definitions
All data was retrospectively analyzed from our computerized database. Operations were classified as urgent if they had not been scheduled for routine admission from the waiting list but still requiring surgery on the current admission for medical reasons and cannot be sent home without surgery. Emergency admissions are defined as those with either ongoing refractory cardiac compromise in whom there should be no delay in surgical intervention irrespective of the time of day or those patients requiring cardiopulmonary resuscitation en-route to the operating theatre prior to anaesthetic induction [4].

The Canadian Cardiac Society (CCS) for angina and the New York Heart Association (NYHA) score for dyspnea were used for classification of cardiac disease. The number of diseased vessels and the left ventricular function were based on angiographic findings. Left ventricular function was defined as ‘good’ if the left ventricular ejection fraction was greater than or equal to 50%, ‘fair’ if the left ventricular ejection fraction was between 30 and 49% and ‘poor’ if the left ventricular ejection fraction was <30%.

Myocardial infarction post operatively was based on ECG (new Q waves, ST segment depression, deep T wave inversions) and enzymatic changes (CK levels over 1000 U/l with a CK-MB over 80–100 IU/ml). Low cardiac output was defined as those patients needing inotropes on leaving theatre, or commenced in the ICU (intensive care unit) (<5 µg/kg per mm of dopamine was excluded) or those patients needing an intra-aortic balloon pump or a VAD (ventricular assist device) at any stage in the post operative course. Postoperative mortality was defined as death occurring within the initial postoperative hospitalization and within 30 days of surgery. All definitions were obtained from the UK National Adult Cardiac Surgical Database (1998) [4].

2.2. Patient Population:
It has been our practice to perform all isolated coronary artery bypass grafting without cardiopulmonary bypass since July 1999. There was no patient selection. Between July 1999 and February 2000 117 patients underwent isolated coronary artery bypass grafting. Of these, 35 patients underwent urgent or emergency coronary artery revascularization.

2.3. Patient characteristics
There were 23 males and 12 females, with a mean age of 64.8±11.9 years (range 32–94). Forty-three percent were 70 years and/or older. Notable risk factors included smoking (60%), hypertension (40%), hypercholesterolemia (57.1%) and previous Q wave myocardial infarction (31.4%). Of these 11 patients (31.4%), three patients (8.6%) had a myocardial infarction in less than 6 h, one patient (2.9%) between 6 and 24 h, two patients (5.7%) between one and 30 days, and one patient (2.9%) greater than 6 months. Twenty-six patients (74.3%) had unstable angina on admission. Sixteen patients (45.7%) had class two or class three symptoms of dyspnea. Twenty-six patients (74.3%) had triple vessel disease.

Eleven patients (31.4%) were on preoperative intravenous nitrates. Nine patients (25.7%) had insertion of preoperative intra aortic balloon pump (IABP) for on going cardiovascular compromise. Three patients had a preoperative cardiac arrest following failed PTCA/Stent.

Other relevant preoperative characteristics are found in Table 1.


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  		Table 1. Preoperative characteristicsa,b

 
2.4. Operative methods
Operations were performed via a full median sternotomy except in one patient who had a minimally invasive direct coronary artery bypass grafting via an anterior thoracotomy (MIDCAB). Standard conduit harvesting and specialized anaesthetic techniques were used. Cardiac stabilization was achieved using the Octopus suction device. Cardiopulmonary bypass was readily available for all cases to enable conversion at any time. A non-primed bypass circuit was available in the operating room with a perfusionist in theatre. The graft to the left anterior descending (LAD) artery was performed first. This was always followed by the right coronary artery graft. The grafts to the circumflex artery (Cx) were performed last. The sequence of coronary artery grafting is important to achieve optimal myocardial perfusion. The left internal thoracic artery (LIMA) to the LAD graft is performed first as it stabilizes a large mass of myocardium and produces the least hemodynamic compromise. With the anterior wall and septum already revascularized the myocardium is better able to withstand further hemodynamic compromise. The approaches to the posterior and lateral wall were achieved by verticalization of the heart. This was best achieved by anchoring a 2/0 silk stitch onto the posterior pericardium between the lower left pulmonary vein and the inferior vena cava. The right pleura was sometimes opened to avoid compression of the heart against the right sternal edge.

