Graft-to-coronary-artery shunt during off-pump coronary artery bypass grafting

We have developed a simple technique for temporary shunt from the saphenous vein graft to the coronary artery during off-pump coronary anastomosis. The ends of a 2-mm diameter tube were inserted into the distal end of the saphenous vein graft in which proximal anastomosis had been established and into the right coronary artery crux. Blood flow sufficient to maintain adequate hemodynamics was obtained through the shunt tube while suturing around the tube. We successfully employed this technique in 5 patients with acute coronary syndrome. We suggest that this technique may represent an addition to the armamentarium for off-pump anastomosis to the right coronary artery.     

Controversies in the use of intraluminal shunts during off-pump coronary artery bypass grafting surgery

Technical advances have made the performance of multivessel off-pump coronary artery bypass feasible. Snaring and intraluminal shunts are the techniques used for vascular control. Snaring provides a bloodless surgical field, is usually well tolerated by the patient, and is supported by years of clinical experience. Intraluminal shunts aim to achieve hemostasis at the arteriotomy site and to allow antegrade flow to provide myocardial protection. There are unresolved issues regarding whether shunts have a clinical benefit, do provide adequate flow to provide myocardial protection, and whether they cause significant endothelial damage. In this article, we have reviewed the literature to lend perspective to these issues.     

Comparison of two stabilizer concepts for off-pump coronary artery bypass grafting

BACKGROUND: This study was designed to evaluate the efficacy of two different stabilizer concepts for off-pump coronary artery bypass grafting. METHODS: Between 2000 and 2001, 100 consecutive patients who underwent off-pump coronary artery bypass grafting were randomly assigned to two stabilization systems: the Medtronic Octopus 3 (n = 50) and the Genzyme Immobilizer (n = 50). During operation, two-dimensional cardiac surface motion was assessed by intravital microscopy using orthogonal polarization spectral imaging in 20 vessels at the anterior wall. Postoperative angiography of 47 vessels revealed anastomotic quality. RESULTS: Patient demographics were similar in both groups regarding age, sex, ejection fraction, and New York Heart Association functional class. In 7 patients the randomized Immobilizer was rejected by the surgeon for lateral or posterior wall revascularization and subsequently switched to the Octopus device. Patients received 1.8 +/- 0.7 grafts in the Octopus and 1.6 +/- 0.5 in the Immobilizer group (p = not significant). Two-dimensional cardiac surface motion was significantly less using the Immobilizer (109.7 +/- 32.4 microm versus 423.5 +/- 129.6 microm; p < 0.001). Time required for anastomosis was significantly shorter in the Immobilizer group (11.3 +/- 3.5 versus 14.9 +/- 2.4 minutes; p < 0.001). Postoperative angiography showed no vessel occlusions but two anastomotic stenoses in each group. CONCLUSIONS: Both stabilizers have been shown useful for off-pump coronary artery bypass grafting. The Immobilizer system showed better epicardial immobilization of the anterior wall resulting in shorter anastomosis times. However, because the Octopus 3 handling is more flexible and allows easier access to all vessels, it is the device of choice for posterior wall revascularization in our institution.     

Spontaneous atrioventricular groove disruption during off-pump coronary artery bypass grafting

Atrioventricular groove tear or disruption is a disastrous and technically challenging complication after mitral valve replacement surgery. This report details the untimely spontaneous occurrence of an atrioventricular tear during manipulation of the heart for off-pump coronary artery bypass grafting and its successful repair. Significant distortion of the mitral annulus and elevation of pulmonary artery pressures in the beating heart likely contributed to the spontaneous tear.     

Our experiences for off-pump coronary artery bypass grafting to the circumflex system

BACKGROUND: Complete revascularization has been difficult in off-pump coronary artery bypass grafting (OPCAB). Hemodynamic deterioration often prevents access to the circumflex territory. This study presents instrumentation for accessing the circumflex territory, and our clinical experience. METHODS: From August 1999 through December 2002, 140 patients underwent OPCAB via sternotomy in our institution. The 114 requiring reconstruction of the circumflex artery are the subjects of this study. There were no exclusion criteria. A series of techniques and instruments were developed to provide access to the circumflex area while hemodynamic stability was preserved, including the left pericardial traction technique, compression of the right pericardium, a right sternal retractor, and a type of shunt tube. RESULTS: Patients received an average of 3.2 grafts (range, 2 to 6). Complete revascularization was achieved in 95% of the cases. Complications included respiratory insufficiency (0.8%), renal dysfunction (7%), and sternal wound infection (0.8%). Blood transfusions were required in 10 patients (8%). No patient suffered perioperative myocardial infarction or stroke. No operation was converted to cardiopulmonary bypass. There was no operative death. Predischarge angiography demonstrated a 99% patency rate. CONCLUSIONS: With our techniques and instruments, off-pump coronary revascularizaion of the circumflex area may be performed safely to achieve complete revascularization. Early clinical results are excellent, but long-term longitudinal follow-up is required to assess the future effectiveness of OPCAB procedure with our techniques.     

Urgent off-pump coronary artery bypass grafting in a patient with HIV

We report a case of successful urgent off-pump coronary artery bypass grafting (CABG) for unstable angina pectoris in a 54-year-old human with human immunodeficiency virus (HIV) infection. We studied the changes in CD4+ cells and HIV-RNA copy during the perioperative period. The results showed that off-pump CABG did not reduce the CD4+ cell count and did not affect the condition of HIV infection in this patient.     

