Off-pump Coronary Artery Surgery Research Articles

Anaortic off-pump coronary artery surgery as a primary strategy to reduce the risk of neurological complications

Vessel Plus is an open acccess journal, which publishes articles related to vascular diseases, including acute respiratory distress syndrome, aneurysm, atherosclerosis, hypertension, stroke, peripheral vascular or pulmonary vascular diseases, etc.

Does bone wax make sense in off-pump coronary surgery? A prospective randomized study.

The effect of bone wax on sternal infection and intraoperative bleeding in off-pump coronary surgery has not been reported in current literature. To prospectively evalute this in a cohort of high risk patients undergoing off-pump coronary artery surgery at our institution. The potential impact on cell saver utilization was also studied. A prospective randomized study was performed in 58 diabetic patients operated on for two-vessel coronary artery disease by the off-pump technique. They were randomly assigned to the wax or no-wax group. There was no significant difference in intraoperative blood loss between the wax (550 ml) and no-wax group (750 ml; p = 0.0711). In multivariate analysis the absence (non-use) of bone wax (odds ratio = 3.9 (1.12-13.51), p = 0.027) and preoperative creatinin level (odds ratio = 1.1 (0.99-1.03), p = 0.03) were identified as independent predictors of blood loss ≥ 750 ml. The number of red blood cell units during hospital stay was similar in both groups (p = 0.42). Wound healing complications were not observed in either group. The use of bone wax does not lead to a higher risk of sternal wound infection. It may reduce the risk of high intraoperative blood loss, thus avoiding the need of a cell saver during off-pump coronary surgery. However, this influence remains questionable.

The Effect of Single Vessel Off-pump and On-pump Coronary Artery Surgery on Postoperative Complications

Giriş ve amaç: Günümüzde koroner bypass ameliyatları hala yaygın olarak on-pump CABG ve off-pump CABG tekniği ile yapılmaktadır. Bu retrospektif klinik çalışmada her iki cerrahi yöntemin kısa ve uzun dönem komplikasyonlarını araştırdık.
 Gereç ve Yöntemler: Bu çalışmaya 2011-2015 yılları arasında kliniğimizde Syntax skorlamasına göre izole tek damar koroner arter hastalığı olan; on-pump (Grup 1) ve off-pump (Grup 2) koroner arter cerrahisi geçiren toplam 43 hasta dahil edilmiştir. Bu hastalarda postoperatif erken dönem komplikasyonlar ve bir yıllık majör advers kardiyovasküler ve serebral olaylar karşılaştırılmıştır.
 Bulgular: Her iki grup arasında demografik verilerde istatistiksel olarak anlamlı fark saptanmadı. Postoperatif komplikasyonlar açısından atrial fibrilasyon off-pump cerrahi yapılan grupta anlamlı olarak daha az saptanmıştır. Yoğun bakımda ve hastanede kalış süreleri, pnömoni, sternal enfeksiyon ve postoperatif drenaj miktarları açısından anlamlı farklılık saptanmamıştır. Operasyon sonrası uzun dönemde majör adverse kardiyovasküler ve serebral olaylar (MACCE) açısından gruplar arasında farklılık saptanmamıştır.
 Sonuç: Sonuç olarak koroner bypass cerrahisinde uygulanacak yöntemin hastanın risk skorlamasına göre belirlenmesini öneriyoruz.

Importance of anastomotic sequencing during off-pump coronary artery bypass surgery: a pilot strategy

Introduction: Off-pump coronary artery surgery is a method preferred by many surgeons today to avoid the adverse effects of cardiopulmonary bypass. However, this method was quite popular at first but was later abandoned by some surgeons due to unfavorable results. We think the anastomosis sequence is an essential issue when performing off-pump surgery. We aimed to examine the effects of this strategy on the results of off-pump coronary artery surgery. Methods: We included 601 patients with isolated coronary artery disease who underwent off-pump coronary artery bypass surgery between January 2020 and 2022. The main goal was to ensure sufficient blood was going through the myocardia while anastomosis was performed on one of the coronary arteries. We tried to create a strategy about the sequence in which we should do the coronary anastomosis. Results: In 2 patients, conversion to on-pump surgery was required in elective conditions due to hemodynamic instability during the operation (0.33%). Only 4 patients required surgical revision because of bleeding (0.67%) in the early postoperative period. We recorded wound infections that could be solved with medical therapy and routine wound dressing in 5 patients (0.83%). Discussion and Conclusion: After applying this strategy, we experienced much more minor and acceptable conversion rates than those reported in the literature. We believe this strategy will benefit other researchers who have just started practicing off-pump surgery.