2.5. Statistical analysis
Data are summarized by frequencies and percentages for the categorical factors and as means, standard deviations, minimums and maximums for the continuous factors. Values are expressed as percentages or as mean±SD except the mean ICU stay, which is expressed as a median value.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 References
 
3.1. Operative results
Thirteen patients (37.1%) had emergency surgery and 22 patients (62.9%) had an urgent procedure. A total of 98 anastomoses (including the sequential) were done in the 35 patients. The mean number of grafts was 2.8±0.8 with a range of 1–4. Two patients (5.7%) received one graft, nine (25.7%) received two, 18 (51.4%) received three and six patients (17.1%) received four grafts. The vessels commonly grafted were the mid LAD (27 grafts), right coronary artery–posterior descending artery (RCA-PDA) (21 grafts) the Int/OM1 (12 grafts) and the OM2 (10 grafts). The RCA was grafted with the radial artery and the mid LAD was mainly anastomosed with the pedicled LIMA in most cases. The vessels grafted and the conduits used are shown in Table 2. There were nine sequential grafts (seven patients had one graft each and one patient had two grafts). Of these four were to the LAD/diagonal and five to the circumflex/PDA territory. The pedicled LIMA was used as a sequential graft in two cases, the radial artery in one and the long saphenous in six cases. All the patients (100%) received at least one arterial graft. Our preference is to perform total arterial revascularization in those aged 70 years and younger and this was achieved in 77.3% in the relevant age group. This was because of relative contraindications to the use of the second internal thoracic artery as in some insulin dependent diabetics, previous radiotherapy and long-term corticosteroid use. Where the Allen's test indicated inadequate collateral ulnar flow the radial artery was not harvested. In these cases the saphenous vein was used.


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  		Table 2. Vessels grafted and conduits useda

 
There was no conversion to cardiopulmonary bypass. Two patients needed intraoperative IABP (5.7%).

3.2. Postoperative complications
The main postoperative complications are as follows: supraventricular arrhythmias eight (22.9%), myocardial infarction one (2.9%) and low cardiac output seven (20%). Of the seven patients having postoperative low cardiac output, six patients had surgery for triple vessel disease, and five of those patients needed emergency surgery. One patient had a transient stroke with complete recovery before discharge from hospital. Two (5.1%) patients needed dialysis for treatment of renal failure.

Twenty-eight patients (80%) were extubated in less than 24 h and six (17.1%) were extubated between 24 and 48 h. One patient had to be ventilated for >5 days for multi system failure. The median length of stay in the ICU was 27.5 h. The mean postoperative hospital stay was 8.3±3.1 days.

There was one postoperative mortality (2.9%). The patient died on the eighth postoperative day following a ventricular fibrillation (VF) cardiac arrest and multi system failure. This patient also had postoperative myocardial infarction, low cardiac output, pulmonary oedema, and renal failure requiring dialysis. The main postoperative complications are given in Table 3.


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  		Table 3. Post operative resultsa,b

 
At the sixth week follow-up all patients were clinically well with no reported angina or shortness of breath and with no new changes in the ECG's.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
References
 
The present retrospective study showed that emergency and urgent myocardial revascularization can be performed safely with good immediate outcome without any exclusion criteria.

Coronary artery revascularization without cardiopulmonary bypass has been used safely in selected groups of patients [1–3,6,7] It is becoming increasingly popular because of the theoretical advantage of avoiding cardiopulmonary bypass. In series of elective cases this technique has been shown to be associated with low perioperative complications [8] and a better postoperative recovery [3,9]. Short-term follow-up has also been reported to be excellent [10,11]. It has been suggested as an ideal technique for high-risk patients [12].

Non-elective CABG without CPB has been reported previously in limited number of patients with some degree of selection [8,9,13–15]. When the cases have been selected, it has been shown that the postoperative recovery period for non-elective cases of beating heart surgery is similar to that of elective cases [13]. This is comparable with our case series, where there has been no case selection.

The most challenging aspect in those patients is to avoid tipping the balance toward more instability. We believe that this problem can be avoided by maintaining a systolic pressure above 100 mmHg, by routinely shunting the target vessel and by first grafting the vessels that requires minimal manipulation of the heart, i.e. the LAD followed by the RCA.

Our case series had no patient selection and all non-elective cases within the time frame specified were operated on by this technique. The postoperative mortality of beating heart surgery in elective selected cases ranges from 1.4 [4] to 2.5% [2]. The early mortality (2.9%) as well as clinical outcome of our series of non-selective emergency and urgent compared very favorably with previous reports of emergency coronary artery bypass with CPB where the early mortality ranged from 4 [16] to 39.3% [17].

The limitations of this study are that it is retrospective, the lack of medium term follow up and lack of postoperative angiography. However, we would like to point out that though the follow up is based on clinical evidence, the vast majority of patients undergoing CABG do not undergo routine postoperative angiography unless their clinical symptoms have not resolved. All patients continue to be followed up by the referring cardiologists and to our knowledge no patients have been referred back or required further intervention for recurrence of angina.

