What is the patency of the gastroepiploic artery when used for coronary artery bypass grafting?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was to investigate the patency of the gastroepiploic artery when used for coronary artery bypass grafting. Altogether 304 papers were found using the reported search, of which 15 presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We concluded that the right gastroepiploic artery has been found to have a good short- and long-term patency when anastomosed to the right coronary artery. Long-term patency is 80-90% at 5 years and around 62% at 10 years. Abdominal complications are low but they do occur. Anastomoses of the gastroepiploic artery to the left anterior descending artery perform much more poorly and should be avoided if possible. The long-term patency of the gastroepiploic artery seems to be similar to that of the saphenous vein.     

Awake coronary artery bypass grafting: utopia or reality?

BACKGROUND: Off-pump coronary artery bypass grafting (OPCAB) was implemented to reduce trauma during surgical coronary revascularization. High thoracic epidural anesthesia further reduced intraoperative stress and postoperative pain. This technique also supports awake coronary artery bypass (ACAB), completely avoiding the drawbacks of mechanical ventilation and general anesthesia in high-risk patients. We compared our first results of the ACAB procedure with the conventional OPCAB operation. METHODS: Thirty-five patients underwent ACAB (group A) with left internal mammary artery to left anterior descending coronary artery grafting using a partial lower ministernotomy (n = 25) or double bypass grafting (n = 9) and even triple vessel coronary artery revascularization (n = 1) through complete median sternotomy. Thirty-four patients (group B), matched for age, sex, and comorbidity with group A, underwent either partial lower ministernotomy (n = 24) or OPCAB by complete sternotomy (n = 10). We recorded clinical outcomes and postoperative visual analog scale pain scores. RESULTS: In group A, 32 patients remained awake throughout the entire procedure. Three patients required secondary intubation because of incomplete analgesia (n = 1) or pneumothorax (n = 2). Patients in group A had a recovery room stay of 6.0 +/- 3.2 hours. In group B, mechanical ventilation was implemented for 4.8 +/- 3.1 hours and intensive care unit stay lasted 12 +/- 6.8 hours. Group A had no in-hospital deaths, compared with 1 death in the conventional OPCAB group. Each group had 1 patient with graft stenosis detected on the predischarge angiogram. Early postoperative pain was significantly less in group A than in group B (visual analog scale of 32 +/- 8 compared with 58 +/- 11, p < 0.0001). CONCLUSIONS: The present data demonstrate the feasibility and safety of surgical coronary revascularization without general anesthesia. Continuation of thoracic epidural analgesia provides better pain control and faster mobilization after such procedures. Surprisingly, the ACAB procedure was well accepted by the patients.     

Coronary artery disease and coronary artery bypass grafting in Behçet's disease

Abstract There is a high frequency of pseudoaneurysm formation in patients with Behçet's disease and their inflammed and fragile tissues are difficult to manipulate. Five patients with Behçet's disease were referred to our cardiovascular surgery department for coronary artery bypass grafting (CABG). Three of them were operated and two were treated medically. Patients that were managed medically had left anterior descending (LAD) lesions below 80% and their stable angina pectoris responded well to medication. There was no early mortality and morbidity. One patient developed pseudoaneurysm of ascending aorta and femoral artery. This patient died in the late postoperative period. At follow‐up the operated patients were in Canadian Cardiovascular Society (CCS) Class I, while the medically treated patients were in CCS Class II. Mean follow‐up period was 41 ± 36.21 months. Coronary artery disease (CAD) is extremely rare detected in patients with Behçet's disease. The affected patients are usually young males. Coronary artery bypass grafting is also rarely performed in these patients and long‐term results of such operations are not available in the literature. We present five patients with Behçet's disease that had CAD, three operated and two medically treated, and report their long‐term results. We suggest a conservative approach in patients with Behçet's disease because of the high risk of pseudoaneurysm formation in the postoperative period. If CABG cannot be avoided we recommend operating the patients on the beating heart with minimal aortic manipulation.     

Internal thoracic artery grafting in the elderly patient undergoing coronary artery bypass grafting: room for process improvement?

OBJECTIVE: The acute and long-term benefits of internal thoracic artery grafting are clear in younger patients undergoing coronary artery bypass grafting. The elderly, however, face higher surgical risks and have shorter life expectancy, and thus the use of internal thoracic artery grafting in this age group has been debated. This study examined the use, complication risks, and operative (30-day) mortality associated with internal thoracic artery grafting in patients 75 years of age and older. METHODS: Between 1996 and 1999, 522,656 patients in the Society of Thoracic Surgeons National Cardiac Database underwent primary, nonemergency-salvage coronary artery bypass grafting; of these, 99,942 were 75 years of age or older. The influence of internal thoracic artery use on operative mortality and 5 major complications in this elderly group was examined by means of (1) risk adjustment (adjusting for 28 baseline risk factors and site) and (2) a treatment propensity score analysis that compares patients with similar baseline likelihood for receiving an internal thoracic artery graft. RESULTS: In the National Cardiac Database 77.4% of patients aged 75 to 84 years received an internal thoracic artery graft compared with 93.5% for those aged 55 years or less. In this elderly group use of the internal thoracic artery was strongly associated with decreased operative mortality (unadjusted mortality, 6.20% vs. 4.05%; P <.0001) that persisted after controlling for baseline risk and provider effects (adjusted odds ratio, 0.85; 95% confidence intervals, 0.79-0.91). This mortality benefit was seen among those with low-to-high baseline propensity for receiving an internal thoracic artery graft. CONCLUSIONS: Use of the internal thoracic artery in elderly patients undergoing coronary artery bypass grafting provides an acute survival benefit. This benefit is similar to that seen in younger patients and persists after adjusting for both patient and provider selection factors. The internal thoracic artery appears to be underused in elderly patients undergoing bypass grafting and is a potential area for quality improvement.     