The Influence of Choice of Surgical Procedure on Long-Term Survival After Cardiac Surgery

There is some interest in long-term survival after various cardiac surgical strategies, including off-pump versus on-pump coronary artery surgery (CAG), mitral valve (MV) repair versus replacement, and aortic valve (AV) bioprosthetic versus mechanical replacement. We studied patients older than 49 years of age, recording risk factors and surgical details at the time of surgery. We classified procedures as: MV surgery with or without concurrent grafts or valves; AV surgery with or without concurrent CAG; or isolated CAG. Follow-up was through the state death register and state-wide hospital attendance records. Risk-adjusted survival was estimated using Cox proportional hazards. Observed survival was compared to the expected age- and sex- matched population survival. During a median follow-up of 14.8 years 5,807 of 11,718 patients died. The difference between observed and expected survival varied between 3.4 years for AV surgery and 9.6 years for females undergoing MV surgery. The risk-adjusted mortality hazard rate after off-pump CAG was 0.93 (95% CI 0.8-1.0, p=0.84), MV repair 0.67 (95% CI 0.6-0.8, p<0.0001), MV bioprosthesis 0.82 (95% CI 0.81 (0.6-1.0, p=0.11) and bioprosthetic AV replacement 1.02 (95% CI 0.9-1.2, p=0.82). Compared to the general population, cardiac surgical patients have a shorter than expected life expectancy. We observed a survival benefit of mitral valve repair over replacement. We did not observe significant survival differences between off-pump and on-pump CAG, nor between bioprosthetic and mechanical replacement.

Off-pump coronary artery surgery with clamshell incision

Cardiovascular Surgery and Interventions publishes original articles on topics in cardiovascular surgery, cardiovascular anesthesia and cardiology. These encompass all relevant clinical, surgical and laboratory studies, editorials, current and collective reviews, technical know-how papers, case reports, interesting images, “How to Do It” papers, correspondence and commentary.

Adenosine as cardioprotective in off-pump coronary artery bypass grafting

ObjectiveTo assess the effect of adenosine as a cardioprotective drug and its role in attenuating ischemia-reperfusion injury during off-pump coronary artery bypass surgery.BackgroundCardioprotective drugs have long been investigated for use during off-pump coronary artery bypass surgery to attenuate ischemia-reperfusion injury and limit hemodynamic instability. Adenosine has been investigated due to its cardioprotective effect that is mediated through A1 and A3 adenosine receptors. Stimulation of these receptors reproduces the infarct-limiting effect of ischemic preconditioning.MethodsAfter approval of the local ethics committee and informed written consent, fifty patients undergoing elective off-pump coronary artery bypass grafting were prospectively studied. The adenosine group received an infusion of Adenoscan at a rate of 50 μg/kg/min for 15 min. The control group received normal saline at the same rate and volume calculated. Pulmonary artery catheter was introduced through the right internal jugular vein. Cardiac output measurements were obtained. Cardiac index, stroke volume, systemic vascular resistance, pulmonary vascular resistance, right ventricular stroke work index, and left ventricular stroke work index were derived. Hemodynamic measurements were recorded together with blood levels of troponin I and CK-MB fraction to detect perioperative myocardial necrosis. Postoperative duration of mechanical ventilation, ICU stay together with inotropic support quantification using inotropic score were recorded.ResultsFifty patients were included in the study. In the adenosine group, the infusion of adenosine resulted in a significant reduction in mean pulmonary artery pressure after stopping drug infusion (18 ± 2.2 mmHg versus 31 ± 4.1 mmHg). There was a recorded increase in cardiac index in the adenosine group that started 15 min after adenosine infusion and lasted for 12 h postoperatively (p < 0.001). Also, adenosine infusion resulted in a reduction in pulmonary vascular resistance that exceeded the reduction in systemic vascular resistance which resulted in a decrease in pulmonary vascular resistance/systemic vascular resistance ratio (0.14 in adenosine group 15 min after injection versus 0.28 in control group) and (0.11 in adenosine group 12 h postoperatively versus 0.26 in control group). The cTroponin I measured 6 h postoperatively was less in the adenosine group compared with the control group (5.8 ± 2.8 ng/ml versus 16.5 ± 3.9 ng/ml).ConclusionAdenosine infusion during off-pump coronary artery surgery may improve cardiac index, reduce the need for inotropes, and have cardioprotective effect.

