Impact of off-pump coronary artery bypass surgery on postoperative bleeding: current best available evidence

Cardiopulmonary bypass (CPB) is a prerequisite for open-heart surgery, and is a procedure routinely used. CPB exposes blood to artificial surfaces, to mechanical trauma from the pump, to alterations in temperature, and to dilution with fluids, whole blood, plasma products, and drugs, and leads to the activation of platelets, coagulation, and fibrinolysis. Coagulopathy during cardiac surgery with CPB results in impairment in hemostasis and subsequently higher morbidity and mortality. Recent advances in surgical techniques and postoperative management have aimed at reducing postoperative morbidity and mortality. Off-pump coronary artery bypass (OPCAB) surgery is one such advance that attempts to avoid the deleterious effects of extracorporeal circulation by performing myocardial revascularization without CPB. Emerging evidence from several randomized controlled trials (RCTs) as well as large registries such as the Society of Thoracic Surgeons (STS) database suggests that OPCAB reduces the postoperative morbidity and mortality. This review article attempts to evaluate the current best available evidence from RCTs on the impact of OPCAB on postoperative bleeding and transfusion requirements.     

Initial experience with beating heart surgery: comparison with fast-track methods.

Cardiopulmonary bypass (CPB) in coronary artery bypass grafting (CABG) may increase postoperative complications in high-risk patients. The goal of this study is to retrospectively review a series of consecutive patients undergoing conventional CABG using a fast-track recovery method and to compare this series with the initial series of patients undergoing beating heart surgery using either the single-vessel minimally invasive approach or the off-pump multivessel bypass technique with a median sternotomy. One hundred fifty-eight consecutive patients underwent CABG. One hundred four patients underwent conventional CABG using CPB with a short-pump fast-track recovery method (Group A). Twenty-nine patients underwent a single-vessel bypass via a left anterior thoracotomy off pump [Group B, minimally invasive direct coronary artery bypass (MIDCAB)]. Twenty-five patients underwent multivessel CABG with a median sternotomy off pump (Group C). Short-pump fast-track (Group A) patients exhibited minimal complications and expedient recovery and received extensive revascularization. Off-pump multivessel patients (Group C) received fewer bypass grafts, had more preoperative comorbidity, and recovered as quickly as lower-risk fast-track short-pump patients (Group A). Single-vessel off-pump patients (Group B, MIDCAB) were younger elective patients and demonstrated no recovery advantage. The overall mortality was 1.8 per cent. The conversion rates from beating heart surgery to CPB for groups B and C were 10.3 and 16 per cent, respectively. The postoperative hospital length of stay for groups A, B, and C were 4.8+/-2.4, 3.9+/-1.8, and 5.2+/-2.3 days, respectively. Eliminating CPB is not as important as reducing exposure for minimizing operative risk. Beating heart surgery is an adjunct to conventional CABG with CPB. The off-pump multivessel bypass technique is best suited for high-risk patients requiring three grafts or fewer, whereas MIDCAB is best suited for single-vessel bypass that cannot be managed using interventional percutaneous techniques; however, the recovery advantage with MIDCAB is not apparent. Patients requiring more than three bypass grafts should undergo conventional CABG with CPB.     

Beating‐Heart Coronary Artery Bypass Grafting With Miniaturized Cardiopulmonary Bypass Results in a More Complete Revascularization When Compared to Off‐Pump Grafting

