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.     

Combined off-pump coronary artery bypass surgery and pulmonary resection

Background

Combined cardiac surgery and pulmonary resection using cardiopulmonary bypass (CPB) has been described previously. There are a few reports of combined procedures done without using CPB. Off-pump coronary artery bypass grafting (OPCABG) eliminates organ dysfunction and suppression of immune system related to extracorporeal circulation.

Methods

Six patients underwent combined OPCABG and lung resection during a 4-year period. Follow-up ranging from 9 months to 3 years is available for these patients.

Results

Malignant pathology was the diagnosis in 5 patients and 1 patient was diagnosed with advanced chronic obstructive pulmonary disease. Right upper lobectomy was performed in 3 patients, left upper lobectomy was performed in 1 patient, right upper and middle bilobectomy was performed in 1 patient, and bilateral lung volume reduction was performed in one patient. Prolonged air leak occurred in 1 patient postoperatively and another patient experienced small right-sided residual pleural space that was resolved at 6 weeks follow-up. There were no operative deaths but there were 2 late deaths. Evidence of recurrence for angina or malignancy upon follow-up was not detected.

Conclusions

A combined procedure is a safe approach in patients diagnosed with concomitant coronary artery and pulmonary disease. Avoidance of CPB may decrease the incidence of postoperative complications.     

Initial experience with sutureless proximal anastomoses performed with a mechanical connector leading to clampless off-pump coronary artery bypass surgery

BACKGROUND: We report our early experience with the Symmetry Aortic Connector (St. Jude Medical, St. Paul, MN) used for sutureless proximal aortosaphenous vein graft anastomoses without any cross clamp during coronary bypass procedures. METHODS: Between November 2001 and August 2002, 206 saphenous vein to aorta proximal anastomoses were created in 132 patients using the Symmetry device. All procedures were performed as part of off-pump coronary artery bypass surgery without any aortic clamping. Intraoperative variables and postoperative data were collected and analyzed retrospectively. RESULTS: All 206 anastomoses (100%) were successfully completed with the connector. Severe atherosclerotic disease of the aorta was documented in 16 patients (12%). Four anastomoses (2%) required additional suture placement. Predeployment problems occurred with 3 grafts (2.5%) during loading of the connector. Average number of distal bypasses was 3.2 per patient. One patient (0.7%) required reoperation for bleeding from a proximal anastomosis. Six patients (4.5%) had perioperative myocardial infarction documented by electrocardiographic changes. Thirty-day operative mortality was 3% (4 patients). Intraoperative transit time flow measurement was performed in all cases (100%). Postoperative angiography in 43 patients at a median 3 months postoperatively revealed occlusion of 9 of the 81 saphenous vein grafts (11%). CONCLUSIONS: The initial experience with a proximal saphenous vein graft to aorta anastomosis using the Symmetry connector demonstrates safety and ease of use. There is however some concern with early graft closure. A prospective randomized study is needed to clarify these concerns.     

Clinical experience with devices for facilitated anastomoses in coronary artery bypass surgery

Recent developments in minimally invasive coronary artery surgery have been driven by the introduction of new technologies which should facilitate precise surgical maneuvers on the beating heart within confined spaces. Such technologies include coronary stabilizer systems, cardiac positioning vacuum-assisted devices, and telemanipulative systems. Despite these developments, standard suturing techniques using running polypropylene material remains a limiting factor in the surgeon's ability to perform complete revascularization with high quality anastomoses through minimal approaches to the chest cavity. Clinical validation of proximal and distal anastomotic devices has the potential to substantially improve and perhaps revolutionize minimally invasive coronary surgery. Ideal characteristics of such devices would include applicability to all conduit types, all coronary sizes, interchangeable proximal/distal sequencing of the anastomosis, and safe bail out for device malfunction. However there is an urgent need to define the performance objectives of such systems as well as the general criteria for proper and comparable evaluation and validation of different systems in animal models and subsequently in controlled prospective clinical studies. This review summarizes the most interesting systems available in both experimental and clinical settings.     

Successful off-pump coronary artery bypass for Behcet's disease

A 66-year-old woman with a 30-year history of Behcet's disease was referred for coronary surgery because of restenosed stent and crescendo angina. We succeeded in operating on her by off-pump coronary bypass with bilateral internal mammary arteries, which were anastomosed to the left anterior descending artery and diagonal artery. The grafts were patent postoperatively and she became free from angina. Coronary surgery for Behcet's disease is extremely rare and this experience prompted us to report this case.     

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.     

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.     

A simple technique of introducing intracoronary shunts for off-pump coronary artery bypass surgery

We describe a simple technique of introducing intracoronary shunts for off-pump coronary artery bypass. This technique, with an aid of micro-bulldog clamp, provides both a test clamp with ischemic preconditioning effect, and a quick and easy introduction of intracoronary shunt, giving a clear visualization of coronary anastomosis site and distal coronary artery perfusion. We recommend this technique as another effective modality in off-pump coronary artery bypass surgery.     

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.     

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.