Evaluation of preoperative intraaortic balloon pumping for high risk off-pump coronary artery bypass grafting

We evaluated the effect of preoperative intraaortic balloon pumping (IABP) support in high risk patients undergoing off-pump coronary artery bypass grafting (OPCAB). Between November 1999 and December 2010, 65 high-risk patients underwent OPCAB with the support of IABP inserted preoperatively. High risks were considered as (1) left main coronary artery stem stenosis > or = 75%, (2) unstable angina requiring intravenous nitrates and heparin, (3) preoperative left ventricular ejection fraction < or = 30%, (4) bilateral carotid artery stenosis > or = 75%. There were no hospital deaths or cerebrovascular complications. During operations, hemodynamics was stable with the support of low dose catecholamines, and no patient needed conversion to on-pump coronary artery bypass grafting. All patients were able to be weaned from IABP within 3 days (mean 5.7 hours) after the operation and were extubated within 4 days (mean 11.5 hours) after the operation. One patient had a peripheral embolism which might be related to insertion of IABP (1.5%). Preoperative IABP in high-risk patients undergoing OPCAB was considered to be useful and safe.     

Aggressive preoperative use of intraaortic balloon pump in elderly patients undergoing coronary artery bypass grafting

BACKGROUND: The use of the intraaortic balloon pump (IABP) in patients undergoing coronary artery bypass grafting has been traditionally associated with a high complication rate and adverse outcomes. However, recent reports show that many of these catastrophic outcomes can be avoided by preoperatively placing the IABP in high-risk patients. To further validate these reports, we defined a set of liberal criteria for preoperative IABP insertion and applied them to a series of elderly patients (70 years or older) undergoing isolated coronary artery bypass grafting. METHODS: Two hundred six consecutive patients who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass were retrospectively reviewed. A rapid recovery protocol emphasizing reduced cardiopulmonary bypass time, an anesthetic protocol for early extubation, perioperative administration of corticosteroids and thyroid hormone, and aggressive diuresis was applied to all patients. Patients who required an urgent operation because of failed percutaneous transluminal coronary angioplasty, a critical left main stenosis (70% or greater), pronounced left ventricular dysfunction (left ventricular ejection fraction 40% or less), or unstable angina refractory to medical therapy or who required an emergency reoperation received preoperative IABP support. RESULTS: The 30-day mortality rate for the entire group was 4.4%. There were 97 patients (47%) who received a preoperative IABP (group II) in comparison with 109 patients (53%) who did not fulfill the preoperative insertion criteria (group I). Patients in group II had a lower left ventricular ejection fraction (mean, 46% versus 59%, p<0.001) and a higher incidence of congestive heart failure (35% versus 17%, p<0.01) and acute myocardial infarction (37% versus 17%, p<0.01) than patients in group I. The average postoperative hospital length of stay for patients in group II was slightly longer than for those in group I (9.0+/-10.5 versus 6.0+/-3.7 days, p<0.01). However, there were no statistically significant differences in complication or mortality rates between the two groups. Only 2 patients (2.2%) had complications related to IABP insertion. Lower extremity ischemia occurred in both patients, and both were treated successfully with thromboembolectomy. CONCLUSIONS: Liberal preoperative insertion of the IABP can be performed safely in high-risk elderly patients undergoing coronary artery bypass grafting, with results comparable to those in lower risk patients.     

Elective intraaortic balloon counterpulsation in high-risk off-pump coronary artery bypass grafting

The beneficial effects of intraaortic balloon pump (IABP) in CABG with cardiopulmonary bypass (CPB) have been reported. However, the benefits of insertion of IABP electively in high-risk off-pump coronary artery bypass grafting (OPCAB) have not been established. Six hundred and twenty-five patients who underwent OPCAB form the study group. High-risk patients fulfilling two or more of the following: left main stem stenosis >70%, unstable angina, and poor left ventricular function, who had elective insertion of IABP preoperatively by the open technique (group I; n = 20) were compared with a similar high-risk group that did not (group II; n = 25). There were no significant differences in risk factors between the two groups (Euroscore 5.68). The mean number of grafts was similar. Postoperatively, there were no significant differences in the need for inotropes, duration of ventilation, arrhythmias, cerebrovascular, gastrointestinal, and infective complications (p = NS). There were no IABP-related complications. Acute renal failure requiring hemofiltration was higher in group II (n = 5; p < 0.05). Four patients (16%) in group II required postoperative IABP. Although intensive care stay was longer in group I (27.6 +/- 15.3 vs. 18.6 +/- 9.1 hours; p < 0.05), patients in group I were discharged earlier from hospital. There was no difference in mortality between the two groups (n = 1 in each group). In high-risk patients undergoing OPCAB, routine preoperative insertion of IABP electively reduces the incidence of acute renal failure. In addition it avoids the need for emergency insertion postoperatively and may result in earlier discharge.     