Application of Cabrol technique to off-pump coronary artery bypass grafting using radial artery

We present the case of a Cabrol-type proximal anastomosis technique in off-pump coronary artery bypass. The patient was a 64-year-old man with significant stenoses on the left main, left anterior descending, and proximal right coronary artery. The obtuse marginal and right coronary arteries were anastomosed with both ends of a radial artery. For the proximal anastomosis during this procedure, we applied the Cabrol-type looping interposition technique. In selected patients, we suggest that this technique allows the effective use of graft length and can reduce a number of ascending aortic manipulations.     

Routine immediate extubation for off-pump coronary artery bypass grafting without thoracic epidural analgesia

BACKGROUND: The expansion of coronary surgery on the beating heart without cardiopulmonary bypass has led to increasing interest in ultra-fast track anesthesia, allowing extubation of the patient in the operating theater. The techniques described to date combined general anesthesia with thoracic epidural analgesia. We report the routine application of a technique that allows immediate extubation in the majority of patients undergoing off-pump coronary artery bypass grafting without thoracic epidural analgesia. METHODS: Fast-track anesthesia using an ultra-shortacting opiate remifentanil, without epidural catheter insertion, was used in 160 unselected patients undergoing off-pump coronary artery bypass grafting (aged 43 to 83 years, mean 65 years). There were an average of 2.2 bypass procedures per patient, with the left internal mammary artery used in 93%. Contraindications to immediate extubation were (except for failure to meet standard extubation criteria) hemodynamic instability and persistent bleeding at the end of operation. Satisfactory postoperative pain control was achieved by continuous remifentanil (0.0125 to 0.05 microg x kg(-1) x min(-1)). RESULTS: Operating theater extubation within 10 minutes of the end of operation was feasible in 150 patients (94%). Five patients (3%) were extubated within 2 hours, and the remaining 5 patients (3%) were converted to standard anesthesia. There were no deaths during hospitalization. Major complications included myocardial infarction and transient ischemic attacks (2 patients each). No pulmonary complications were seen. Episodes of atrial fibrillation occurred in 21% of the patients undergoing operation. CONCLUSIONS: Immediate extubation is possible in most patients after off-pump coronary artery bypass grafting even without thoracic epidural analgesia. We believe this type of less invasive cardiac anesthesia is safe and promising.     

Left ventricular rupture during off-pump coronary artery bypass grafting

Left ventricular rupture is a highly lethal, but rare, complication of myocardial infarction. We report the first case of a postinfarction, intraoperative left ventricular apical rupture during an off-pump coronary artery bypass grafting due to the application of apical suction used to expose target vessels.     

Safe coronary artery occlusion with a new tourniquet in off-pump bypass grafting

Coronary artery occlusion during off-pump coronary artery bypass grafting may lead to mechanical trauma of the arterial wall. My colleagues and I describe a safe coronary artery occlusion technique in off-pump bypass grafting that uses a new spring-equipped tourniquet, which enables precise adjustment of the least force necessary to occlude the coronary flow. This prevents snare-induced vessel wall damage.     

External shunt for off-pump coronary artery bypass grafting: distal coronary perfusion catheter

We invented a simple external shunt catheter for off-pump coronary artery bypass grafting. This catheter maintains coronary perfusion from femoral artery, prevents ischemia, reduces back-bleeding, and acts as a suture guide by preventing accidental missuturing of the posterior coronary wall. The insertion and withdraw technique is easier than intraluminal shunt. This catheter would be a useful tool for myocardial protection during off-pump revascularization.     

Severe coronary artery disease with coarctation of the aorta: role of off-pump coronary artery bypass grafting

Severe coronary artery disease with coarctation of the aorta is an unusual and challenging clinical problem. We encountered three adults with severe coronary artery disease and tight coarctation of the aorta. Since angina was the dominant symptom in all, off-pump coronary artery bypass grafting (OPCABG) was done as a first stage. All survived the operation. After a gap of 3 weeks, coarctation repair has been done in 1 patient. We believe that OPCABG offers some unique advantages in this difficult situation.     

Assessment of ascending aorta using epiaortic ultrasonography during off-pump coronary artery bypass grafting

BACKGROUND: Use of an aortic partial clamp for proximal anastomosis during off-pump coronary artery bypass is known to increase the risk of fatal complications. The purpose of this study was to assess the management of the ascending aorta evaluated with epiaortic ultrasonography during off-pump coronary artery bypass. METHODS: Intraoperative ultrasonography of the ascending aorta with a 10-MHz probe was performed consecutively in 155 patients undergoing off-pump coronary artery bypass between August 1999 and July 2001. The findings from ultrasonography, surgical modifications, and operative results were analyzed. RESULTS: In 54 patients (34.8%), epiaortic ultrasonography showed atherosclerotic findings in the anterior side of the ascending aorta (group A). The remaining 101 patients had either normal findings or atherosclerotic findings in only the posterior side (group NA). A proximal anastomosis to the aorta was preoperatively planned in 117 patients (group A, 42; group NA, 75). In group A, a graft modification without clamping was implemented in 29 patients (24.8% of 117 patients), whereas the clamp site was modified to a different segment in 13 patients (11.1% of 117 patients). In all 75 patients in group NA, partial clamping was used in the standard fashion. There were no cerebral infarctions or operative deaths related to partial clamping. However, aortic dissection occurred in 1 patient in group NA. CONCLUSIONS: In 35% of patients undergoing off-pump coronary artery bypass, epiaortic ultrasonography identified atherosclerotic findings in the anterior wall of the ascending aorta. This study suggests that revascularization without aortic manipulation during off-pump coronary artery bypass is indicated in as many as 25% of patients.