Multivessel off-pump coronary artery bypass grafting in a nonagenarian: anesthesiologic management

A 90-year-old male admitted with history of angina (three-vessel disease) on medical therapy for hypertension and chronic renal failure was scheduled for elective coronary artery bypass grafting (CABG). After standard premedication and monitoring anesthesia was induced with propofol and maintained with isoflurane. Middle dose opioids and atracurium were also given. Multivessel revascularization was done through median sternotomy and anastomoses were performed with the aid of coronary stabilization and shunting. Cerebral and renal perfusion were maintained with high arterial pressure (140/70 mmHg) and continuous infusion of fenoldopam (0.05 microg kg(1) m(-1)). The perioperative period was uneventful. Elderly patients are at increased risk for mortality and morbidity after CABG. The procedure can be performed safely on elderly patients without using cardiopulmonary bypass and preventing cerebral and renal ipoperfusion.     

The clinical outcome of off-pump coronary artery bypass surgery in the elderly patients

Objective: There has been a body of evidence showing that off-pump coronary artery bypass (OPCAB) may reduce morbidity and mortality in the elderly patients. We reviewed our experience, retrospectively, on elderly patients aged 75 years and older who were operated on using the OPCAB technique. We compared their outcome to a similar group of elderly patients who were operated on using conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) during the same period of time. Methods: Registry data and patients' notes and charts were reviewed for 56 consecutive elderly OPCAB patients (age 78.5±3.5 years) and 87 consecutive CPB patients (age 77.2±2.4 years, P=0.01). Both groups had similar risk factor profiles: Parsonnet score 17.4±4.4 (OPCAB) versus 16.6±5.2 (CPB), P=0.19. We studied in detail their preoperative and postoperative data in order to compare the outcomes of both techniques. Results: The length of stay in the intensive therapy unit (ITU) was 35.4±52.9 h for OPCAB patients and 77.6±144.9 h for CPB patients (P=0.0008). No patient died within 30 days in the OPCAB group, whilst ten (11%) CPB patients (P=0.0066) died within 30 days. The incidence of serious complications (including pulmonary oedema, septicaemia, permanent stroke and renal dysfunction requiring haemofiltration or haemodialysis) was one (2%) in the OPCAB group and 11 (13%) in the CPB group (P=0.028). CPB patients required a significantly higher number ten (12%) of intra-aortic balloon pumps (IABP) inserted compared to only one patient (2%) in the OPCAB group who required IABP insertion (P=0.05). Nine (11%) CPB patients were re-operated on for bleeding compared to no OPCAB patient (0%) needing re-operation, P=0.011. Conclusions: Although the mean age of the OPCAB group was significantly higher than the CPB group, the OPCAB group showed a significant reduction in postoperative serious morbidity, ITU stay and mortality. We believe that such a conclusion may have some effect on the decision-making and cost-effectiveness when performing coronary bypass surgery on the elderly population.     

Multivessel off-pump coronary artery bypass grafting can be taught to trainee surgeons

BACKGROUND: Although Off-Pump Coronary Artery Bypass (OPCAB) surgery is being increasingly explored and practised in many cardiac units worldwide, there have been only few reports documenting the training of surgeons in this new technique. The purpose of this study was to address the reproducibility of the OPCAB in a unit where this technique is used extensively. METHODS: Registry data, notes, and charts of 64 patients who were operated on by four trainee cardiac surgeons over a period of thirteen months at Harefield Hospital, were reviewed retrospectively. These trainees were part of an accredited training program for cardiothoracic training and were trained by a single consultant trainer in a cardiac unit after it had an established recent experience in performing nonselective OPCAB for all in-coming patients. Five (7.8%) patients (with 17 distal anastomoses) consented and underwent early postoperative angiography to check the quality of the grafts and anastomoses. RESULTS: The mean age of the study patients was 65.6 and the mean Parsonnet score was 9.4. There was a mean of 2.9 grafts per patient and circumflex territory anastomoses were performed in 48 (75%) patients. No operation required conversion to Cardiopulmonary Bypass (CPB). Angiography of the five patients revealed 17 satisfactory (100%) distal anastomoses. CONCLUSION: With appropriate training, it is possible for trainees to learn OPCAB and perform multivessel revascularization in relatively high-risk patients with good results.     

Vasoplegic syndrome after off-pump coronary artery bypass surgery.