Intraaortic balloon pump therapy facilitates posterior vessel off-pump coronary artery bypass grafting in high-risk patients

Background. Displacement of the heart to expose posterior vessels during coronary artery bypass grafting (CABG) without cardiopulmonary bypass (off-pump CABG, or OPCAB) may impair cardiac function. We used the intraaortic balloon pump (IABP) preoperatively to reduce operative risk and to facilitate posterior vessel OPCAB in high-risk patients with left main coronary artery disease (> 75% stenosis), intractable resting angina, postinfarction angina, left ventricular dysfunction (ejection fraction < 35%), or unstable angina.

Methods. One hundred and forty-two consecutive patients who underwent multivessel OPCAB including posterior vessel revascularization were studied prospectively. The patients were divided into group I (n = 57), which received preoperative or intraoperative IABP, and group II (n = 85), which did not receive IABP. In group I, there were 34 patients with left main coronary artery disease, 24 patients with intractable resting angina, 8 patients with left ventricular dysfunction, 5 patients with postinfarction angina, and 40 patients with unstable angina. Seven patients received intraoperative IABP support owing to hemodynamic instability during OPCAB.

Results. There was no operative mortality in group I and 1 death in group II. The average number of distal anastomoses was not different between group I and group II (3.4 ± 0.9 versus 3.5 ± 0.9, p = not significant). There were no significant differences in the number of posterior vessel anastomoses per patient. There were no differences in ventilator support time, length of stay in the intensive care unit, hospital stay, and morbidity between the two groups. There was one IABP-related complication in group I.

Conclusions. IABP therapy facilitates posterior vessel OPCAB in high-risk patients, and surgical results are comparable with those in lower-risk patients.     

The effect and role of the intraaortic balloon pumping in off-pump coronary artery bypass

Eighty consecutive patients who underwent off-pump coronary artery bypass (OPCAB) were studied. They were divided into group I (n = 10) which received preoperative intraaortic balloon pumping (IABP), and group II (n = 70) which did not receive IABP. The indications for preoperative IABP were severe left main coronary artery disease in 7 patients, severe 3 vessel disease in 3 patients, unstable angina in 5 patients, acute myocardial infarction in 3 patients. There was no operative mortality in both groups. The average number of distal anastomosis 2.7/patients in group I and 3.3/patients in group II. There was no differences in ventilator support time, length of stay in the intensive care unit and morbidity between 2 groups. The average postoperative IABP support time was 5.4 hours. There was no IABP-related complication in group I. IABP was very effective to perform OPCAB surgery safety. Preoperative IABP may be effective modality to support OPCAB surgery not only in emergent case but also in elective case.     

Usefulness of preoperative intraaortic balloon pump therapy during off-pump coronary artery bypass grafting in high-risk patients

BACKGROUND: In off-pump coronary artery bypass grafting (OPCABG) surgery, the most critical complication is hemodynamic deterioration, which can occur during displacement of the heart to expose the target vessels. Preoperative intraaortic balloon pump (IABP) therapy improves cardiac performance and facilitates access to the target coronary artery while maintaining hemodynamic stability, especially in high-risk patients. METHODS: One hundred thirty-three consecutive patients who underwent OPCABG through sternotomy between April 2000 and July 2003 were studied. We compared the clinical results of 32 patients who underwent preoperative IABP placement (group 1) with those of 101 patients who did not have IABP placement (group 2). Of the 32 patients satisfying the insertion criteria, 15 had critical left main artery disease, 20 had unstable angina, 5 had acute myocardial infarction, and 5 had left ventricular dysfunction. RESULTS: There were no significant differences in the average number of distal anastomoses performed between group 1 and group 2 (3.1 +/- 0.8 versus 3.3 +/- 0.9, p = not significant). The complete revascularization rate was 95% in both group. There was no conversion to on-pump surgery in either group. There was no operative death in group 1 and only 1 death in group 2. In group 1, the number of patients who required prolonged ventilatory support (longer than 48 hours) was higher (3 versus 1, p = 0.036), and there was a higher incidence of low cardiac output syndrome (1 versus 0, p = 0.074). There were no IABP-related complications in group 1. CONCLUSIONS: Preoperative IABP therapy for high-risk coronary patients is very effective in preventing hemodynamic instability and providing surgical results comparable with those in moderate- to lower-risk patients.     

