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Eur J Cardiothorac Surg 2001;20:908-912
© 2001 Elsevier Science NL

Multivessel off-pump coronary artery bypass surgery in the elderly

Philippe Demers, Raymond Cartier

Department of Surgery, Montreal Heart Institute, Research Center, 5000 Bélanger Street East, Montreal, Quebec, Canada, H1T 1C8

Received 5 June 2001; received in revised form 23 July 2001; accepted 17 August 2001.

Corresponding author. Tel: +1-514-376-3330, ext. 3715; fax: +1-514-376-1355
e-mail: rc2910{at}aol.com


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Comments
 References
 
Objective: Coronary artery bypass grafting in the elderly patient is associated with increased perioperative morbidity and mortality. The avoidance of cardiopulmonary bypass (CPB) in this population is potentially beneficial. We examined our initial experience with off-pump multivessel coronary artery revascularization in patients aged 70 years and older. Methods: In a consecutive series of 300 off-pump coronary artery bypass (OPCAB) operations performed by a single surgeon between 1996 and 1999, 98 patients were aged 70 years and older. These patients were compared with a consecutive cohort of 497 patients aged 70 years and older operated on with CPB in the same institution from 1995 to 1996, period where OPCAB surgery was not performed in our institution. Results: Patients in the beating heart group were older (75±4 vs. 74±3 years; P=0.001). Gender distribution and other preoperative risk factors were comparable for the two groups. On average, 3.0±0.8 and 2.8±0.7 grafts per patient were completed in the OPCAB and the CPB groups, respectively (P=0.007). Perioperative mortality rates (OPCAB group, 3.1%; CPB group, 3.6%), perioperative myocardial infarction (OPCAB, 2.0%; CPB, 5.1%) and neurologic events (OPCAB, 1.0%; CPB, 3.2%) were comparable for the two groups. The incidence of postoperative atrial fibrillation was lower in the OPCAB group (42 vs. 54%; P=0.05). The need for allogenic blood transfusions was significantly less in the OPCAB group (53 vs. 82%; P=0.001). Conclusions: In patients aged 70 years and older, multivessel OPCAB surgery is associated with lower rates of postoperative atrial fibrillation and reduced transfusion requirements. Multivessel OPCAB in the elderly patient is an acceptable alternative to procedures performed with CPB.

Key Words: Off-pump coronary artery bypass • Elderly • Coronary surgery


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Comments
 References
 
Coronary artery bypass grafting (CABG) surgery is performed in an increasing number of patients aged 70 years and older. Despite a decrease in perioperative mortality over the last two decades in CABG surgery [1,2], age is still an independent risk factor for morbidity and mortality [2]. Elderly patients undergoing myocardial revascularization have an increased incidence of comorbid conditions and a diminished physiologic reserve, leading to increased perioperative complications and resource utilization [3]. Specifically, the risk of neurologic events is higher in patients over the age of 70 years [4]. Despite the increase in perioperative morbidity and mortality, favorable long-term results after coronary artery bypass grafting (CABG) in patients over 70 years of age can be expected [5].

Less invasive cardiac surgical procedures are gaining increased interest in the surgical community. Multivessel off-pump coronary artery bypass (OPCAB) surgery has been made possible by the development of innovative techniques and various stabilization systems [6,7]. Multivessel OPCAB operations have been shown to reduce perioperative morbidity, transfusion requirement, and postoperative length of stay, especially in high-risk patients, including patients aged 70 years and older [8–13]. Avoidance of cardiopulmonary bypass (CPB) and minimization of aortic manipulations might be particularly beneficial to the elderly patients considering their higher incidence of ascending aortic atherosclerosis [14]. This report describes our initial experience with multivessel OPCAB in patients aged 70 years and older.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Comments
 References
 
Between September 1996 and January 1999, 300 consecutive OPCAB operations were performed by a single surgeon (R.C.). This represented 95% of the myocardial revascularization caseload during the same period. In this group, 98 patients were aged 70 years and older. These patients were compared to a control cohort of 497 consecutive patients aged 70 years and older, operated with CPB by all cardiac surgeons (six surgeons including the author) at the Montreal Heart Institute in 1995 and 1996. The control cohort was selected from an earlier period to have a representative, unselected group of patients operated with CPB, before the beginning of off-pump procedures. After 1996, a significant number of coronary revascularizations were performed off-pump at our institution, resulting in a selection bias. All salvage procedures, defined as unstable hemodynamics or severe ischemia that could not be stabilized preoperatively, were excluded in both groups. The only contraindications for the OPCAB procedure were a deep intramyocardial left anterior descending artery (LAD) and a preoperative unstable hemodynamics.