Dynamic Tests to Predict Fluid Responsiveness After Off-Pump Coronary Artery Bypass Grafting

To test the hypothesis that a positive end-expiratory pressure test and the mini-fluid challenge predict fluid responsiveness in patients after off-pump coronary artery bypass grafting. Single-center pilot prospective observational study. City Hospital #1 of Arkhangelsk, Russian Federation. Thirty-two adult patients after off-pump coronary artery surgery. To assess fluid responsiveness, after arrival to the intensive care unit, all patients received a test with increase in positive end-expiratory pressure from 5 to 20 cmH2O for 2 minutes, a mini-fluid challenge test with administration of crystalloids at 1.5 mL/kg during 2 minutes, and standard fluid challenge test using 7 mL/kg during 10 minutes. The patients with an increase in cardiac index by ≥15% after a standard fluid challenge test were defined as fluid responders. According to receiver operating characteristic analysis, a decrease in mean arterial pressure exceeding 5 mmHg in 120 seconds of the positive end-expiratory pressure test identified fluid responsiveness with an area under the curve of 0.73 (p = 0.03). The reduction in pulse pressure and stroke volume variations by more than 2% during mini-fluid challenge test predicted positive response to fluid load with an area under the curve of 0.77 and 0.75, respectively (p < 0.05). Both the positive end-expiratory pressure test and the mini-fluid challenge test are feasible after off-pump coronary artery bypass grafting and can be used to predict fluid responsiveness in these patients.

One-Stage Repair of Adult Aortic Coarctation and Concomitant Cardiac Diseases: Ascending to Abdominal Aorta Extra-Anatomical Bypass Combined with Cardiac Surgery

To evaluate one-stage repair with ascending to abdominal aorta extra-anatomical bypass combined with cardiac surgery for adult aortic coarctation (COA) concomitant with cardiac diseases. Between February 2009 and September 2016, 24 consecutive patients (79.17% male, mean age 36.04±13.67years) with COA and concomitant cardiac diseases underwent one-stage repair (ascending to abdominal aorta extra-anatomical bypass combined with cardiac surgery). Two (2) patients who underwent off-pump coronary artery surgery combined with ascending to abdominal aorta bypass did not require cardiopulmonary bypass. Twenty-two (22) patients underwent one-stage repair under cardiopulmonary bypass. No in-hospital mortality was observed. There was a significant reduction in baseline systolic blood pressure from 159.80±23.58 to 127.0±6.86mmHg. Mean upper-lower limb blood gradient pressure decreased significantly from 37.80±8.73 to 11.47±2.12mmHg after surgery. Two (2) patients required prolonged mechanical ventilation for respiratory dysfunction. One patient needed temporary continuous renal replacement therapy. No re-exploration for bleeding and gastrointestinal complications was needed. There was no postoperative paraplegia or permanent neurological abnormalities. Grafts were patent for all patients and no graft-related complications were observed in the hospital. Median follow-up was 41.50 months (interquartile range [IQR] 16.75-64.50 months) and 6-year survival was 76.39%. Median number of antihypertensive drugs was 0 (IQR 0-1), which was a significant reduction compared with preoperative drugs (2, IQR 1-3). Ascending to abdominal extra-anatomical aorta bypass combined with cardiac surgery is a safe and effective one-stage repair technique for patients with COA concomitant with cardiac diseases.