Routine preoperative insertion of IABP in high-risk off-pump coronary artery bypass grafting

The beneficial effects of intraaortic balloon pump (IABP) in coronary artery bypass graft surgery with cardiopulmonary bypass have been reported. However, whether preoperative insertion of IABP in high-risk off-pump coronary artery bypass grafting (OPCAB) has any beneficial effects remains to be established. We report our experience of preoperative insertion of IABP in OPCAB.     

Intraaortic balloon pumping in patients undergoing coronary artery bypass grafting

Beneficial effect of preoperative intraaortic balloon pumping (IABP) treatment in high-risk patients who had open heart surgery have been demonstrated. The purpose of this study is to determine the impact of preoperative IABP use on survival in high-risk patients undergoing coronary artery bypass grafting (CABG). METHODS: Two hundred seventy-seven consecutive patients having CABG at our institution were reviewed. Patients having an IABP were identified retrospectively and grouped into one of 3 groups as follows. Group A (n = 14): preoperative IABP for high-risk urgent or elective cases. Group B (n = 26): preoperative IABP for emergency cases. Group C (n = 6): unplanned intraoperative or postoperative IABP. RESULTS: Forty-six patients had an IABP (16.6% of total). Parsonnet score in group B was significantly higher (p < 0.05). Length of operation for group C was significantly longer (p < 0.05). Overall hospital mortality in the total group of 277 cases was 4.2%. Hospital mortality was 7.1% in group A, 7.7% in group B, and 50% in group C. Hospital mortality in group C was significantly higher (p < 0.01). CONCLUSIONS: The beneficial effect of preoperative treatment with IABP in high-risk patients undergoing CABG was confirmed. This approach resulted in a significantly lower hospital mortality.     

Operative techniques in awake coronary artery bypass grafting

BACKGROUND: Off-pump coronary artery bypass grafting was implemented to reduce trauma of surgical coronary revascularization by avoiding extracorporeal circulation. High thoracic epidural anesthesia further reduces intraoperative stress and postoperative pain. In addition, this technique even allows awake coronary artery bypass grafting, avoiding the drawbacks of mechanical ventilation and general anesthesia in high-risk patients. METHODS: Thirty-four patients underwent awake coronary artery bypass grafting with left internal thoracic artery to left anterior descending coronary artery by partial lower ministernotomy (n = 20), H-graft technique (n = 2), or rib cage-lifting technique (n = 2). In 9 cases we performed double bypass grafting, and in 1 case we performed triple-vessel coronary artery revascularization through complete median sternotomy. In addition to clinical outcomes, visual analog scale pain scores were recorded on days 1, 2, and 3 after surgery. RESULTS: Thirty-one patients remained awake throughout the whole procedure. Three patients required secondary intubation because of incomplete analgesia (n = 1) or pneumothorax (n = 2). Procedure time was 90 +/- 31 minutes, and recovery room stay was 4.2 +/- 0.6 hours. There were no in-hospital deaths or serious postoperative complications. In 1 case a graft occlusion was documented on predischarge angiography. Early postoperative pain was low (visual analog scale score of 30 +/- 6). CONCLUSION: These data demonstrate the feasibility and safety of various surgical coronary revascularization techniques without general anesthesia. Continuation of thoracic epidural analgesia provides good pain control and fast mobilization postoperatively. Surprisingly, the awake coronary artery bypass grafting procedure was well accepted by the patients.     