OBJECTIVE: The vasoplegic syndrome (VS) has been implicated in life-threatening complications after open heart surgery, where the whole-body inflammatory reaction is attributed to the cardiopulmonary bypass (CPB). Off-pump coronary artery bypass grafting (OPCAB) has been recently achieving growing enthusiasm mainly due avoiding the side effects of CPB. However herein the occurrence of VS in OPCAB is reported. METHODS: The vasoplegic syndrome usual findings occurring in the early postoperative period include severe hypotension, tachycardia, normal or elevated cardiac output and low systemic vascular resistance. Four patients underwent to OPCAB presented all the signs of VS intraoperatively or within the first 6 postoperative h. RESULTS: The patients needed aggressive vasoactive drug support for hemodynamic stabilization and all of them developed complications. These patients also had tendency to require administration of blood and blood derivatives due to diffuse and oozing type bleeding. Mean intensive care unit stay of surviving patients was 70 h and mean period of postoperative hospitalization was 9 days. Tumor necrosis factor-alpha blood levels in one patient were elevated postoperatively though no signs of infection were observed. One patient died. CONCLUSIONS: Although vasoplegic syndrome can complicate OPCAB surgery, the rationale for avoiding CPB remains valid considering the benefits provided by OPCAB.     

Multivessel distal sutureless off-pump coronary artery bypass grafting procedure using magnetic connectors

Proximal anastomotic devices for beating heart coronary artery bypass grafting (CABG) have been developed to avoid ascending aortic manipulation. Distal anastomotic devices may become an extremely useful tool to assist in enabling minimally invasive (robotic) multivessel CABG. As a transition phase toward this ultimate goal we have been using a distal anastomotic device for the left internal mammary artery-left anterior descending artery (LIMA-LAD) anastomosis. In addition we recently performed two off-pump coronary artery bypass procedures that were distally completely sutureless.     

Integrated approach to off-pump coronary artery bypass surgery

BACKGROUND: The Off-Pump Coronary Artery Bypass (OPCAB) technique is becoming more popular in many cardiac units throughout the world. This relatively new technique has prompted surgeons and anaesthetists to review and modify the routine approach to Coronary Artery Bypass Surgery (CABG). In this study we reviewed and analysed the outcome of an integrated anaesthetic and surgical peri-operative approach that allowed routine use of OPCAB and avoided the use of cardiopulmonary bypass (CPB). METHODS: We reviewed and analysed the data on the first consecutive 285 patients who were operated on using the OPCAB technique. These represent our initial experience with applying the OPCAB technique non-selectively for all patients over a period of 16 months. RESULTS: All patients had at least 2-vessel disease. 807 grafts were performed (mean 2.8 per patient) of which 647 (80%) were arterial (mean 2.3 per patient). 179 (63%) patients underwent total arterial revascularization. Eight patients required cardiopulmonary bypass; all other operations were completed off-pump. Complications--mortality 3 (1%); renal failure 24 (8%); stroke 3 (1%) and atrial fibrillation 60 (21%). CONCLUSION: This retrospective analysis shows that provided a combined and integrated anaesthetic and surgical approach is used, beating heart technique for CABG can be safely offered to all patients with a good outcome.     

Myocardial protection for off-pump coronary artery bypass surgery

Myocardial protection during off-pump coronary artery bypass surgery (OPCAB) is a multifactorial problem. Careful, individualized choice of graft sequence and maintenance of stable systemic hemodynamics are of central importance. Recently refined techniques for atraumatic rotation of the heart and visualization of coronary anastomoses allow precise and controlled grafting of all coronary territories without cardiopulmonary bypass in the large majority of cases. Perfusion-assisted direct coronary artery bypass (PADCAB) techniques, in which coronary perfusion pressure is independent of systemic arterial pressure, can avoid or abort a downward hemodynamic spiral, which may occasionally occur during complex, multivessel OPCAB. PADCAB promotes collateral myocardial perfusion and avoids the cumulative global effect of sequential episodes of regional ischemia, improving myocardial protection during OPCAB.     