Association Between Elevated Echocardiographic Index of Left Ventricular Filling Pressure and Acute Kidney Injury After Off-Pump Coronary Artery Surgery.

The ratio of the early transmitral flow velocity to early diastolic velocity of the mitral annulus (E/e') is an echocardiographic index of mean left ventricular (LV) filling pressure. We investigated the association between the preoperative E/e' ratio and postoperative acute kidney injury (AKI) during off-pump coronary artery bypass surgery (OPCAB).Methods and Results:We reviewed 585 patients who underwent OPCAB and with preserved LV ejection fraction determined by preoperative echocardiography. AKI was determined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression analysis was performed. E/e' was also analyzed as 3 categories (E/e' <8, 8≤E/e'≤15, and E/e' >15) and as a continuous variable. A propensity score analysis was used to match the patients with E/e' >15 and E/e' ≤15. A preoperative E/e' >15 was an independent predictor for AKI (odds ratio 3.01, 95% confidence interval 1.40-6.17). E/e' >15 was also an independent predictor for AKI when E/e' was analyzed with 3 categories or as a continuous variable. In the matched sample, the incidence of AKI and 1-year mortality was significantly higher in patients with E/e' >15. Among patients undergoing OPCAB with preserved LV systolic function, a preoperative E/e' ratio >15 was an independent predictor of postoperative AKI. Measurement of the preoperative E/e' ratio may help to assess the risk of postoperative AKI.

The Effect of On-Pump and Off-Pump Bypass Operations on Oxidative Damage and Antioxidant Parameters

Objective The aim of the study is to determine the oxidative status in on-pump and off-pump coronary artery surgery and contribute to possible surgical choices in clinical practices in accordance with the information obtained as a result of this study. Methods 52 patients undergoing open heart surgery (26 patients in on-pump group and 26 patients in off-pump group) were included in the study. MDA, GPx, GSH, CAT, and SOD were investigated in blood samples. Results In the on-pump group, it was determined that there were a significant increase in MDA level in the peroperative period compared to the preoperative and postoperative periods and a significant increase in GSH level in the postoperative period than in the preoperative period. Additionally, while there was a significant decrease in CAT activity in the postoperative period than in the peroperative period, there was a statistically significant increase in SOD enzyme activity in the postoperative period compared to the preoperative and peroperative periods. A statistically significant increase was observed in SOD enzyme activity in the postoperative period in on-pump compared to off-pump group. Conclusion It is thought that this oxidative damage can be suppressed by administering a suitable antioxidant supplement in the preoperative and peroperative periods among patients undergoing the on-pump operation.

PP.14.07] PREOPERATIVE PREDICTIVE FACTORS FOR NON-VALVULAR POSTOPERATIVE ATRIAL FIBRILLATION IN PATIENTS UNDERGOING CORONARY BYPASS SURGERY (ON-PUMP VERSUS OFF-PUMP)