The technique of miniaturized cardiopulmonary bypass (M‐CPB) for beating‐heart coronary artery bypass grafting (CABG) is relatively new and has potential advantages when compared to conventional cardiopulmonary bypass (CPB). M‐CPB consists of less tubing length and requires less priming volume. The system is phosphorylcholine coated and results in minimal pump‐related inflammatory response and organ injury. Finally, this technique combines the advantages of the off‐pump CABG (OPCAB) with the better exposure provided by CPB to facilitate complete revascularization. The hypothesis is that CABG with M‐CPB has a better outcome in terms of complete coronary revascularization and perioperative results as that compared to off‐pump CABG (OPCAB). In a retrospective study, 302 patients underwent beating‐heart CABG, 117 (39%) of them with the use of M‐CPB and 185 (61%) with OPCAB. After propensity score matching 62 patients in both groups were demographically similar. The most important intra‐ and early‐postoperative parameters were analyzed. Endpoints were hospital mortality and complete revascularization. Hospital mortality was comparable between the groups. The revascularization was significantly more complete in M‐CPB patients than in patients in the OPCAB group. Beating‐heart CABG with M‐CPB is a safe procedure and it provides an optimal operative exposure with significantly more complete coronary revascularization when compared to OPCAB. Beating‐heart CABG with the support of a M‐CPB is the operation of choice when total coronary revascularization is needed.     

Multivessel off-pump coronary artery bypass surgery in the elderly.

OBJECTIVE: Coronary artery bypass grafting in the elderly patient is associated with increased perioperative morbidity and mortality. The avoidance of cardiopulmonary bypass (CPB) in this population is potentially beneficial. We examined our initial experience with off-pump multivessel coronary artery revascularization in patients aged 70 years and older. METHODS: In a consecutive series of 300 off-pump coronary artery bypass (OPCAB) operations performed by a single surgeon between 1996 and 1999, 98 patients were aged 70 years and older. These patients were compared with a consecutive cohort of 497 patients aged 70 years and older operated on with CPB in the same institution from 1995 to 1996, period where OPCAB surgery was not performed in our institution. RESULTS: Patients in the beating heart group were older (75+/-4 vs. 74+/-3 years; P=0.001). Gender distribution and other preoperative risk factors were comparable for the two groups. On average, 3.0+/-0.8 and 2.8+/-0.7 grafts per patient were completed in the OPCAB and the CPB groups, respectively (P=0.007). Perioperative mortality rates (OPCAB group, 3.1%; CPB group, 3.6%), perioperative myocardial infarction (OPCAB, 2.0%; CPB, 5.1%) and neurologic events (OPCAB, 1.0%; CPB, 3.2%) were comparable for the two groups. The incidence of postoperative atrial fibrillation was lower in the OPCAB group (42 vs. 54%; P=0.05). The need for allogenic blood transfusions was significantly less in the OPCAB group (53 vs. 82%; P=0.001). CONCLUSIONS: In patients aged 70 years and older, multivessel OPCAB surgery is associated with lower rates of postoperative atrial fibrillation and reduced transfusion requirements. Multivessel OPCAB in the elderly patient is an acceptable alternative to procedures performed with CPB.     

Off-pump technique in coronary artery bypass grafting in elderly patients

Background: The use of cardiopulmonary bypass (CPB) during coronary artery bypass grafting (CABG) is associated with substantial morbidity and mortality, especially in the elderly. The purpose of this study was to evaluate the feasibility of beating heart coronary artery revascularization in patients aged at least 80 years. Methods: A retrospective chart review was carried out for 17 patients aged over 80 years who underwent isolated off‐pump CABG at the Tri‐Service General Hospital, Taiwan, during the period July 1999 to December 2000. The demographic characteristics, operative data, postoperative results and short‐term outcomes of patients were compared with those of 12 patients who underwent conventional CABG using CPB during the same time period. Results: The off‐pump group consisted of 13 men and four women with a mean age of 82.2 ± 0.9 years and an ejection fraction of 53.4 ± 4.1%. The on‐pump group consisted of eight men and four women with a mean age of 83.5 ± 0.5 and an ejection fraction of 42.0 ± 4.8%. The mean number of anastomoses performed per patient was 3.1 ± 0.3 in the off‐pump group and 3.0 ± 0.14 in the on‐pump group. There was no occurrence of stroke, myocardial infarction, re‐entry for bleeding or renal failure among patients in the off‐pump group. Intubation time (10.6 vs 48.4 h), intensive care unit stay (2.9 vs 4.2 days) and postoperative stay (12.7 vs 18.1 days) were significantly shorter in the off‐pump group than in the on‐pump group. No patient died in the off‐pump group, whereas one patient died in the on‐pump group. Conclusions: The results of this study suggest that the off‐pump technique is a safe and efficacious method for myocardial revascularization in elderly patients and that the short‐term outcome obtained with this technique are promising. Our data suggest that the off‐pump technique is preferable in these patients.     

