Minimally invasive coronary artery revascularization: off-pump bypass grafting and the hybrid procedure

Background. Coronary artery bypass grafting without cardiopulmonary bypass (off-pump-CAB; OPCAB) as a minimally invasive procedure has been used increasingly to treat coronary artery disease. The procedure makes multivessel revascularization possible, with new instruments and techniques, and hybrid therapy (combination of angioplasty and OPCAB) can be a new method of treating coronary disease. We present our experience using OPCAB and our strategy for coronary revascularization.

Methods. Of 216 patients treated with OPCAB, the lesion was single in 100 and multivessel in 116. Preoperative risks that could increase the mortality and morbidity rates were present in 127 patients, excluding 55 who were 75 years old or older.

Results. There were four hospital deaths, three of which were noncardiac, and five operative morbidities: transient cerebral ischemia in 3, perioperative myocardial infarction in 1, and congestive heart failure in 1. A postoperative angiogram was done in 157 patients (220 grafts), and with heart stabilization the patency rate without stenosis improved to 93.6%. For 116 patients with multivessel disease, technically complete revascularization was done in 84%, either with multivessel revascularization in 61 patients or the hybrid procedure in 37 patients. Among 20 patients with left main trunk lesion, five had the hybrid procedure. Angina recurred in 3, including 1 who died suddenly of infarction. The angiogram at recurrence showed restenosis of left main lesion and occlusion of the graft to the left anterior descending artery. Postoperative follow-up for 2 years showed 12 patients with recurrent angina and five late deaths from noncardiac-related events.

Conclusions. The heart stabilizer and new techniques for coronary revascularization with a beating heart have improved the anastomotic quality of grafts. The hybrid procedures were effective in selected patients but were considered contraindicated in patients with left main trunk lesion. OPCAB was safe, effective, and suitable especially in patients with high risks for coronary artery bypass grafting.