Objective: Postoperative atrial fibrillation (POAF) after isolated coronary revascularization is the most frequent rhythm disorder after cardiac surgery, with a reported incidence between 10% and 40%, associated with hemodynamic instability, increased morbidity and mortality. The aim of this study was to identify significant preoperative predictors for non-valvular POAF in patients undergoing on-pump and off-pump coronary artery surgery. Design and method: Retrospective study included 226 consecutive patients revascularized at Clinic of Cardiac Surgery, Clinical Center of Serbia, between September and December 2014. Patients were divided in two groups: on-pump (N: 176) and off-pump (N: 50). In both groups, we investigated the association of preoperative factors (gender, age, body mass index [BMI], type of coronary artery disease [CAD], left ventricular systolic function, preoperative angina pectoris [AP] and myocardial infarction [MI], preoperative size of the left atrium and left ventricle, degree of mitral regurgitation [MR], arterial hypertension, diabetes, hyperlipidemia, chronic lung disease, preoperative transient ischemic attack or cerebrovascular insult, peripheral arterial disease and smoking) with the occurrence of non-valvular POAF, using the Logistic regression analysis. Exclusion criteria were severe MR and preoperative AF. Results: The incidence of POAF was 23.45% (on-pump: 22.2%, off-pump: 28%; p > 0.05). There were statistically significant differences between two study groups considering: type of CAD (X2 = 5,030; p = 0,026), left ventricular systolic function (X2 = 12,896; p < 0,001), preoperative MI (X2 = 6,668; p = 0,010), preoperative size of the left atrium (X2 = 13,046; p < 0,001) and left ventricle (EDD: t = 3,439; p = 0,001, ESD: t = 3,162; p = 0,002) and presence of diabetes mellitus (X2 = 6,841; p = 0,009). In the off-pump group, an independent preoperative predictor of POAF was preoperative size of left atrium (OR 34.000; 95% CI 1.479–781.787; p: 0.027). We found that patients with very enlarged left atrium (>5 cm) had significantly higher risk of POAF. Paradoxically, an independent inverse relationship of preoperative arterial hypertension and the risk of POAF was documented in the on-pump group (OR 0.088; 95% CI 0.009–0.874; p: 0.038), most likely due to the more frequent preoperative use of beta-blockers in patients with a history of hypertension. Conclusions: Independent preoperative predictors for POAF are preoperative size of left atrium in off-pump and arterial hypertension in on-pump revascularized patients.

Acute, Severe Pulmonary Arterial Hypertension During Off-Pump Coronary Artery Surgery: Is New Myocardial Ischemia, Cardiac Repositioning, or External Mitral Valve Compression the Culprit?

Acute, Severe Pulmonary Arterial Hypertension During Off-Pump Coronary Artery Surgery: Is New Myocardial Ischemia, Cardiac Repositioning, or External Mitral Valve Compression the Culprit?

Myocardial conditioning techniques in off-pump coronary artery bypass grafting.

Off-pump coronary artery bypass surgery by avoiding cardioplegic arrest seems to reduce the risk of ischemic myocardial injury. However, even short-term regional ischemic periods, hemodynamic instability and arrhythmias associated with the procedure can be responsible for myocardial damage. Conditioning, a potential cardio-protective tool during on-pump cardiac surgery, has hardly been investigated in the context of off-pump surgery. There are virtually no large trials on remote ischemic preconditioning and the majority of reports have focused on central ischemic conditioning. Similarly, volatile anesthetic agents with conditioning effect like ischemic preconditioning have been shown to reduce cardiac injury during on-pump procedures but have not been validated in the off-pump scenario. Here, we review the available evidence on myocardial conditioning, either with ischemia/reperfusion or volatile anesthetic agents in patients undergoing off-pump coronary artery surgery.

Clinical SYNTAX Score Can Predict Acute Kidney Injury following On-Pump but Not Off-Pump Coronary Artery Bypass Surgery

Background: The complexity of coronary artery disease is usually a neglected factor in risk stratification systems. We aimed to analyze the discriminative ability of the clinical SYNTAX score (CSS) for acute kidney injury (AKI) following on- and off-pump coronary artery surgery. Methods: A total of 193 patients were reviewed in this study. Patients were divided into two groups according to the surgical procedure (group I: off-pump coronary artery bypass grafting, n = 89; group II: on-pump coronary artery bypass grafting, n = 104). Preoperative demographic data, the CSS and postoperative renal functions were evaluated. The postoperative AKI classification was made using the RIFLE (Risk, Injury, Failure, Loss of function, and End-stage renal disease) criteria. Results: Postoperative AKI occurred in 14 of 89 patients (15.7%) in group I and in 29 of 104 patients in group II (27.8%; p = 0.046). The CSS did not vary much between the groups (31.52 ± 13.08 vs. 29.89 ± 15.70; p = 0.638). In group I, the CSS was not different between patients with AKI and those without AKI (30.167 ± 3.93 vs. 31.91± 14.75; p = 0.78). In group II, the CSS was 36.85 ± 18.33 in patients with AKI and 28.02 ± 12.32 in those without, and the difference was significant (p = 0.02). The discriminative ability of the CSS for postoperative AKI using the AUC analysis was 0.500 in group I and 0.840 in group II. Conclusion: The CSS may be a simple and successful means of risk prediction of postoperative AKI in on-pump coronary artery surgery.

