Routine immediate extubation after off-pump coronary artery bypass surgery: 514 consecutive patients

OBJECTIVE: The purpose of this study was to evaluate the feasibility of routine immediate extubation in patients undergoing off-pump coronary artery bypass surgery. DESIGN: Case series. SETTING: Private hospital. PARTICIPANTS: Five hundred forty-eight consecutive patients undergoing off-pump coronary bypass surgery, representing 5 years of a single anesthesiologist's practice, were evaluated for routine immediate extubation. Thirty-four patients were excluded because they were already intubated, in preoperative cardiogenic shock, or converted to on-pump during the procedure. INTERVENTION: Patients received general anesthesia or general anesthesia plus thoracic epidural analgesia (25%) and underwent off-pump coronary bypass surgery. MEASUREMENTS AND MAIN RESULTS: All 514 patients who were intended to be immediately extubated were expeditiously extubated in the operating room. The numbers of reintubations, morbidity, and mortality were low. CONCLUSIONS: Routine immediate extubation of most off-pump coronary artery bypass patients appears feasible and most probably safe.     

Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery

BACKGROUND: Postoperative pain may be severe after coronary artery bypass surgery. High thoracic epidural analgesia (HTEA) provides intense analgesia. METHODS: Eighty patients were randomized to HTEA or intravenous morphine analgesia (control). Patients received coronary artery bypass surgery (CABG) with cardiopulmonary bypass. Pain was measured by visual analogue scale 0 to 10. Psychologic morbidity, intraoperative hemodynamics, ventricular function, lung function, and physiotherapy cooperation were also assessed. On the third postoperative day HTEA and morphine were ceased and only oral medications were used. Acetaminophen, indomethacin, and tramadol were allowed as supplemental analgesics in both groups. RESULTS: The primary endpoint of pain scores was significantly less with HTEA on postoperative days 1 and 2 at rest, 0.02 +/- 0.2 versus 0.8 +/- 1.8 (p = 0.008) and 0.1 +/- 0.4 versus 1.2 +/- 2.7 (p = 0.022), respectively, and with coughing 1.2 +/- 1.7 versus 4.4 +/- 3.1 (p < 0.001) and 1.5 +/- 2.0 versus 3.6 +/- 3.1 (p = 0.001), respectively. When HTEA and morphine were ceased on day 3, there were no significant differences. The secondary endpoints of postoperative depression (p = 0.033) and posttraumatic stress subscales (p = 0.021) of the Minnesota Multiphasic Personality Inventory were lower with HTEA. Extubation occurred earlier with HTEA, 2.6 versus 5.4 hours (p < 0.001). HTEA showed improved physiotherapy cooperation (p < 0.001), arterial oxygen tension (p = 0.041), and peak expiratory flow rate (p = 0.001). Mean arterial pressure was lower with HTEA (p = 0.036), otherwise there were no differences in intraoperative hemodynamics or ventricular function. CONCLUSIONS: Epidural analgesia reduces pain after coronary operation and is associated with improved physiotherapy cooperation, earlier extubation, and reduced risk of depression and posttraumatic stress.     

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.     

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.     

Postoperative internal thoracic artery spasm after coronary artery bypass grafting

Spasm of the left internal thoracic artery in the perioperative period represents a life-threatening complication after coronary artery bypass grafting. We present a case in which graft spasm was treated with the administration of intra-arterial nitroglycerin and verapamil. Although vasospasm is more often seen in radial artery grafts, this case demonstrates that left internal thoracic artery grafts are also prone to spasm.     

High thoracic epidural anesthesia for off-pump coronary artery bypass surgery

OBJECTIVE: To assess the feasibility of high thoracic epidural anesthesia combined with sevoflurane for off-pump coronary artery bypass surgery and to evaluate the postoperative pain control, side effects, and perioperative hemodynamics. DESIGN: Retrospective review of prospectively collected data. SETTING: A university teaching hospital. PARTICIPANTS: One hundred six consecutive patients receiving thoracic epidural combined with sevoflurane. INTERVENTION: From November 1999, the patients undergoing off-pump coronary artery bypass grafting were offered the epidural-inhalation anesthetic approach. MEASUREMENTS AND MAIN RESULTS: Insertion of the epidural catheter was successful in all but 2 patients; 1 bloody tap occurred and the dura was never punctured, although 1 patient presented with postoperative paraplegia. An emergency spinal cord nuclear magnetic resonance excluded signs of medullary compression caused by epidural or spinal hematoma. Visual analog scale scores for pain during the first 24-hour period were < 2 in all patients. Mean time to extubation was 4.6 +/- 2.9 hours. The average intensive care unit stay was 1.5 +/- 0.8 days. Incidences of perioperative myocardial infarction, myocardial ischemia, and atrial fibrillation were 2.8%, 7.5%, and 10.6%, respectively. Two patients died: 1 from multiorgan failure and the other from myocardial infarction. Heart rate, mean arterial pressure, cardiac index, and systemic vascular resistance were not affected by thoracic epidural alone. Mean arterial pressure and cardiac index decreased (p < 0.05) when general anesthesia was induced and remained stable thereafter. Neither heart rate nor systemic vascular resistance changed from baseline during operation. CONCLUSIONS: Thoracic epidural as an adjunct to general anesthesia is a feasible technique in off-pump coronary artery bypass surgery. It induces intense postoperative analgesia and does not compromise central hemodynamics.     

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.     

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.     

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.