Midterm outcomes of off-pump and on-pump coronary artery revascularization in renal transplant recipients

Abstract Objectives: Renal transplant recipients have high mortality from cardiac causes and are frequently in need of coronary interventions. Surgical coronary revascularization is associated with significant morbidity and mortality in this patient population. This study was undertaken to evaluate outcomes of on‐pump versus off‐pump revascularization in renal transplant recipients. Methods: We retrospectively reviewed 43 renal transplant recipients who underwent surgical coronary revascularization with functioning allografts. Revascularization was performed on‐pump [coronary artery bypass grafting (CABG)] in 21 patients and off‐pump [off‐pump coronary artery bypass (OPCAB)] in 22 patients. Results: Preoperative characteristics did not differ between the two groups except for age and incidence of prior sternotomy. Total operative time and transfusion requirements were similar. The on‐pump group received a higher number of bypass grafts (p = 0.03). Overall 30‐day, one‐year, five‐year, and eight‐year survival was 90%, 76%, 61%, and 32% for CABG group, and 95%, 86%, 62%, and 48% for OPCAB group (p = 0.53). The postoperative peak creatinine was higher in the CABG patients than in OPCAB patients (p = 0.04). At discharge, there was no difference in mean creatinine between the two groups. The rate of return to permanent dialysis after revascularization was similar (28% for CABG and 22% for OPCAB, p = 0.73). There was no difference in dialysis‐free survival up to eight‐years postrevascularization (p = 0.63). Conclusions: Despite higher mortality risk, surgical coronary revascularization can be performed safely in renal transplant recipients. OPCAB resulted in no improvement in patient survival or renal allograft function compared to on‐pump revascularization. (J Card Surg 2011;26:591‐595)     

Stroke in octogenarians undergoing coronary artery surgery with and without cardiopulmonary bypass

BACKGROUND: Myocardial revascularization in elderly patients is associated with a morbidity and a mortality substantially higher than those observed in younger patients. The aim of this study was to analyze the potential benefits of coronary artery bypass grafting without cardiopulmonary bypass (CPB) for octogenarians. METHODS: Of 269 octogenarians who underwent coronary artery bypass grafting at our institution between January 1995 and May 1999, 172 had the operation with CPB (CPB group) and 97, without CPB (off-pump group). Revascularization of the circumflex system or right coronary artery were not considered contraindications to off-pump grafting. Demographic data, preoperative risk factors, comorbid conditions, angiographic findings, postoperative complications, and outcomes were compared. RESULTS: The groups were comparable for age, sex, Canadian Cardiovascular Society class, operative priority (elective, urgent, or emergent), preoperative risk factors, and left ventricular ejection fraction. A significantly higher proportion of reoperations was observed in the off-pump cohort (16 of 97, 16.5%) compared with the CPB cohort (8 of 172, 4.7%) (p = 0.002). There was a trend toward a higher graft-patient ratio in the CPB group (3.3 versus 1.8; p = not significant). Freedom from postoperative complications was significantly higher in the off-pump group than in the CPB group (83 of 97, 85.6%, versus 129 of 172, 75%; p = 0.04). The incidence of stroke was 0% in the off-pump cohort compared with 9.3% (16 of 172) in the CPB cohort (p < 0.0005). Although there was a trend toward higher 30-day and risk-adjusted mortality rates in the off-pump group than in the CPB group (10.3% versus 5.2% and 2.8% versus 1.8%, respectively), the differences were not significant. The length of hospitalization was slightly lower in the off-pump group (9.1 versus 10.8 days; p = not significant). CONCLUSIONS: This investigation suggests that patients 80 years of age and older undergoing off-pump coronary artery bypass grafting can experience significantly lower rates of perioperative stroke and overall complications compared with those undergoing the same procedure with CPB, although a trend toward higher mortality rates was observed in the off-pump group.     