2.1. Off-pump surgical technique
The technique used has already been described in detail in Refs. [7,8]. In brief, all the procedures were performed through a median sternotomy under general anesthesia with narcotics, benzodiazepines, and muscle relaxants. Arterial hypotension and electrocardiographic ST-segment depression were treated with alpha-agonists and nitroglycerin, respectively, to maintain hemodynamic stability. The distal right coronary artery (RCA) and the LAD were directly accessed with minimal heart manipulation. The posterior descending artery (PDA) and the obtuse marginal artery were accessed by more extensive mobilization of the posterior pericardium and rotation of the operating table. For the circumflex territory, four pericardial traction sutures were positioned below the phrenic nerve and between the left pulmonary veins and the inferior vena cava. Vessel occlusion was achieved through external encircling with rubber bands (Retract-O-Tape; Quest Medical Inc., Allen, TX, USA). No intraluminal occlusive device, shunt, or gas insufflation was used. Coronary artery immobilization was achieved with a reusable mechanical stabilizer (CorVasc System; CoroNéo Inc., Montreal, Canada).

2.2. Strategy of revascularization
The vessel with the most critical lesion, in either the LAD or the RCA territory, was revascularized first. The PDA was generally favored over the distal RCA to minimize the risk of ischemic transient atrioventricular block. The circumflex territory was revascularized after the anterior and inferior territories have been grafted. All proximal anastomoses were completed during a single partial clamping of the aorta to minimize aortic manipulation.

2.3. Statistics
Continuous variables are expressed as mean±standard deviation, while categorical variables are presented as percentages. Continuous variables were analyzed by analysis of variance and categorical variables were analyzed using either {chi}2 or Fisher's exact test. For data presenting skewed distribution, results are expressed as the median and 25th and 75th percentiles, and the Kruskal–Wallis test was used. Statistical significance was assumed at P=0.05.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Comments
 References
 
3.1. Demographics
Patients in the OPCAB group were older, 75±4 years compared to 74±3 years in the CPB group (P=0.005). There were no differences in the gender distribution, incidence of diabetes mellitus, arterial hypertension, and chronic obstructive pulmonary disease (Table 1). Furthermore, the incidence of unstable angina, left main disease, and left ventricular dysfunction (left ventricular ejection fraction (LVEF) <40%) was similar in the two groups. Preoperative intraaortic counterpulsation (IAC) was used in 15 and 5% of the patients in the OPCAB and CPB groups, respectively (P=0.003). This difference was mainly due to the more aggressive use of IAC by interventional cardiologists of our institution in the more recent years. Finally, the incidence of reoperation was the same in both groups, 7% (P=ns). Parsonnet score was 17±8 in OPCAB patients.


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  		Table 1. Preoperative demographicsa

 
3.2. Perioperative technical data
The average number of grafts per patient was significantly higher in the OPCAB group compared to the CPB group (3.0±0.8 vs. 2.8±0.7, P=0.007). This difference is reflected in the graft distribution of the two groups (Table 2). Ischemic time was 28±11 min in OPCAB (summation of all regional ischemia) and 44±17 min in CPB cases (P=0.001). The rate of complete revascularization achieved in the off-pump group was 91%, circumflex territory was grafted in 62% of the patients, which is comparable to what has been reported with standard technique in our institution [8]. No OPCAB patient necessitated conversion to CPB. No intraoperative conversion to CPB was necessary in this series of off-pump operations. There was no difference in the use of internal thoracic artery graft between the two groups (Table 3). The lower rate of saphenous vein graft utilization in the OPCAB group was explained by the use of the radial artery in 8% of these patients. Coronary endarterectomies were completed in 7% of the off-pump group.