Cardioprotection with sevoflurane during off-pump coronary artery surgery

Methods Study included 48 patients induced in anesthesia with 8 vol.% sevoflurane within high 100% oxygen flow (5 L/min). Patients randomized into two groups: sevoflurane group (n = 24) in which anesthesia maintained with 1 MAC of endtidal sevoflurane concentration, and propofol group (n = 24), in which anesthesia maintained with continuous propofol infusion in doses of 2 to 3 mg/kg/h. Inclusion criteria were angiographically verified CAD and LVEF higher than 40%. Exclusion criteria were: AV conduction disturbances, AF with rapid ventricular response, myocardial infarction within 6 months, or diabetes mellitus. Pulmonary artery catheter used for the consecutive hemodynamic measurements. Cardiac index, heart rate, mean arterial pressure and central venous pressure were measured 5 minutes after anesthesia induction, on the beginning of ischemia, 15 minutes after ischemia and 15 minutes after sternum closure. For analysis between groups and time-points, a two-way analysis of variance (ANOVA) was performed and only p < 0.05 was considered statistically significant.

Antiplatelet therapy at the time of coronary artery surgery: can a personalized approach improve outcomes?

We read with great interest the recently published multicentre cohort study by Kremke et al. [1]. Patients exposed to antiplatelet therapy (APT) at the time of coronary artery surgery (CAS) had greater postoperative bleeding volumes and greater transfusion requirements [1]. Exposure to clopidogrel, but not aspirin, was associated with greater reoperation rates and was an independent risk factor for severe postoperative bleeding, although mean bleeding volumes were not significantly different in the aspirin and clopidogrel subgroups [1]. Despite current guidelines, it is apparent that many patients are proceeding with CAS without the 5-day delay off clopidogrel. The efficacy of platelet inhibition with clopidogrel varies widely among patients, from intensive platelet inhibition to poor platelet response [2], and these variations could, to some degree, explain the non-significant differences in mean bleeding volumes in the aspirin and clopidogrel subgroups [1]. The effect of clopidogrel on bleeding mainly depends on two factors: (i) observed platelet inhibition, which depends on inherent platelet activity prior to clopidogrel administration and platelet inhibitory response to clopidogrel and (ii) newborn platelets ability to restore normal aggregation after clopidogrel discontinuation. Therefore, the use of suitable point-of-care platelet function analysers seems to be reasonable in this field. Recently, we found aspirin(P = 0.014) and clopidogrel(P = 0.003) sensitive platelet function tests to be predictive of excessive postoperative bleeding in patients following CAS [2]. Of note, 76.3% patients were transfused with no significant differences among the groups with regard to the preoperative APT administration regime (P = 0.636) [2]. However, transfused patients had significantly lower values of aspirin-sensitive platelet function tests (P = 0.002) [2]. In our opinion, the study cohort is somehow heterogeneous. Eligible procedures were either isolated CAS or CAS combined with aortic valve replacement (AVR) [1]. AVR certainly extends the duration of cardiopulmonary bypass, which was recently described as a predictor of transfusion requirements [3]. After matching, authors reported a slightly greater use of antifibrinolytic drugs in the APT group [1]. Both on-pump and off-pump procedures were included [1]. Authors reported that off-pump surgery and perioperative use of tranexamic acid were associated with a lower risk of severe postoperative bleeding [1]. The use of antifibrinolytic drugs should be equally balanced since there is evidence that antifibrinolytic therapy reduces bleeding and transfusion outcomes [4]. It would be interesting to see if exclusion of CAS + AVR and off-pump CAS patients would bring different results. During the study period, thromboelastometry-guided blood component therapy became available at two of three participating centres [1]. At the same time, multivariate analysis revealed that surgery at one of the participating centres was one of independent risk factors for severe postoperative bleeding [1]. Spiess et al. [5] reported thromboelastography-guided haemostatic management to have significantly reduced the incidence of overall transfusion and mediastinal re-exploration due to excessive bleeding. Thus, perhaps one could assume that one centre, which was found to be independent risk factor for severe postoperative bleeding, was in fact the one without thromboelastometry guided transfusion therapy available. The largest extent of chest tube output together with the greatest transfusion rates, was observed in the subgroup of patients exposed to dual APT [1]. Those results are in line with the results recently published by Miceli et al. [6]. Further incremental platelet inhibition may be observed in the group of patients receiving dual APT. Therefore, the role of aspirin and clopidogrel administration management should be separately assessed by drug-specific platelet function tests, thus facilitating an individual therapeutic approach for discontinuation management of each antiplatelet agent preoperatively.