Quality of life and survival after transmyocardial laser revascularization with the holmium:YAG laser

BACKGROUND: The purpose of this investigation was to assess postoperative survival and quality of life with transmyocardial laser revascularization (TMR) in high-risk patients. METHODS: During a 24-month period, 81 consecutive patients underwent either sole therapy TMR (n = 34) or TMR with coronary artery bypass grafting (n = 47) using a holmium:yttrium-aluminum-garnet (YAG) laser. Outcomes were assessed in three high-risk groups, including patients with left ventricular dysfunction (ejection fraction < or = 0.40) (n = 37), unstable angina (n = 30), and congestive heart failure (n = 33). Disease-specific quality of life was assessed using the Seattle Angina Questionnaire in 58 late survivors and compared with an age-matched cohort undergoing coronary artery bypass grafting only (no TMR) (n = 20). RESULTS: Overall mortality was 6% +/- 3% (+/- 70% confidence limit) and appeared higher with left ventricular dysfunction (11% +/- 5% vs 2% +/- 2%), but the difference did not reach statistical significance (p = 0.17; power = 0.16). There was also no statistical difference with unstable angina (10% +/- 6% vs 4% +/- 3%; p > 0.53) or congestive failure (9% +/- 5% vs 4% +/- 3%; p > 0.66). However, survival at 18 months was significantly lower with left ventricular dysfunction (62% +/- 9% vs 90% +/- 5%; p < 0.003) and congestive failure (48% +/- 10% vs 96% +/- 3%; p < 0.001). For sole therapy TMR, quality of life was diminished comparing TMR with coronary artery bypass grafting (p < 0.004) and coronary artery bypass grafting only (p < 0.002). CONCLUSIONS: Transmyocardial laser revascularization can be performed in high-risk patients, but survival is significantly impaired in patients with left ventricular dysfunction and congestive failure, and quality of life is diminished without some degree of direct revascularization.     

Economic impact of preoperative intraaortic balloon pump therapy in high-risk coronary patients

BACKGROUND: The efficacy of preoperative intraaortic balloon pump therapy in high-risk coronary patients has been demonstrated earlier. METHODS: This study investigates the economic aspect by a detailed cost analysis of pooled information from two previously published randomized studies and 144 consecutive low-risk coronary artery bypass graft operations. Costs for patients receiving preoperative intraaortic balloon pump therapy before aortic cross-clamping (n = 62) were compared to those in a control group (n = 50). Detailed cost analysis was based on data provided by the hospital finance department. RESULTS: The total hospital costs were as follows: low-risk coronary artery bypass graft operations cost 35,335+/-1,694 Swiss francs ($23,400+/-$1,121); high-risk coronary artery bypass graft without preoperative intraaortic balloon pump therapy cost 65,892+/-31,719 Swiss francs ($43,637+/-$21,006); and high risk coronary artery bypass graft with preoperative intraaortic balloon pump therapy cost 41,948+/-10,379 Swiss francs ($27,780+/-$6,874) (p = 0.0015). There were no significant differences in average cost among the preoperative intraaortic balloon pump therapy subgroups. CONCLUSIONS: Preoperative intraaortic balloon pump therapy in high risk coronary patients is significantly cost-beneficial, With an average saving of 24,000 Swiss francs ($16,000) on the total hospital cost, a 36% cost reduction.     