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  		Table 2. Graft distribution

 

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  		Table 3. Vascular conduitsa

 
3.3. Perioperative bleeding and transfusion requirements
Perioperative blood loss was significantly lower in the OPCAB group (Table 4). A significant reduction in the proportion of patients requiring allogenic blood transfusion was observed in the OPCAB group (53 vs. 82%; P=0.001). However, among the patients who received blood products, the number of red cell packs and total blood products were the same in both groups.


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  		Table 4. Postoperative bleeding and transfusion needa

 
3.4. Hematology and biochemistry
These two profiles are presented in Table 5. Despite a lower preoperative mean value, the postoperative and discharge hemoglobin values were higher in the OPCAB group. The postoperative creatinine serum level increased more in the CPB group. The average creatine kinase MB (CK-MB) values were significantly lower in the OPCAB group on the day of surgery and the following day.


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  		Table 5. Hematology and biochemistrya

 
3.5. Perioperative morbidity and mortality
The perioperative mortality rate was 3.1 and 3.6% in the OPCAB and CPB groups, respectively (P=ns). Causes of death in the OPCAB group (three patients) were as follows: multiorgan failure in one patient, type A aortic dissection in one patient, and sudden death in one patient. The incidence of the most common perioperative complications are listed in Table 6. The incidence of myocardial infarction (either a maximal CK-MB value >100 IU/l, any new abnormal wall motion on ultrasound or a positive pyrophosphate radionuclide scan) was equivalent in both groups. The incidence of atrial fibrillation was reduced in the OPCAB group. The lower use of postoperative intraaortic balloon pump (IABP) in the OPCAB group reflected the increased proportion of patients with a preoperative IABP in this group. Interestingly, the incidence of a neurologic event was similar in the two groups. Pulmonary complications occurred in 11 and 5% of the patients of the OPCAB and CPB groups, respectively, and this difference was statistically significant. Finally, a shorter postoperative hospital stay was observed in the OPCAB group.


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  		Table 6. Perioperative morbidity and mortalitya

 

   4. Comments
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Comments
References
 
Technical improvements, better stabilization, and increasing experience have increased the number and the safety of coronary revascularization procedures performed on the beating heart. Less invasive multivessel OPCAB operations may be of particular benefit in high-risk patients, including the elderly. The avoidance of CPB is associated with a lower inflammatory response [15,16] and a lower degree of myocardial injury [17,18]. Recent series have documented a lower release of S100ß protein and a lower incidence of high intensity transient signals with transcranial Doppler monitoring with improved early neurocognitive functions [19,20]. However, other studies failed to show any improvement in neurologic or neuropsychologic outcomes with the avoidance of CPB at long term [21], although, some significant benefits have been observed early on after surgery [20,21]. A decreased rate of renal dysfunction was observed in a prospective randomized study comparing on-pump vs. off-pump operations in an unselected population [22]. Moreover, numerous series have shown that perioperative blood loss and the need for allogenic blood products are reduced with the avoidance of CPB [8,9,23,24]. Minimization of aortic manipulation, with avoidance of aortic cannulation and aortic cross-clamping may reduce atheromatous embolization in patients with atherosclerosis of the ascending aorta. In selected cases, OPCAB with arterial conduits, composite grafts (Y or T grafts), and alternative sites for proximal anastomoses allows complete revascularization with elimination of aortic manipulation [14,25].

In the present study, we compared two groups of patients aged 70 years and older undergoing multivessel CABG operations with and without CPB. The patients in the OPCAB group were older but other preoperative risk factors were comparable in the two groups. Patients in the OPCAB group were more likely to have a preoperative IAC, resulting from a more aggressive use of IABP by interventional cardiologists in the recent years. The mean number of grafts per patient was higher in the OPCAB group, and complete revascularization was achieved in 91% of these patients despite the avoidance of CPB. Also, there was no conversion to CPB in these consecutive series of 98 off-pump operations in elderly patients.

