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Eur J Cardiothorac Surg 2002;21:36-40
© 2002 Elsevier Science NL

Off-pump coronary artery bypass surgery in the left ventricular dysfunction

Sadik Eryilmaz*, Tümer Çorapçioglu, Neyyir Tuncay Eren, Levent Yazicioglu, Kaan Kaya, Hakki Akalin

Department of Cardiovascular Surgery, Ankara University Faculty of Medicine Hospital, Ankara, Turkey

Received 9 July 2001; received in revised form 18 October 2001; accepted 18 October 2001.

* Corresponding author. Tel.: +90-532-203-8253; fax: +90-312-312-2103
e-mail: sadikeryilmaz{at}hotmail.com


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: The purpose of this study is to report our experience in off-pump coronary artery surgery in patients who have left ventricular dysfunction. Methods: Off-pump coronary artery surgery was performed to 48 patients who were chosen randomly among 265 patients having two or more coronary artery disease and whose ejection fraction (EF) was less than 30%. In these patients fractioned shortening (FS) was evaluated by echocardiography, EF with multiple gated acquisition (MUGA) and ischaemic regions with myocardial perfusion scintigraphy both pre- and postoperatively. Coronary artery angiography was done to all patients at the end of the 1st year and patients were evaluated according to New York Heart Association (NYHA) classification. Results: There were three deaths. The clinical situations of 41 of 45 patients (91.1%) improved after the operation. These four patients who didn't improve in NYHA status were the ones in whom complete revascularization couldn't be done. The FS and EF values were significantly increased at the 1st month, and 1st year. The constant perfusion defects and irreversible damaged areas changed into dynamic myocardial tissue in the 1st year scintigraphies. Discussion: Off-pump CABG can be done with an acceptable mortality and clinic results in patients who have ventricular dysfunction.

Key Words: Off-pump CABG • Left ventricular dysfunction


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Left ventricle function is an essential prognosis determiner in coronary artery surgery [1,2]. Despite the technological improvements in monitorization, techniques of anaesthesia, methods of myocardial protection, operative techniques and novelty and the progress in postoperative care, the mortality in coronary artery surgery with depressive ventricle reaches to 37% [3]. On the other hand, medically treated patients who have two or more coronary artery disease and who has ventricular dysfunction has a worse prognosis than surgically treated ones [4].

Recent studies denoted that the results of coronary artery surgery performed without cardiopulmonary bypass (CPB) in high risk patients who has left ventricular dysfunction is better than the results of on-pump group.

Although it is hard to work on a beating heart, off-pump bypass surgery has important benefits. Especially it does not have the inflamatuary, neurologic and renal effects of CPB. The requirement of blood transfusion and extended ventilator support are less in this technique so the related complications are few.

In this study we prospectively examined the life quality, functional capacity, life expectancy and mortality of off-pump CABG operations in patients who has severe depressive left ventricles and whose ejection fraction (EF) was less than 30%.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
Coronary artery bypass surgery was performed to 1168 patients between January 1997 and February 2001 in our clinic. The EF of these 265 patients, which was angiographically evaluated, was less than 30%. Fractioned shortening (FS) and EF of 48 patients in this group who have three or more vessels disease were measured by echocardiography, MUGA and rest perfusion scintigraphy. The ischaemic areas were evaluated by scintigraphy pre- and postoperatively. Forty-five patients, who were alive at the end of 1st year also evaluated by coronary angiography. Between January 1997 and December 1997, 11 patients; between January 1998 and December 1998, 16 patients; between January 1999 and December 1999, 21 patients were operated and included in this study. All the patients in this group were operated without cardiopulmonary bypass. Patients involved in this study were informed about the study and informed consent was obtained. Instutional Review Board approval was taken.

A total of 29 of the patients were male (60.4%), while 19 were female (39.6%) and the average age was 61±12 (42–76 years). Smoking (72.9%) was the most important risk factor. The other factors were: hypertension (58.3%), old myocardial infarction (75%) and diabetes mellitus (66.6%). The preoperative clinic and demographic data of the patients are shown in Table 1.