Off-pump multivessel coronary artery surgery in high-risk patients

BACKGROUND: Coronary artery bypass surgery on cardiopulmonary bypass is associated with significant morbidity and mortality, which may be more marked in high-risk patients. We evaluated our results of off-pump coronary artery bypass (OPCAB) in high-risk patients with multivessel coronary artery disease and compared them with results in similar patients who underwent operation on cardiopulmonary bypass. METHODS: A total of 1,075 patients who underwent OPCAB between October 1996 and June 2001 and who had one or more of the following risk factors were included in the study: poor left ventricular function (EF < or = 30%), advanced age (> 70 years), left main stenosis, acute myocardial infarction, and redo coronary artery surgery. These patients were compared with 2,312 similar patients who underwent coronary artery bypass grafting on cardiopulmonary bypass during the same period. Preoperative risk factors, intraoperative variables, and postoperative results were analyzed and compared between two groups. RESULTS: The average number of grafts was 3.0 +/- 0.4 and 3.2 +/- 0.3 in the off-pump (OPCAB) and on-pump (CCAB) groups, respectively. Hospital mortality was 3.2% and 4.5% in OPCAB and CCAB groups respectively (p = 0.109). Perioperative myocardial infarction, requirement of inotropic agents, stroke, and renal dysfunction were comparable in two groups. Intubation time (19 +/- 5 vs 24 +/- 6 hours, p < 0.001), mean blood loss (362 +/- 53 vs 580 +/- 66 mL, p < 0.001), atrial fibrillation (14.3 vs 19.7%, p < 0.001), and prolonged ventilation (4.6 vs 7.6%, p = 0.002) were less in OPCAB group. Intensive care unit stay (20 +/- 8 hours) and hospital stay (6 +/- 3 days) were significantly less in the OPCAB group (p < 0.001). CONCLUSIONS: Off-pump coronary artery surgery can be safely performed in high-risk patients with multivessel coronary artery disease. Operative mortality is comparable to that associated with on-pump surgery, and avoidance of cardiopulmonary bypass is associated with reduced postoperative morbidity in these patients.     

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.     

Off-pump coronary artery bypass grafting in patients with significant left ventricular dysfunction

Objective  Off-pump coronary artery bypass grafting (OPCAB) is known to preserve left ventricular function better than conventional coronary artery bypass grafting (CCAB). This study was carried out to investigate the safety, feasibility and efficacy of off-pump coronary artery bypass grafting in patients with significant left ventricular dysfunction. Methods  Three hundred and eighty eight consecutive patients with preoperative left ventricular ejection fraction ≤ 39% who underwent CABG between January 2001 through October 2007 were included in this retrospective study. Two hundred and eleven patients were operated by off-pump technique (group 1) and 178 patients were operated by on-pump technique (CCAB) (group 2). The postoperative outcomes were analyzed. Of these, 204 (52.57%) patients were diabetics, 355 (91.49%) patients had documented prior myocardial infarction, 316 (81.44%) patients were in canadian cardiovascular society(CCS) class III and 47 (12.11%) patients were in CCS class IV. Results  There was no significant difference in the number of grafts per patient between the two groups [group 1 3.02 ± 0.76 vs group 2 3.18 ± 0.72 (P=0.07) and the index of completeness of revascularization was comparable [1.08 ± 0.08) (OPCAB) vs 1.04 ± 0.06 (CCAB) (p=0.52)] The left internal thoracic artery was anastomosed to left anterior descending artery in 98% of patients. Operative mortality was 2.8% (6 deaths) following OPCAB and 3.93% (7 deaths) following CCAB (p=0746). Postoperative usage of IABP support was higher in CCAB group (12 patients vs 4 patients: P<0.03) and usage of moderate or higher doses of inotropic support was also higher in the conventional group (p<0.0006). More worsening of preexisting renal insufficiency was observed in CCAB group (p=0.01) and no significant difference in the incidence of atrial fibrillation was observed between the groups. Conclusions  Off-pump coronary artery bypass grafting is feasible and safe in patients with depressed left ventricular function and the postoperative morbidity was less in OPCAB group compared to on-pump group.     

术前置入主动脉内球囊反搏对高危冠状动脉旁路移植术患者预后的影响

目的比较高危冠心病患者术前预防性置入主动脉内球囊反搏(IABP)和被动紧急置入IABP对临床预后的影响. 方法 35例接受冠状动脉旁路移植手术同时需接受IABP置入的患者,根据置入的时机不同分为两组.术前置入组 接受术前预防性置入IABP;对照组术中或术后接受紧急置入IABP.比较两组围术期死亡率、心肌梗死发生率、术后心功能不全和需要正性肌力药物辅助的程度、IABP使用的时间、术后呼吸机辅助时间和重症监护治疗病房(ICU)停留时间. 结果术前置入组围手术期死亡率和心肌梗死发生率分别为11.1%和0%,较对照组低(65.4%,50%;P＝0.007,0.013);两组呼吸机辅助通气时间、IABP使用时间、术后需正性肌力药物辅助时间以及术后平均住ICU时间差别均有显著性意义(P＜0.05). 结论术前预防性置入IABP能降低围术期死亡率、心肌梗死发生率,减少对正性肌力药物的需要量和缩短住ICU时间.     