Beating heart surgery: why expect less central nervous system morbidity?

BACKGROUND: The incidence and etiology of brain dysfunction after conventional coronary artery bypass surgery using cardiopulmonary bypass (CPB) are reviewed. METHODS: Stroke rates and incidences of cognitive dysfunction from various studies are considered. Mechanisms of injury including cerebral embolization as detected by transcranial Doppler and retinal angiography, and imaging-based evidence for postoperative cerebral edema, are discussed. Preliminary results from a prospective clinical trial assessing cognitive dysfunction after beating heart versus conventional coronary artery bypass with CPB are discussed. RESULTS: Initial evidence for lower overall postoperative morbidity, and for a lower incidence of cognitive dysfunction specifically, after nonpump coronary revascularization is presented. CONCLUSIONS: Beating heart surgery results in less potential for generation of cerebral emboli and appears to produce a lower incidence of cognitive dysfunction in both short- and intermediate-term postoperative follow-up periods as compared with conventional coronary artery bypass surgery using CPB.     

Aortocoronary bypass grafting in high-risk patients over 75 years. Propensity score analysis of on versus off-pump, early and midterm results

AIM: Bypass surgery in high risk patients over the age of 75 results in increased mortality and morbidity, which may be also related to the cardiopulmonary bypass system. METHODS: Using the propensity score analysis, we have selected two homogeneous groups of high-risk elderly patients undergoing coronary surgery: 41 patients operated with cardiopulmonary bypass- coronary artery bypass graft (CPB-CABG), and 78 patients operated without cardiopulmonary bypass (off-pump coronary artery bypass graft, OPCABG). All preoperative and operative variables were similar and outcomes were compared. RESULTS: Perioperative mortality was higher in the patient group operated with CPB (12.2%) as compared to patients operated without CPB (1.3%, P = 0.01). Perioperative complications were more frequent in the CPB-CABG group. Logistic regression analysis showed that avoiding CPB was an independent protective factor for mortality and morbidity. Midterm survival, freedom from angina, freedom from reintervention, and Canadian Cardiovascular Society (CSS) class were comparable between the 2 groups. CONCLUSION: OPCABG is safe in the high risk elderly population and significantly reduces postoperative mortality and morbidity. There are no differences in midterm results between the 2 groups of patients in our study.     

Off‐pump,minimally invasive and robotic coronary revascularization yield improved outcomes over traditional on‐pump CABG

Coronary artery disease is a global health concern, with increasing morbidity and mortality. Surgical coronary artery bypass grafting has been performed on cardiopulmonary bypass for nearly four decades, with excellent long‐term durability. Beating‐heart coronary surgery has been increasing in frequency in an attempt to decrease cardiopulmonary bypass‐related morbidity. Furthermore, with increasing expertise and technology, minimally invasive and robotic techniques have been developed to enhance post‐operative recovery, patient satisfaction and cosmesis. Several clinical trials have demonstrated decreased morbidity and more rapid recovery following off‐pump, minimally invasive and robotic procedures when compared to on‐pump coronary artery bypass grafts (CABGs). An equivalent extent of revascularization and medium‐term anastomotic patency has been demonstrated among all approaches. Furthermore, for a large number of patients who do not have anatomy amenable to traditional coronary revascularization, adjunctive molecular therapies may provide alternative myocardial micro‐revascularization. Copyright © 2008 John Wiley & Sons, Ltd.     

Conscious off pump coronary artery bypass surgery--an audit of our first 151 cases.

PURPOSE: An audit of our first 151 cases of conscious off pump coronary artery bypass (COPCAB) surgery with epidural anesthesia as sole anesthetic. METHODS: Patients underwent conscious off pump coronary artery bypass (OPCAB) surgery using high thoracic epidural anesthesia. The epidural catheter was inserted on the day before the surgery. RESULTS: There were 118 male and 33 female patients. The incision was via midsternotomy except in 3 patients. Single graft was performed in 25 patients, double in 61, triple in 46, quadruple in 19. Twenty-nine patients developed pneumothorax. Three patients required conversion to general anesthesia. In one patient cardiopulmonary bypass (CPB) was instituted. There was no mortality in the group. CONCLUSION: Our experience shows that conscious OPCAB surgery can be performed safely in selected patients.     