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  		Table 1. Clinical and demographical characteristics of patients

 
2.1. Operative technique
Median sternotomy was done to all patients. Left internal thoracic artery (LITA) and saphenous vein grafts of all patients, radial artery from non-dominant arm of four patients and right internal thoracic artery (RITA) of two patients are prepared by standard techniques. To provide a better image in lateral and posterior target vessels, pericardium was tractionized by two or three deep sutures and two sponges were put under the heart. The patient was situated in slightly right lateral decubitus and 20 degree of Trendelenburg position. A non-primed bypass circuit was available in the operating room with a perfusionist in order to enable conversion at any time. We did not use any stabilizator or intraluminary shunt in any operation. During the operation 1–5 mg i.v. beta-blocker (metoprolol) was administered to the patients whose hemodynamic situations were suitable to keep the heart rate between 50 and 60 beats/min. A total of 100 U/kg heparine was administered to the patients to keep activated clothing time (ACT) between 200 and 300 s.

Silicone snare sutures were put to the proximal and distal of the anastomosis when needed, to provide bloodless area during coronary anastomosis and additionally bulldog clamps were used on some patients. In distal anastomosis LITA-left anterior descending artery (LAD) anastomose was performed first, and then the other anastomosis were done. After each distal anastomosis, the proximal anastomosis was performed by using a side clamp. The proximal anastomosis of the radial artery was performed to the ascending aorta. The operative data of the patients are shown in Table 2.


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  		Table 2. Operative data of patients

 
2.2. Follow up
Echocardiography to measure FS (Toshiba 140 A), scintigraphy to examine myocardial perfusion (GE Camstar 4000 I, GE Optima, GE Starcam 3200) and MUGA to evaluate EF (GE Camstar 4000 I, GE Optima, GE Starcam 3200) were done to all patients preoperatively, at the end of the 1st month and 1st year and every year after the operation. Coronary artery angiography was performed to all alive patients (n=45) at the end of the 1st year. In the clinical evaluation the symptoms of heart failure and anginal complaints were classified according to New York Heart Association (NYHA) both preoperatively and postoperatively.

2.3. Statistical analysis
All data were expressed as the mean±SD. The statistical evaluation of the results has been made according to the t-test for paired samples.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
A total of 28 of 48 patients (58.3%) were NYHA Class III and the other 20 patients (41.6%) were in NYHA Class IV when they enrolled our clinic for operation. In the pursuits, all of the patients were clinically evaluated when they were called for postoperative annual controls and examined by the same doctor. Whereas 19 of 28 (67.8%) previously Class III patients became Class II and five of them Class I, and no change were observed in four patients. Fifteen of 20 (83.3%) Class IV patients became Class II and only two of them (6.6%) to Class III, three patients (10%) in this group died postoperatively. Clinical situations of 41 of 45 patients (91.1%) improved shortly after the operation.

The revascularization was performed to LAD and diagonal arteries of all patients. Right coronary artery (RCA) of 31 patients and circumflex artery (Cx) arteries of 11 patients were revascularized. Totally 138 distal anastomosis were performed, 48 of these were LITA, two were RITA, four were radial artery and 84 of them were sapheneous grafts. The flow of LITA was not suitable for LAD in two patients, sapheneous anastomosis was used for LAD in these patients and two LITAs were anastomosed to the diagonal artery. In six patients total revascularization couldn't be done. Three of the non-vascularized vessels were PDA whereas other three were Cx. One of the six patients to whom complete revascularization couldn't be done, died in the early postoperative period, also there wasn't an improvement in NYHA status in four of these patients.

Intra-aortic balloon pump (IABP) was inserted to five patients (10.4%) before the operation. During the operation we needed to insert IABP to seven patients (14.5%) in whom low cardiac output syndrome developed due to beta-blocker, and to eight patients (16.7%) in the intensive care unit after the operation.