Perioperative mortality rates were low and comparable in the OPCAB and CPB groups. The incidence of postoperative myocardial infarction, need for inotropic support, and neurologic event, was not significantly reduced with the elimination of CPB. The reduced need for postoperative IABP in the OPCAB group likely reflected the increased incidence of preoperative IABP in these patients. Interestingly, the incidence of atrial fibrillation was significantly reduced with the avoidance of CPB. The significant increase in pulmonary complications (intubation for >24 h, atelectasis, or pneumothorax) in the OPCAB group may be related to the placement of deep pericardial sutures associated with inadvertent lung laceration. To minimize this potential complication, it is important to deflate the lung during this maneuver and to keep sutures as superficial as possible. Patients in the OPCAB group had reduced intraoperative blood loss and a need for allogenic blood products compared to the CPB group, despite a lower preoperative hemoglobin concentration and a comparable value at the time of discharge. Moreover, postoperative CK-MB release and serum creatinine concentration were both significantly reduced in the OPCAB group, suggesting a better myocardial preservation and a lower degree of renal injury with avoidance of CPB. The difference in postoperative length of stay is difficult to interpret due to the fact that the CPB cohort was chosen from a non-contemporary period and with recent trend toward early discharge from the hospital.

Low mortality rates comparable with those after conventional on-pump revascularization have been reported after off-pump operations in elderly patients [9–12]. Recently, lower rate of neurologic events (0 vs. 9.3%, P<0.05) was observed in octogenarians undergoing coronary artery surgery without CPB compared to CABG with CPB [26]. However, other studies, in accordance to our results, failed to show any improvement in neurologic outcome with off-pump operations in the elderly. A more aggressive approach toward multivessel OPCAB with avoidance of aortic manipulation using multiple arterial conduits, composite grafts, or alternative sites for proximal anastomoses may be the solution to reduce atheromatous embolization and central nervous system morbidity in elderly patients. As suggested by our results, a reduction in the incidence of atrial fibrillation in elderly patients undergoing off-pump operations was also observed in two recent series [10,27], although other investigators failed to show any difference [11]. Minimal right atrial and aortic fat pad manipulations with off-pump operations may, at least partially, explain this reduction in the incidence of atrial fibrillation. Finally, in accordance with our results, a significant reduction in the need for allogenic blood transfusions was observed in several series of elderly patients undergoing revascularization without CPB [9–11].

The present study has several limitations. First, the cohort of patients undergoing OPCABG were compared to a non-contemporary cohort of patients operated with CPB. This might obscure the comparison between the two groups in terms of postoperative length of stay given the trend toward earlier discharge from the hospital in the recent years. Second, despite that there were no major differences in preoperative risk factors between the two groups, confounding factors such as the non-randomized nature of the study and the fact that patients in the two groups were not operated by the same surgeon, may have resulted in differences between the two study groups. A prospective, randomized study in elderly patients comparing coronary revascularization with and without CPB would help to confirm benefits of OPCABG.

Some areas of caution concerning OPCAB deserve mention. First, we found that patients with a moderately dilated ascending aorta (4.0–4.5 cm) do not tolerate aortic side-clamping well, which is likely to lead to aortic dissection. One patient suffered aortic dissection 2 weeks after an off-pump procedure and died during the surgical attempt to correct the dissection. This patient had a moderately dilated aorta. Also, in cases of reoperation in the presence of patent vein grafts, aortic side-clamping may lead to severe hemodynamic instability, and the surgeon has to rely on internal thoracic arteries or alternative sites for proximal anastomoses.

In conclusion, multivessel OPCABG in the patients aged 70 years and older is an acceptable alternative to conventional CABG with CPB, provided an adequate technique for heart positioning and coronary stabilization. In these patients, multivessel OPCAB is associated with comparable mortality and a reduction in the incidence of atrial fibrillation and in the need for allogenic blood transfusions.


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

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H. Shennib, M. Endo, O. Benhamed, and J. F. Morin
Surgical revascularization in patients with poor left ventricular function: on- or off-pump?
Ann. Thorac. Surg., October 1, 2002; 74(4): S1344 - 1347.
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K.-B. Kim, C. H. Kang, W.-I. Chang, C. Lim, J. H. Kim, B. M. Ham, and Y. L. Kim
Off-pump coronary artery bypass with complete avoidance of aortic manipulation
Ann. Thorac. Surg., October 1, 2002; 74(4): S1377 - 1382.
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