Off-pump arterial grafting: 125 cases using the Medtronic-Utrecht Octopus.

Abstract

The use of arterial grafts in coronary bypass surgery requires a high degree of cardiac stabilization, traditionally achieved with cardiopulmonary bypass and cardioplegic arrest. The Medtronic-Utrecht Octopus has recently been developed as an advanced cardiac stabilization device, based on its unique suction method for regional epicardial immobilization and retraction. The objective of this study was to investigate the feasibility of using this device to enable total arterial revascularization on the beating, working heart. From May 1997 to November 1998, off-pump coronary artery bypass using exclusively arterial grafts was performed in 125 selected patients (108 males), aged 2682 years (mean 61.1 +/- 10.5 years). Coronary artery immobilization was achieved with the Octopus, which uses local epicardial suction and avoids cardiac compression. Aortic anastomoses were avoided: both internal thoracic arteries and the right gastroepiploic artery were used as pedicle grafts in all but one case. All radial artery grafts and one right internal thoracic artery were used as Y-grafts from the left internal thoracic artery. There were four surgical approaches: sternotomy (98 patients), left anterior small thoracotomy (20 patients), anterolateral thoracotomy (six patients) and a subxiphoid approach in one patient. Sternotomy: 187 grafts were performed in 98 patients (mean 1.9 grafts per patient). There were 99 grafts to anterior wall vessels, 47 grafts to posterior wall vessels and 41 grafts to lateral wall vessels. Left anterior thoracotomy: 20 patients had a single graft to the left anterior descending artery (LAD). Left anterolateral thoracotomy: three patients had a single graft to a circumflex branch, while three had composite grafts to the LAD and circumflex systems. Subxiphoid: one patient had a single graft to the posterior descending branch of the right coronary artery. There were no peri-operative deaths in any group. No patient required conversion to cardiopulmonary bypass. Three patients required conversion from a limited-access approach to sternotomy. There was one re-operation for bleeding. Postoperative stay was 27 days (mean 3.6 +/- 1.1; median 3 days) for anterior thoracotomy, 3-4 days (mean 3.5 +/- 0.6) for anterolateral thoracotomy, and 378 days (mean 6.6 +/- 8.7; median 4 days) for sternotomy. There were two late deaths in salvage patients; no patient has required cardiac intervention or re-operation. The Octopus maintains excellent local cardiac immobilization--enabling the routine use of arterial grafts in off-pump coronary surgery. It allows easy access to anterior wall vessels on the heart, and relatively straightforward access to the posterior wall. Circumflex branches are graftable with careful case selection and adjunctive technical maneuvers.