Anaesthesia for off-pump coronary artery bypass grafting surgery

Coronary artery bypass grafting (CABG) surgery may be undertaken with or without cardiopulmonary bypass (CPB) that is on- or off-pump. Although mortality and the incidences of coronary artery graft occlusion, myocardial infarction and stroke are equivalent, off-pump is associated with less blood loss, transfusion, requirement for inotropes, atrial fibrillation and chest infection compared with on-pump CABG surgery. Traditional high-dose opioid techniques of general anaesthesia should be avoided and either inhalation or total intravenous (IV) anaesthesia may be used. Meticulous monitoring, including electrocardiograph (ECG) and invasive arterial pressure measurement, is required. During grafting, good communication between anaesthetist and surgeon is essential. Maintenance of diastolic arterial pressure (DAP) is the key to preventing myocardial ischaemia and cardiovascular collapse. Surgical positioning for grafting to minimize hypotension is paramount and during grafting, IV fluid loading or vasoconstrictors and inotropes are effective treatments. Correction of bradycardia with atropine 0.3 mg IV or epicardial pacing also helps to maintain DAP. Persisting hypotension may require intra-aortic balloon pumping or conversion to on-pump CABG surgery. As there is less blood loss, there is a minimal requirement for cardiovascular support and early recovery of consciousness associated with off-pump compared with on-pump CABG surgery; patients in some institutions may be managed in a recovery room then transferred to a high-dependency unit, thus bypassing ICU.     

Current results of off-pump coronary artery bypass surgery

Whether to use or not use cardiopulmonary bypass-cardioplegic arrest to perform coronary artery bypass surgery is the main controversy presently facing our surgical specialty. The reported clinical outcomes are mainly retrospective and highly debatable for conclusiveness regarding the benefits of off-pump surgery. As more centers and larger patient cohorts are analyzed and reported, particularly over the last 2 years, off-pump surgery appears to provide significantly improved outcomes with decreased bleeding and transfusion requirements, less myocardial enzyme release, less ventilatory time, and decreased hospital stay and costs. Reported off-pump benefits for the major outcomes of operative mortality and stroke are encouraging, but less conclusive. From experienced centers, early off-pump angiographic graft patency has been comparable to previously published conventional results. High-risk, elderly patients may benefit the greatest from off-pump surgery. Although in relative technical infancy, off-pump coronary artery bypass grafting has demonstrated enough benefit outcomes that it is no longer an experimental procedure, but a valid surgical revascularization method requiring further investigation and continued usage.     

Retropericardial hematoma complicating off-pump coronary artery bypass surgery

We report the case of a retropericardial hematoma after triple-vessel off-pump coronary artery bypass grafting. Transesophageal echocardiography demonstrated a retropericardial hematoma that compressed the left atrium anteriorly and suppressed cardiac function. Injury to the pulmonary vein during placement of deep pericardial sutures and postoperative infusion of heparin were the likely causes of this rare but potentially fatal complication of an off-pump bypass operation.     

Anaesthesia for off-pump coronary artery bypass grafting surgery

Coronary artery bypass grafting (CABG) surgery may be undertaken with or without cardiopulmonary bypass (CPB), that is, on- or off-pump. Traditional high-dose opioid techniques of general anaesthesia should be avoided and either inhalation or total intravenous (IV) anaesthesia may be used. Meticulous monitoring, including electrocardiograph and invasive arterial pressure measurement, is required. During grafting, good communication between anaesthetist and surgeon is essential. Maintenance of diastolic arterial pressure (DAP) is the key to preventing myocardial ischaemia and cardiovascular collapse. Surgical positioning for grafting to minimize hypotension is paramount and during grafting, IV fluid loading or vasoconstrictors and inotropes are effective treatments. Correction of bradycardia with atropine 0.3 mg IV or epicardial pacing also helps to maintain DAP. Persisting hypotension may require intra-aortic balloon pumping or conversion to on-pump CABG surgery. As there is less blood loss, there is a minimal requirement for cardiovascular support and early recovery of consciousness associated with off-pump compared with on-pump CABG surgery; patients in some institutions may be managed in a recovery room then transferred to a high-dependency unit, thus bypassing the intensive care unit.     

Coronary endarterectomy with off-pump coronary artery bypass surgery

BACKGROUND: The aim of this study is to review our experience in coronary artery endarterectomy performed without cardiopulmonary bypass. METHODS: Between May 1998 and June 2000 off-pump coronary endarterectomy was performed on 11 patients who had unstable angina pectoris. The mean ejection fraction (EF) was 26.3 +/- 4.4, and all of the patients were New York Heart Association (NYHA) III or IV. Off-pump open left anterior descending (LAD) endarterectomy was performed on 7 patients, and closed endarterectomy of the right coronary artery (RCA) was done on the remaining 4. RESULTS: There were no deaths. None of the procedures was converted to on-pump operation; all the endarterectomies and bypasses were performed on the beating heart. All patients were completely revascularized, the left internal mammary artery was bypassed to the LAD in all operations, and all other grafts were of saphenous vein. At the end of the first year all bypasses to the endarterectomized arteries were patent. The overall patency rate was 95.6%. The mean postoperative EF was 34.7 +/- 9.1, which was significantly higher than the preoperative one (p < 0.05). At the end of the first year 9 patients were NYHA I or II and all were angina free in Canadian Cardiovascular Society class 0 or I. CONCLUSIONS: Endarterectomy without cardiopulmonary bypass can be performed in patients with severe left ventricular dysfunction who are expected to benefit from the complete revascularization.     