In conclusion, CABG without CPB in a non-elective setting is feasible and can be performed safely without prior patient selection. We do not at this stage aim to show the superiority of off-pump surgery, but merely that it is feasible. A definitive conclusion warrants a randomized-controlled trial.


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

  1. Pym J. Off-pump arterial grafting: 125 cases using the Medtronic-Utrecht octopus. Eur J Cardio-thorac Surg 1999;16(Suppl. 1):S88-S94.[Abstract/Free Full Text]
  2. Buffolo E., de Andrade C.S., Branco J.N., Teles C.A., Aguiar L.F., Gomes W.J. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thoracic Surg 1996;61(1):63-66.[Abstract/Free Full Text]
  3. Bredee J.J., Jansen E.W.L. Coronary artery bypass grafting without cardiopulmonary bypass. Curr Opin Cardiol 1998;13:476-482.[Medline]
  4. Wiklund L., Radberg G., Berglin E. Bypass surgery on beating heart without heart-lung machine. A new technique revitalises an old method. Lakartidningen 1999;96(48):5363-5365.[Medline]
  5. Buffolo E., Gerola L.R. Coronary artery bypass grafting without cardiopulmonary bypass through sternotomy and minimally invasive procedure. Int J Cardiol 1997;62(Suppl. 1):S89-S93.
  6. Barriuso Vargas C., Mulet Melia J., Ninott Sugranes S., Sureda Barbosa C., Bahamonde Romano J.A., Castella Pericas M. Coronary surgery without extracorporeal circulation and Octopus cardiac stabilizer. Rev Esp Cardiol 1999;52(9):741-744.[Medline]
  7. Tasdemir O., Vural K.M., Karagoz H., Bayazit K. Coronary artery bypass grafting on the beating heart without the use of extracorporeal circulation: review of 2052 cases. J Thoracic Cardiovasc Surg 1998;16(1):68-73.
  8. Tezcaner T., Catav Z., Yorgancioglu C., Moldibi O., Suzer K., Zorlutana I.Y. Coronary artery bypass surgery without cardiopulmonary bypass. Cardiovasc Surg 1998;6(2):139-144.[Medline]
  9. Ardehali A., Kessler D., Foroushani F., Laks H. Multivessel coronary artery bypass surgery without cardiopulmonary bypass. Am Heart J 1999;138(5 Pt 1):983-986.[Medline]
  10. Cartier R. Systematic off-pump coronary artery revascularization: experience of 275 cases. Ann Thoracic Surg 1999;68(4):1494-1497.[Abstract/Free Full Text]
  11. Turner W.F. "Off-pump" coronary artery bypass grafting: the first one hundred cases of the Rose City experience. Ann Thoracic Surg 1999;68(4):1482-1485.[Abstract/Free Full Text]
  12. Pompilio G., Antona C., Cannata A., Lotto A., Alamanni F., Gelpi G., Tartara P., Biglioli P. Coronary surgery without extracorporeal circulation: the short-term results in high-risk patients. J Cardiol 1999;29(3):246-254.
  13. Hirose H., Amano A., Yoshida S., Nagao T., Sunami H., Takahashi A., Nagano N. Emergency off-pump coronary artery bypass grafting under a beating-heart. Ann Thoracic Cardiovasc Surg 1999;5(5):304-309.
  14. Go R., Mori K., Abe T., Kohyama A., Kataoka Y., Bandoh M. Coronary artery bypass grafting on the beating heart in patients with severe cardiac dysfunction; on the necessity of cardiopulmonary bypass. Masui 1997;46(9):1209-1214.[Medline]
  15. Spooner T.H., Dyrud P.E., Monson B.K., Dixon G.E., Robinson L.D. Coronary artery bypass on the beating heart with the Octopus: a North American experience. Ann Thoracic Surg 1998;66(3):1032-1035.[Abstract/Free Full Text]
  16. Greene M.A., Gray L.A., Jr, Slater A.D., Ganazel B.L., Mavroudis C. Emergency aortocoronary bypass after failed angioplasty. Ann Thoracic Surg 1991;1(2):194-199.
  17. Murakami T., Fujiwara T., Fukuhiro Y., Tabuchi A., Ishida A., Endoh K., Kikugawa D., Masaki H., Inada H., Morita I. Long-term results of emergency coronary artery bypass grafting. Jpn Heart J 1996;37(4):447-453.[Medline]



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