Elective preoperative use of intra aortic balloon counterpulsation in high risk group of coronary artery disease patients to facilitate off pump surgery

Background To avoid the deleterious effects of cardio-pulmonary bypass, off pump coronary artery bypass graft surgery (OPCABG) is increasingly the procedure of choice in the majority of patients needing myocardial revascularization. However patients at high operative risk are sometimes not given the advantage of off pump surgery because of haemodynamic deterioration during displacement of the heart to access the target vessels, or deterioration per se due to the factor causing the high risk (eg unstable hemodynamics) leading to institution of cardio-pulmonary bypass (CPB). Preoperative intraaortic balloon counterpulsation (IABC) therapy improves cardiac performance and facilitates the access to the anastomotic site during off pump coronary artery bypass grafting while maintaining haemodynamic stability. Methods Two hundred and twelve patients for isolated coronary artery bypass grafting (CABG) between June 2000 and June 2006 were studied in whom preoperative IABC was instituted. Initially, the trial was started in two groups and patients were computer randomized to ‘IABC’ and ‘No IABC’ groups. The trial was abandoned after 15 cases in each group, because of the adverse outcomes in ‘No IABC’ group. Left main stenosis was present in 31.1%, triple vessel disease in 87.7%, recent myocardial infarction in 21.2%, 35.8% were hypertensive, and 32% were diabetic. Results Out of 212 cases in whom preoperative IABC was instituted OPCABG was possible in the majority (88.2%), while of 15 cases in ‘No IABP’ group all CABG were done on CPB. Mortality and average stay in ICU was markedly lower in patients where IABC was instituted preoperatively. Conclusions Elective preoperative IABC in patients with high-risk coronary artery disease permits OPCABG in the majority, reduces the ICU stay, leads to earlier weaning from intra aortic balloon pump (IABP), reduces the morbidity and mortality, and is more economical.     

Inflammatory response after coronary revascularization with or without cardiopulmonary bypass

BACKGROUND: We sought to investigate the effect of multiple coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass (CPB) on the perioperative inflammatory response. METHODS: Sixty patients undergoing CABG were randomly assigned to one of two groups: (A) on pump with conventional CPB and cardioplegic arrest, and (B) off pump on the beating heart. Serum samples were collected for estimation of neutrophil elastase, interleukin 8 (IL-8), C3a, and C5a preoperatively and at 1, 4, 12, and 24 hours postoperatively. Furthermore, white blood cell (WBC), neutrophil, and monocyte counts were carried out preoperatively and at 1, 12, 36 and 60 hours postoperatively. Overall incidence of infection and perioperative clinical outcome were also recorded. RESULTS: The groups were similar in terms of age, weight, gender ratio, extent of coronary disease, left ventricular function, and number of grafts per patient. Neutrophil elastase concentration peaked early after CPB in the on-pump group, with a decline with time. Repeated-measures analysis of variance between groups and comparisons at each time point (modified Bonferroni) showed elastase concentrations were significantly higher in the on-pump than the off-pump group (both p < 0.0001). IL-8 increased significantly after surgery in the on-pump group, with no decline during the observation period (p = 0.01 vs off pump). C3a and C5a rose early after surgery in both groups when compared with baseline values. Postoperative WBC, neutrophil, and monocyte counts were significantly higher in the on-pump than the off-pump group (p < 0.01). Finally, the incidence of postoperative overall infections was significantly higher in the on-pump group (p < 0.0001 vs off pump). CONCLUSIONS: CABG on the beating heart is associated with a significant reduction in inflammatory response and postoperative infection when compared with conventional revascularization with CPB and cardioplegic arrest.     