Systematic off-pump coronary artery bypass.

PURPOSE: We assessed the feasibility of systematic off-pump coronary artery bypass (OPCAB) and identified risk factors for on-pump conversion. METHODS: Between July 1, 2002 and December 31, 2003, OPCAB was attempted for all patients who required isolated coronary artery bypass in our institution. The perioperative results of patients were prospectively entered into a structured database, the results were analyzed to identify the risks of requirement of cardiopulmonary bypass. RESULTS: OPCAB was performed in all but 4 patients, giving an OPCAB success rate of 98.3% (229/233). The reason for cardiopulmonary bypass was hemodynamic instability occurring during reoperative surgery in 3, and cardiogenic shock in 1. The isolated risk factor for on-pump conversion was reoperation (relative risk 11.6). Mean number of distal anastomoses performed under OPCAB was 3.7+/-1.2, and the complete revascularization rate was 92.1% (211/229). There was one hospital death (0.4%). During a mean follow-up period of 1.0+/-0.4 years, two patients developed angina, which were treated with catheter intervention; otherwise, there was no death, or other cardiac events observed. CONCLUSION: Systematic OPCAB was feasible except in patients undergoing reoperative surgery or patients with on-going deep cardiogenic shock. Systematic OPCAB provided successful complete revascularization and its short term results were acceptable.     

高龄冠心病病人非体外循环冠状动脉旁路移植术后心房颤动的临床分析

目的 探讨高龄冠心病病人非体外循环冠状动脉旁路移植术术后心房颤动的相关因素.方法 111例高龄非体外循环冠状动脉旁路移植术,分为心房颤动和无心房颤动两组,回顾性分析冠状动脉病变情况、旁路移植血管的部位及支数、术后电解质变化、循环血容量变化、抗心律失常药物的使用等因素对心房颤动发生率的影响.结果 27例手术后心房颤动,发生率24.3%.在单因素分析中,房颤组病人与非房颤组病人术后中心静脉压、术后血清K+、Mg2+、动脉血SPO2等指标差异有统计学意义,P<0.05.结论 围术期电解质、血氧饱和度、循环血容量改变及发生围术期心梗是高龄病人冠状动脉旁路移植手术后发生心房颤动的危险因素.     

Minimally invasive direct coronary artery bypass and off-pump coronary artery bypass surgery: anesthetic considerations

Many new surgical technologies are being developed, with the overall aim of improving outcomes. One common feature of many new technologies is that they offer a safer approach than previous techniques; one of the greatest forces for change over the last 30 years is risk reduction. Cardiac surgery risk has been effectively undercut by percutaneous-based procedures, which have offered dramatic reductions in risk--at least in the short term. Beating heart techniques, whether minimally invasive direct coronary artery bypass (MIDCAB), off-pump coronary artery bypass surgery (OPCAB), or in other forms, such as percutaneous valve replacement, are likely to dramatically increase over the next decade. What role OPCAB and MIDCAB techniques will play in this new era is anyone's guess.     

不停跳冠状动脉旁路移植术联合同期肺切除术

目的总结不停跳冠状动脉旁路移植术联合同期肺切除术的经验。方法7例不稳定性心绞痛或心肌梗死合并可切除肺部病变患者,实施不停跳冠状动脉旁路移植术联合同期肺切除术。所有患者术前行冠状动脉造影证实不宜行冠状动脉成形术或支架植入术。采用胸骨正中切口,不停跳冠状动脉旁路移植术后行肺切除术。左上肺叶切除2例,右上肺叶切除1例,右上、中叶切除1例,右下肺叶切除1例,左侧肺减容术1例,双侧肺减容术1例。结果本组无住院死亡,但有1例后期死亡。术后并发症包括1例胸骨哆开再次开胸固定、1例房颤。病理检查结果5例肺部恶性肿瘤、2例慢性阻塞性肺气肿。患者随访2～31个月,所有患者术后没有再次出现心肌缺血症状,1例行右肺上、中叶切除患者术后19个月出现局部复发。结论胸骨正中切口不停跳冠状动脉旁路移植术联合同期肺切除术是安全有效的并能降低术后并发症。