Is routine application of off-pump coronary artery bypass grafting warranted?

The limitation and indication of off-pump coronary artery bypass grafting (OPCAB) remain controversial. Since May 1999, we have applied OPCAB for all isolated coronary bypass cases routinely. Intraoperative conversion to CCAB occurred in 8 patients (10.8%). The main reasons for conversion were intramyocardial coronary arteries and arythmia-induced hemodynamic instability in the acute phase of myocardial infarction. We evaluated the results of OPCAB as compared to conventional coronary artery bypass (CCAB) as a historical control. The operative mortality was 1.6% in both groups. Postoperative complications including renal failure and requirements of circulatory support were significantly less in OPCAB. Postoperative max CPK-MB value, the amount of postoperative bleeding and the requirement of transfusion were also significantly less in OPCAB. Only neurological complication in OPCAB was temporary delirium in a high-aged patient, whereas three patients developed neurological complications including permanent stroke in CCAB. Right heart bypass was effectively utilized to maintain hemodynamics and expose the posterior vessels in patients with severely dilated and poorly functioning left ventricle (EF: 24-31%) and a patient with multiple severe stenosis in cerebral arteries. Coronary angiogram performed after the operation demonstrated 94% of graft patency. These results warrant the further application of OPCAB for multivessel surgical revascularization.     

What factors influence the results of coronary artery bypass grafting in aged patients?

AIM: Early and late results were studied in order to improve the indication for coronary artery bypass grafting (CABG) and to enhance RESULTS: METHODS: A total of 1 973 patients aged 70 years and older who had undergone isolated CABG were studied. Elective operations (EL) were performed in 1 716 patients and 257 patients underwent urgent or emergency operations (UR/EM). Patients were divided into two groups; 104 patients aged 80 years and older (Oct. Group) and 1 869 patients of septuagenarians (Sept. Group). There were no differences between the groups in the number of diseased vessels. RESULTS: Total operative mortality rates in the Oct. and the Sept. groups were 7% and 4%, respectively. The operative mortality of elective surgery was 4% in both groups. The operative mortality of UR/EM CABG was significantly higher in the Oct. group than in the Sept. group (21% vs 6%). Operative mortality was significantly higher in patients with preoperative poor (<49%) left ventricular ejection fraction (LVEF) than in patients with higher (>50%) LVEF (6% vs 3%). Among preoperative risk factors, diabetes mellitus and peripheral vascular disease were significant contributory factors to operative death. In the follow-up study, 70% patients of the Oct. group and 72% patients of the Sept. group survived. Preoperative number of diseased vessels and number of CABG grafts did not influence the early and late RESULTS: CONCLUSION: Preoperative poor LVEF, diabetes mellitus and peripheral vascular disease were significant contributory factors to operative death. When feasible, CABG in octogenarians should be performed electively.     

Debate over patient-centered care: Percutaneous coronary intervention or coronary artery bypass grafting?

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) have developed as effective therapies to treat coronary artery disease. Initial CABG is associated with lower mortality than initial medical management, especially among high- and intermediate-risk patients with coronary artery disease. However, PCI is currently the most frequent initial treatment delivered by interventional cardiologists to treat multivessel coronary artery disease, despite substantial evidence from meta-analyses of randomized trials and registry data favoring CABG. Recent advancements in PCI did not result in detectable improvements in death or myocardial infarction compared with medical therapy, although significant reductions in target lesions or vessel revascularization were identified after implantation of a drug-eluting stent (DES) rather than a baremetal stent. The SYNTAX trial compared patients with left main and/or three-vessel coronary artery disease treated with DES or CABG. The results of the trial demonstrated the 1-year inferiority of PCI compared with CABG with respect to major adverse cardiac and cerebrovascular events. Nevertheless, patients with coronary artery disease continue to receive more recommendations for PCI and fewer for CABG than are indicated in the guidelines. A multidisciplinary team approach should be the standard of care when recommending interventions for treating complex coronary artery disease among patients for whom CABG is superior in terms of survival and freedom from reintervention.     

Cardioprotective effect of pretreatment with β-glucan in coronary artery bypass grafting

Background. β-glucan pretreatment has been shown to attenuate inflammatory response and to protect against ischemia-reperfusion injury in animal studies. The aims of the present study were to examine the safety of pretreatment with β-1,3/1,6-glucan in patients scheduled for coronary artery bypass grafting (CABG), and to investigate whether β-1,3/1,6-glucan pretreatment could suppress inflammatory response and protect against ischemia-reperfusion injury following CABG. Methods. Twenty one patients scheduled for CABG were assigned to oral β-1,3/1,6-glucan 700?mg (Group 1) or 1?400?mg (Group 2) five consecutive days before surgery and were compared with a control group (Group 3). Blood samples were drawn preoperatively and on the first, third and fifth postoperative day for analysis of acute-phase reactants, hematology, cytokines and myocardial enzymes. Results. The study drug was well tolerated. Creatine kinase isoenzyme MB was significantly lower in Group 2 compared with controls on the first postoperative day (p?=?0.028). Mean change in cardiac troponin T was lower in Group 2 compared with controls (p?=?0.028). Conclusions. β-1,3/1,6-glucan pretreatment is safe in patients undergoing CABG and may protect against ischemia reperfusion injury following CABG.