Rare case-series of electrocautery burn following off-pump coronary artery bypass grafting

:With an increasing number of off-pump coronary artery surgery procedures in high-risk patients with coagulopathy, including renal failure, hepatic failure and anticoagulant drug-using patients, the frequency of related complications such as repeated exploration for bleeding is also increasing. The associated co-morbidity and repeated use of electrocautery in postoperative bleeding leaves patients susceptible to electrocautery ulcers. In this case series, rare cases of cautery burn with unique causative mechanisms are described.

Anaortic, off-pump coronary artery surgery: should it be the standard-of-care?

Recent trials have shown that coronary artery bypass grafting remains the standard-of-care for multivessel coronary artery disease. However, the main criticism of surgery in these trials has been the higher rate of stroke. Off-pump coronary artery bypass grafting (OPCAB) has been suggested as a technique to reduce the rate of stroke. However, large randomized trials comparing coronary artery bypass grafting with OPCAB have failed to show any neurological benefit, most probably because surgeons in these trials fail to avoid manipulation of the ascending aorta. Herein, the authors review a technique of OPCAB surgery where manipulation of the ascending aorta is completely avoided – ‘anaortic OPCAB’ – facilitated by the use of composite and in situ grafts using bilateral internal mammary arteries.

Hemodynamic Changes during Off-Pump Coronary Ar-tery Bypass Graft Surgery: Experience Using Pericardial Bands for Target Stabilization

Background: The off-pump coronary artery bypass graft surgery (OPCAB) may produce significant hemodynamic instability necessitating conversion to on-pump surgery. This study evaluated the hemodynamic parameters in patients undergoing OPCAB using pericardial bands for stabilization of the coronary target sites. Methods: In 250 patients undergoing OPCAB the hemodynamic parameters including continuous cardiac output and systemic venous oxygen saturation (SvO2) were recorded at baseline after pericardiotomy, during each coronary artery anastomosis at 3, 5, 10, 15 min, and after release of the pericardial bands used for target stabilization. Vasopressors were used to maintain mean arterial pressure (MAP) > 60 mmHg. Results: SvO2 and cardiac index (CI) decreased significantly after target stabilization and during all coronary anastomoses with greater decreases noted during obtuse marginal branch of left circumflex (OM) anastomosis. The MAP and heart rate were maintained without significant change but central venous pressure increased significantly during all coronary anastomoses. The significant increase in pulmonary capillary wedge pressure and mean pulmonary artery pressure were noted only during anastomosis of the left anterior descending artery. The highest dose of vasopressor was used during OM anastomosis. Conclusions: During OPCAB surgery using pericardial bands for coronary target stabilization, MAP was maintained constantly, but SvO2 and CI decreased immediately after target stabilization and reduced further during all coronary artery anastomoses. During OM anastomosis SvO2 and CI were significantly lower as compared to that of LAD and right coronary artery. Careful monitoring and management of hemodynamic variables are warranted to avoid conversion to on-pump technique.