Seven patients (14.6%) were receiving 5–7 µg/kg per min dobutamine, four patients (8.3%) were receiving 6-µg/kg per min dopamine preoperatively. During or after the operation 14 patients (29.1%) were administered 5–7 µg/kg per min dobutamine and seven patients (14.6%) were administered 6–8 µg/kg per min dopamine. Inotropic drug administration was ceased in 3 days time.

The mean FS measured with echocardiography was 12.95% (±1.53) preoperatively, it was 14.6% (±1.54) in the 1st month, which was significantly increased (P<0.001) (t-test for paired samples) (Fig. 1). Mean FS reached to 15.86% in the 1st year and to 16% (±1.9) in the patients who were followed up for 3 years and which was also significant according to preoperative results (P<0.001) (Table 3).



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  		Fig. 1. Left ventricle ejection fraction measured by MUGA and fractioned shortening measured by echocardiography, preoperatively and postoperatively.

 

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  		Table 3. Left ventricle functions of patients (by MUGA and echocardiography)

 
The mean EF measured with MUGA was 24.6% (±3.9) preoperatively, it was observed that the ventricle functions of the patients increased both in the early and late postoperative period and it was 26.9% (±3.1) (Fig. 1) at the end of the 1st month, which was a significant improvement (P<0.001). Mean EF results with MUGA in preoperative period and at the end of the 1st year after the operation can be seen in Fig. 2.



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  		Fig. 2. Ejection fractions measured by MUGA preoperative and postoperative 1st year.

 
The constant perfusion defects and irreversible damaged areas changed into dynamic myocardial tissue with sparse living cells in the 1st year scintigraphies.

At the end of the 1st year, the coronary arteriographies showed LITA occlusion in three patients (graft patency rate 93.3%) and saphenous vein graft occlusion in 14 patients (graft patency rate 83.3 %). Four radial artery grafts and two RITA grafts were patent. When all the grafts were evaluated at the end of the 1st year, 87.7% were patent.

Three of 48 patients (6.25%) died, two of these patients died in postoperative early period in intensive care unit and the other one died due to myocardial infarction in the postoperative 6th month. They were over 70 years old and had diabetus mellitus, hypertension, renal failure and COPD and needed IABP and intensive inotropic support after the operation.

Three patients had postoperative inferior MI. One was the patient who died on the 6th month. Remaining two patients had MI in the postoperative early period. One in the 3rd h, the other on the 7th h. IABP was inserted and both of them recovered with medical and IABP treatment. PDA couldn't be revascularized in one of these two patients.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
It was reported in many studies that the most important determiner of risk factor of coronary artery surgery is EF of left ventricle [5]. Other factors are; old MI [6], age at the time of surgery [6,7] and severity of coronary artery disease [5–7] identified as independent risk factors on survival.

It is observed that the survival of coronary artery surgery was improved in patients who have depressed ventricles [4,8]. Although the side effects of cardiopulmonary bypass are minor and reversible, there can be irreversible or even fatal effects in patients who have ventricular dysfunction. To reduce that kind of complications, off-pump surgery technique was began to be used in these high-risk patients [9,10]. Left ventricular segmental wall motion has been found to be better in patients who underwent beating heart operations, compared with the classic on-pump CABG technique [11]. Nowadays off-pump coronary artery bypass with median sternotomy became more popular even for the multi-vessel diseases [12].

In our study, we measured EF with MUGA to evaluate the left ventricle functions of the patients before the operation. It is found that the postoperative EF results were statistically significant and better when preoperative and postoperative values compared (Fig. 2). It is also observed that preoperative FS results were statistically significant and better similarly in the measurements done by echocardiography

We also bypassed the arteries of regions, which were reported as dead myocardium in preoperative scintigrapies. In control MUGA and echocardiographies we saw that the myocardium, which had patent bypasses angiographically, gained contractility. In the control scintigraphies at the end of the 1st year we saw that the regions defined as constant perfusion defects and irreversible damaged areas changed into dynamic myocardial tissue with sparse living cells. Also patients were at a better NYHA class according to their preoperative status.