Renal dose dopamine in open heart surgery. Does it protect renal tubular function?

BACKGROUND: This prospective, randomized study assessed the effect of dopamine on renal tubular function in patients who had coronary artery bypass grafting. METHODS: Two groups of patients with normal preoperative renal function were randomly divided into a dopamine group (n=11), who received dopamine in a dose of 2 mg/kg x min, and a control group (n=11), who received no treatment. Dopamine infusion was initiated 24 hours before the operation and was continued for 48 hours postoperatively. Measurements of renal function obtained 2 days before the operation were considered preoperative and were repeated on the 1st, 3rd, and 7th postoperative days. Urinary excretion of b2-Microglobulin (b2-M), considered a sensitive means for diagnosing proximal tubular damage, was measured during the early (day 3) and late (day 7) postoperative period. RESULTS: There were no significant differences respect to the clearances of creatinine, osmotic, and free-water in the dopamine group compared with the control group (p>0.05). Urine microalbumin levels significantly increased on postoperative day 3 in both groups. During the early postoperative period, excretion of urine b2-M was significantly greater in the dopamine group than in the control group (p<0.05). CONCLUSIONS: Consequently, in patients with normal preoperative renal and cardiac function scheduled for elective coronary artery bypass grafting, renal dose dopamine infusion alone may not provide sufficient protection on tubular function and increases renal tubular injury during the early postoperative period.     

Initial experience with MIDCAB grafting using the gastroepiploic artery.

BACKGROUND: Minimally invasive direct coronary artery bypass grafting with the gastroepiploic artery can be used in primary operations and reoperations to revascularize the inferior or anterior surface of the heart. METHODS: Patients who had symptomatic coronary artery disease limited to a single coronary distribution were selected. Coronary targets were grafted with the pedicled gastroepiploic artery through a small midline epigastric incision. Patients were followed with scheduled outpatient clinic visits, Doppler examination, and selective recatheterization. RESULTS: Between May 1995 and November 1997, 74 patients underwent gastroepiploic artery minimally invasive direct coronary artery bypass grafting; 33 (45%) had a primary operation and 41 (55%), a reoperation. Grafting was performed to the distal right coronary artery (n = 38), the posterior descending artery (n = 28), or the distal left anterior descending coronary artery (n = 8). There were six deaths (8%) within 30 days after operation. Twenty patients (28%) underwent recatheterization; there were two graft occlusions, two graft stenoses, and five anastomotic stenoses. Of 60 patients seen 2 or more weeks after operation, 53 (88%) had resolution of anginal symptoms at a mean follow-up of 10.9 months (range, 0 to 30 months). CONCLUSIONS: Inferior minimally invasive direct coronary artery bypass grafting with the gastroepiploic artery avoids the risks of repeat sternotomy, aortic manipulation, and cardiopulmonary bypass. Patency rates, however, were lower than expected, and there is significant morbidity and mortality associated with high-risk patients undergoing the procedure. Continued follow-up is essential to evaluate long-term graft patency and patient survival.     

On-pump versus off-pump coronary artery bypass grafting: impact on postoperative renal failure requiring renal replacement therapy

BACKGROUND: Despite refinements in perioperative patient management postoperative renal failure requiring hemofiltration or dialysis is still a common complication after coronary artery bypass grafting associated with impaired patient outcome. METHODS: Prospective data on 9,631 patients receiving myocardial revascularization with (coronary artery bypass grafting [n = 8,870]) or without cardiopulmonary bypass (off-pump coronary artery bypass grafting [n = 761]) between April 1996 and August 2001 were evaluated by univariate and multivariate logistic regression analysis. RESULTS: Overall prevalence of postoperative continuous renal replacement therapy was 4.1% (coronary artery bypass grafting, 4.3%; off-pump coronary artery bypass grafting, 1.8%; p = 0.001). Thirty of 40 selected preoperative and intraoperative patient and treatment related variables had a high association with the requirement for postoperative renal replacement therapy; fifteen of these variables were independent predictors in the whole study population. Off-pump coronary artery bypass surgery was identified as having a significantly lower predictive value for postoperative continuous renal placement therapy. In the subgroup of patients undergoing off-pump coronary artery bypass grafting surgery, a second multivariate logistic regression model revealed preoperative cardiogenic shock, urgent operation, intraoperative low cardiac output, and high transfusion requirement as independent predictors for postoperative renal replacement therapy. CONCLUSIONS: Patients with preoperative nondialysis dependent renal insufficiency are at a high risk for further decline in renal function requiring postoperative continuous renal replacement therapy. Off-pump coronary artery bypass surgery is associated with a lower prevalence of postoperative renal replacement therapy after coronary artery bypass grafting.     