Concomitant carotid endarterectomy and coronary bypass surgery: should cardiopulmonary bypass be used for the carotid procedure?

BACKGROUND AND OBJECTIVES: With the increasing age of patients undergoing coronary artery bypass grafting (CABG), a greater number have associated clinically significant carotid disease. This study determined the morbidity and mortality for combined carotid endarterectomy (CEA)/CABG using cardiopulmonary bypass (CPB) for both procedures versus a combined approach using CPB only during CABG. PATIENTS AND METHODS: Between 1993 and 2000, 65 patients (Group I) underwent combined CEA and CABG using CPB for both surgical procedures and 88 patients (Group II) underwent combined CEA and CABG using CPB only during CABG. The demographic, clinical, and carotid and coronary angiographic data were similar between groups. In Group I, 22 (33.8%) patients and 32 (36%) patients in Group II presented with contralateral carotid artery stenosis. RESULTS: CPB time was significantly longer in Group I, 127+/-21 minutes versus 98+/-11 minutes in Group II patients (p = 0.001). The incidence of surgical revision for bleeding and deep sternal wound infection was higher in Group I patients, 2 (3%) versus 1 (1.1%) and 5 (7.7%) versus 2 (2.2%), respectively, but not significant. Hospital mortality in Group I was 6% (4 patients) versus 5.7% (5 patients) in Group II (p = ns). Neurologic complications occurred in 4 (6%) and 5 (5.7%) patients in Group I and II, respectively (p = ns). Postoperative renal dysfunction was more common in Group I patients (22 [33.8%]) then in Group II patients 16 (19%) (p = 0.04). Of these patients, (16 [19%]) 8 (12.3%) in Group I and 6 (6.8%) in Group II required postoperative ultrafiltration (p = ns). Infectious complications were more frequent in Group I patients, 5 (7.7%) versus 2 (2.3%), but not statistically significant (p = ns). Overall actuarial survival at 1, 3, and 5 years, including all deaths, was 92%, 88%, and 82% in Group I versus 93%, 86%, and 81% in Group II (p = ns). Overall freedom from stroke at 5 years was 87.5% in Group I and 86.4% in Group II. CONCLUSIONS: We conclude that combined CEA/CABG using CPB only during the myocardial revascularization procedure remains the technique of choice in patients with coronary and carotid artery disease, offering better outcome in terms of perioperative morbidity than a combined CEA/CABG using CPB for both procedures.     

Beating versus arrested heart revascularization: evaluation of myocardial function in a prospective randomized study.

OBJECTIVE: Conventional coronary artery bypass grafting (CABG) is both safe and effective. Nevertheless, the use of cardiopulmonary bypass (CPB) and cardioplegic arrest are associated with several adverse effects. Over the last 2 years there has been a revival of interest in performing CABG on the beating heart. In this prospective randomized study we evaluated the efficacy and safety of on and off pump coronary revascularization on myocardial function. METHODS: Eighty patients (65 males, mean age 61+/-9.7 years) undergoing first time CABG were prospectively randomized to: (i) conventional revascularization with CPB at normothermia and cardioplegic arrest with intermittent warm blood cardioplegia (on pump) or (ii) beating heart revascularization (off pump). Troponin I (Tn I) release was serially measured as a specific marker of myocardial damage. Haemodynamic measurements as well as inotropic requirement, incidence of arrhythmia and postoperative myocardial infarction were also recorded. RESULTS: There were no significant differences between the two groups in terms of age, sex, extent of disease, left ventricular function and number of grafts. There were no deaths or intraoperative myocardial infarctions in either group. Tn I release was constantly lower in the off pump group and this was significant at 1, 4, 12 and 24 h postoperatively. Furthermore, in this group there was a significantly reduced incidence of arrhythmias. Inotropic requirements were less in the off pump group but this did not reach statistical significance. CONCLUSION: These results suggest that off pump coronary revascularization is a safe and effective strategy for myocardial revascularization. Myocardial injury as assessed by Tn I release is also reduced when compared with conventional coronary revascularization with CPB and cardioplegic arrest.     