We performed incomplete revascularization to six of 48 patients. The incompletely revascularized coronary artery was Cx after its high obtus branch in three patients and PDA in other patients. There were improvements in ventricular functions, in MUGAs and echocardiographies, of 41 (91.1%) patients who have been completely revascularized and were alive at the end of the 1st year.

Despite the early period, the patency rate of arterial grafts are calculated as 94.4% (n=54; 48 LITA, two RITA and four radial arteries) in the control coronary angiographies and this result was highly satisfying compared to the on-pump operations [13].

Consequently with or without the help of stabilizators and intraluminary coronary shunts, off-pump total revascularization by full sternotomy can be applied and be preferred with an acceptable mortality on the risky patients who have depressed ventricle functions and multiple coronary artery disease.


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

  1. Roques F., Nashef S.A.M., Michel P., Gauducheau E., de Vincentiis C., Baudet E., Cortina J., David M., Faichney A., Gabrielle F., Gams E., Harjula A., Jones M.T., Pintor P.P., Salamon R., Thulin L. Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19 030 patients. Eur J Cardiothorac Surg 1999;15(6):816-823.[Abstract/Free Full Text]
  2. The Multicenter Postinfarction Research Group. Risk stratification and survival after myocardial infarction. N Engl J Med 1983;309:331-336.[Abstract]
  3. Tugtekin S.M., Gulielmos V., Cichon R., Kappert U., Matschke K., Knaut M., Schuler S. Off-pump surgery for anterior vessels in patients with severe dysfunction of the left ventricle. Ann Thorac Surg 2000;70:1034-1036.[Abstract/Free Full Text]
  4. Arom K.V., Flavin T.F., Emery R.W., Kshettry V.R., Petersen R.J., Janey P.A. Is low ejection fraction safe for off-pump coronary bypass operation?. Ann Thorac Surg 2000;70:1021-1025.[Abstract/Free Full Text]
  5. Jhonson W.D., Brenowitz J.B., Kayser K.L. Factor influencing long-term (10–15 year) survival after a successful coronary artery bypass operation. Ann Thorac Surg 1989;48:19-25.[Abstract]
  6. Lawrie G.M., Morris G.C., Jr, Earle N. Long-term results of coronary bypass surgery: analysis of 1698 patients followed 15–20 years. Ann Surg 1991;213:377-385.[Medline]
  7. Kirklin J.W., Naftel D.C., Blackstone E.H., Pohost G.M. Summary of a concensus concerning death and ischemic events after coronary artery bypass grafting. Circulation 1989;79(Suppl. I):I-81-I-91.
  8. Alderman A.L., Fisher L.D., Litwin P., Kaiser G.C., Myers W.O., Maynard C., Levine F., Schloss M. Results of coronary artery surgery in patients with poor left ventricular function (CASS). Circulation 1983;68:785-795.[Abstract/Free Full Text]
  9. Buffolo E., de Andrade J.C.S., Branco J.N.R., Teles C.A., Aguiar L.F., Gomes W.J. Coronary artery bypass grafting cardiopulmonary bypass. Ann Thorac Surg 1996;61:63-66.[Abstract/Free Full Text]
  10. Isik O., Daglar B., Kirali K., Balkanay M., Arbatli H., Yakut C. Coronary bypass grafting via minithoracotomy on the beating heart. Ann Thorac Surg 1997;63:57-63.[Abstract/Free Full Text]
  11. Wos S., Bachowski R., Ceglarek W., Domaradzki W., Matuszewski M., Kucewicz E. Coronary artery bypass grafting without cardiopulmonary bypass: initial experience of 50 cases. Eur J Cardiothorac Surg 1998;14(Supp. I):38-42.
  12. Emery RW, Arom KV, Flavin TF, Kshettry VR. Minimally invasive cardiac surgery: the first thousand cases. Presented at the International Society for Minimally Invasive Cardiac Surgery (ISMICS) Annual Meeting, Atlanta, Georgia, June 8–10, 2000
  13. Svennevig J.L. Off-pump vs on-pump surgery: a review. Scand Cardiovasc J 2000;34:7-11.[Medline]



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