Neurocognitive deficit following coronary artery bypass grafting: a prospective study of surgical patients and nonsurgical controls

Background

To objectively measure long-term neurocognitive deficit in patients undergoing coronary artery bypass grafting and compare the findings with nonsurgical controls.

Methods

We prospectively measured neurocognitive function in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (n = 104; mean age 64.1 years old; EuroSCORE 2.7 [means]). A cohort of age- and sex-matched patients (n = 80; mean age 63.4 years old) served as nonsurgical controls. After CABG, neurocognitive function was serially reevaluated at 7-day (n = 104), 4-month (n = 100), and 3-year follow-up (n = 88). Neurocognitive function was objectively measured by means of cognitive P300 evoked potentials. Additionally, standard psychometric tests were performed (Trailmaking Test A, Mini Mental State Examination).

Results

As compared to preoperative measures (364 ± 36 ms), cognitive P300 evoked potentials were prolonged (=impaired) at 7-day (381 ± 36 ms; p = 0.001), 4-month (378 ± 31 ms; p = 0.08), and 3-year follow-up (379 ± 35 ms; p = 0.002), respectively. Trailmaking Test A was abnormal, as compared to preoperative, at 3-year follow-up (p < 0.001). Before the operation, surgical patients were fully comparable in P300 measures to nonsurgical controls (363 ± 32 ms; p = 0.362). Most importantly, throughout the entire postoperative follow-up cognitive measures in surgical patients were prolonged (=impaired) as compared with controls (7-day p = 0.001; 4-month p = 0.002 and 3-year p = 0.003, respectively). In stepwise multivariate regression analysis, neurocognitive deficit at 4-month follow-up (p < 0.001), age (p = 0.012), and persistent atrial fibrillation (p = 0.024) were predictive for long-term neurocognitive deficit at 3-year follow-up.

Conclusions

As shown by means of objective measures, and in comparison to nonsurgical controls, coronary artery bypass grafting with cardiopulmonary bypass grafting causes long-term neurocognitive deficit.     

Resource utilization in on- and off-pump coronary artery surgery: factors influencing postoperative length of stay--an experience of 1,746 consecutive patients undergoing fast-track cardiac anesthesia

OBJECTIVE: The purpose of the present investigation was to examine factors influencing resource utilization in patients undergoing on-pump coronary artery bypass graft and off-pump coronary artery bypass (OPCAB) graft surgery at a major university hospital. The resources examined were time to extubation, packed red blood cell (PRBC) transfusion, intensive care length of stay (ICULOS), preoperative and postoperative length of stay (PLOS), and total length of stay (LOS). DESIGN: Observational study of consecutive patients undergoing on- and off-pump coronary artery bypass surgery. SETTING: Tertiary care cardiac referral center. PARTICIPANTS: One thousand seven hundred forty-six consecutive male and female patients undergoing primary coronary artery bypass graft (CABG) surgery over a period of 3 years (1999-2001). Eight hundred eighty-one patients underwent CABG with pump, and 865 patients underwent off-pump coronary artery bypass (OPCAB) surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The mean time to extubation after surgery was 7.4 hours for on-pump patients and 5.8 hours for the OPCAB group (p72 hours to postoperative tracheal extubation compared with 1.5% in the OPCAB group (p=0.041). Hospital mortality was 2.7% for the on-pump group and 1.0% for the OPCAB group (p=0.010). CONCLUSION: The authors found that patients undergoing on-pump CABG have significantly longer time to tracheal extubation, increased blood use, longer ICULOS, PLOS, and total LOS and higher in-hospital mortality, which would translate into significant differences in the expenses associated with these 2 surgical approaches to coronary surgery.