Does off-pump coronary surgery reduce morbidity and mortality?

OBJECTIVE: To compare hospital outcomes of on-pump and off-pump coronary artery bypass surgery. METHODS: From 1997 to 2000, primary coronary artery bypass grafting was performed in 481 patients off pump and in 3231 patients on pump. Hospital outcomes were compared between propensity-matched pairs of 406 on-pump and 406 off-pump patients. The 2 groups were similar in age (P =.9), left ventricular function (P =.7), extent of coronary artery disease (P =.5), carotid artery disease (P =.4), and chronic obstructive pulmonary disease (P =.5). However, off-pump patients had more previous strokes (P =.05) and peripheral vascular disease (P =.02); on-pump patients had a higher preoperative New York Heart Association class (P =.01). RESULTS: In the matched pairs the mean number of bypass grafts was 2.8 +/- 1.0 in off-pump patients and 3.5 +/- 1.1 in on-pump patients (P <.001). Fewer grafts were performed to the circumflex (P <.001) and right coronary (P =.006) artery systems in the off-pump patients. Postoperative mortality, stroke, myocardial infarction, and reoperation for bleeding were similar in the 2 groups. There was more encephalopathy (P =.02), sternal wound infection (P =.04), red blood cell use (P =.002), and renal failure requiring dialysis (P =.03) in the on-pump patients. CONCLUSIONS: Both off- and on-pump procedures produced excellent early clinical results with low mortality. An advantage of an off-pump operation was less postoperative morbidity; however, less complete revascularization introduced uncertainty about late results. A disadvantage of on-pump bypass was higher morbidity that seemed attributable to cardiopulmonary bypass.     

连续170例冠状动脉旁路移植术治疗冠心病

目的 回顾应用冠状动脉旁路移植术（ＣＡＢＧ）治疗冠心病的早期效果和经验。方法 １７０例（男１５２例,女１８例;年龄３５－８０岁,平均６６．７岁）冠心病病人中９７％为多支冠状动脉病变。８１例左室射血分数≤４５％,其中２１例〈３０％。８４％病人心绞痛ＣＣＳⅢ－Ⅳ级。除１例在左前外侧小切口非体外循环下手术,余均为正中开胸低温体外循环下ＣＡＢＧ。     

Quantification of fat mobilization in patients undergoing coronary artery revascularization using off-pump and on-pump techniques

Fat mobilization during cardiopulmonary bypass (CPB) is a recognized risk of the procedure. Intravascular mobilization of fat emboli subsequent to CPB has been implicated in some of its recognized pathophysiologies, particularly with regard to cerebral embolic injury. The aim of this study was to investigate whether fat mobilization is still a real issue in modern perfusion practice and to determine whether off pump coronary artery bypass techniques minimize this risk. Thirty patients undergoing routine elective coronary artery bypass graft (CABG) surgery were divided into two groups. Group 1 patients underwent off pump coronary artery bypass (OPCAB) procedures, and group 2 underwent CABG supported with CPB. Blood samples were taken from the CPB patients at the beginning, middle, and end of the procedure, from the suction line, from the arterial line, and from the venous line for measurement of fat emboli present. Samples were taken at corresponding time-points from the OPCAB patients for similar measurements. Fat emboli were counted manually using Oil red O staining and light microscopy. The fat emboli were sized using calibrated microspheres as a visual size contrast. No fat emboli were observed in any of the blood samples taken from the OPCAB patients. There were fat emboli present in all samples taken during CPB from all sources. The count was highest in the suction system and lowest in the venous blood and tended to increase during CPB. There was an absence of large fat emboli in the venous blood, which tends to indicate that the larger fat emboli lodge in the microvasculature. OPCAB surgery eliminates the risk of fat embolization in patients undergoing coronary revascularization. The suction system is the major source of fat emboli during CPB, and despite the multiple filtration components of the CPB system, fat emboli of various and significant sizes do reach the patient. Fat embolization remains a risk in routine elective CABG surgery. Cardiotomy suction should be eliminated where possible.     

Off-pump complete revascularization through a left lateral thoracotomy (ThoraCAB): the first 200 cases

BACKGROUND: Conventional coronary bypass surgery is associated with substantial morbidity caused by cardiopulmonary bypass (CPB) and median sternotomy. This report describes an innovative technique to perform complete revascularization through a lateral thoracotomy without CPB (thoraCAB). METHODS: From February 2000 to April 2001 a total of 200 patients underwent thoraCAB. The patient is positioned with the left side elevated to 45 degrees. A 5- to 6-inch incision is made over the left fourth or fifth intercostal space from just medial to the nipple to the anterior axillary line. The left internal thoracic artery is harvested as a pedicle graft under vision. Proximal anastomoses are first completed on the ascending aorta, followed by the distal coronary anastomoses on the beating heart using a stabilizer. Intercostal nerve freezing is done using a cryoprobe. RESULTS: Complete revascularization was achieved in all patients. The number of grafts averaged 2.9 +/- 1.08 per patient. One patient (0.5%) died of renal failure. Two patients (1%) were converted to CPB. No strokes were observed. Three patients (1.5%) required prolonged ventilation (>48 hours). Five patients (2.5%) had postoperative bleeding requiring reexploration. Of the patients, 16 (8%) developed new-onset postoperative atrial fibrillation. CONCLUSIONS: ThoraCAB has been feasible in the vast majority of patients requiring coronary bypass surgery. The prevalence of postoperative atrial fibrillation was low. Postoperative pain maybe lessened with intercostal nerve freezing.     

Concomitant Carotid Endarterectomy and Coronary Bypass Surgery: Should Cardiopulmonary Bypass Be Used for the Carotid Procedure?

Abstract Background and Objectives: With the increasing age of patients undergoing coronary artery bypass grafting (CABG), a greater number have associated clinically significant carotid disease. This study determined the morbidity and mortality for combined carotid endarterectomy (CEA)/CABG using cardiopulmonary bypass (CPB) for both procedures versus a combined approach using CPB only during CABG. Patients and Methods: Between 1993 and 2000, 65 patients (Group I) underwent combined CEA and CABG using CPB for both surgical procedures and 88 patients (Group II) underwent combined CEA and CABG using CPB only during CABG. The demographic, clinical, and carotid and coronary angiographic data were similar between groups. In Group I, 22 (33.8%) patients and 32 (36%) patients in Group II presented with contralateral carotid artery stenosis. Results: CPB time was significantly longer in Group I, 127 ± 21 minutes versus 98 ± 11 minutes in Group II patients (p = 0.001). The incidence of surgical revision for bleeding and deep sternal wound infection was higher in Group I patients, 2 (3%) versus 1 (1.1%) and 5 (7.7%) versus 2 (2.2%), respectively, but not significant. Hospital mortality in Group I was 6% (4 patients) versus 5.7% (5 patients) in Group II (p = ns). Neurologic complications occurred in 4 (6%) and 5 (5.7%) patients in Group I and II, respectively (p = ns). Postoperative renal dysfunction was more common in Group I patients (22 [33.8%]) then in Group II patients 16 (19%) (p = 0.04). Of these patients, (16 [19%]) 8 (12.3%) in Group I and 6 (6.8%) in Group II required postoperative ultrafiltration (p = ns). Infectious complications were more frequent in Group I patients, 5 (7.7%) versus 2 (2.3%), but not statistically significant (p = ns). Overall actuarial survival at 1, 3, and 5 years, including all deaths, was 92%, 88%, and 82% in Group I versus 93%, 86%, and 81% in Group II (p = ns). Overall freedom from stroke at 5 years was 87.5% in Group I and 86.4% in Group II. Conclusions: We conclude that combined CEA/CABG using CPB only during the myocardial revascularization procedure remains the technique of choice in patients with coronary and carotid artery disease, offering better outcome in terms of perioperative morbidity than a combined CEA/CABG using CPB for both procedures.