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Ann Thorac Surg 1996;61:63-66
© 1996 The Society of Thoracic Surgeons
Escola Paulista de Medicina, Hospital São Paulo, Disciplina de Cirurgia Cardiovascular, São Paulo, SP, Brazil
Accepted for publication July 26, 1995.
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. In a consecutive series of 8,751 patients operated on in our institution for coronary artery disease from 1981 to 1994, 1,274 patients received coronary artery bypass grafting without cardiopulmonary bypass.
Results. Results indicate that the operation can be performed with an acceptable mortality (2.5%), and that all types of arterial conduits can be used. Most commonly the left anterior descending and right coronary arteries were bypassed. The incidence of arrhythmias and of pulmonary and neurologic complications were significantly lower in this group of patients compared with patients receiving coronary artery bypass grafting with cardiopulmonary bypass. Most importantly, there was decreased cost when the procedure was used because no extracorporeal circulation, cardioplegia sets, or other cannulas were used.
Conclusions. We conclude that the continuing use of coronary artery bypass grafting without cardiopulmonary bypass is justified and that, with proper selection of patients, the procedure is safe and cost-effective.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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For editorial comment, see page 10.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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The arterial blood pressure, electrocardiogram, central venous pressure, and urine output were monitored throughout the procedure. Anesthesia was induced and maintained using neuroleptic and analgesic agents. After median sternotomy, the left internal mammary artery (LIMA) was dissected simultaneously with harvesting of the long saphenous vein. Traction sutures were applied to the margins of the pericardium, displacing the heart superiorly. For exposure of the left anterior descending coronary artery (LAD), the heart was luxated slightly medially and ventrally with a moist sponge placed behind its laterodorsal aspect. Exposure of the distal right coronary artery in the atrioventricular groove was achieved by displacement of the right ventricle medially at its marginal border. The patient was heparinized using half the dose normally used for CPB (2 mg/kg). Immediately before occlusion of the coronary artery, verapamil (5 mg) was administered intravenously to reduce the systemic blood pressure and the heart rate. A 5-0 Prolene (Ethicon, Somerville, NJ) suture was applied around the coronary artery proximal and distal to the site selected for the arteriotomy. The suture was snared with a thin silicone tube, thereby allowing for a dry operative field. A longitudinal incision (6 mm) was made and an anastomosis with saphenous vein, LIMA, or other conduit was performed using a running 7-0 Prolene suture. The time of coronary occlusion varied between 11 and 19 minutes. The proximal anastomoses were performed after a tangential clamp was applied to the ascending aorta using a continuous suture of 6-0 Prolene. In cases of multiple grafts, the coronary artery with the most severe stenosis or occlusion was bypassed first. After all anastomoses were completed, heparin was neutralized with protamine sulfate.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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. Note that a large proportion of patients were more than 60 years of age. Preoperative clinical conditions were as follows: chronic coronary insufficiency, 885 (69.5%); unsuccessful angioplasty, 116 (49 for acute ischemia and 67 chronic ischemia) (9.1%); reoperations, 86 (6.8%); after thrombolysis, 67 (5.3%); unstable angina (includes angina in hospital evolution of myocardial infarction, intermediate syndrome, angina crescendo), 66 (5.2%); and acute evolving myocardial infarction (operated on within 6 hours of pain onset), 54 (4.2%). Patients undergoing operation for failed percutaneous transluminal coronary angioplasty were either treated as an emergency (49/116 patients) or an elective case (67/116 patients). Patients presenting with acute myocardial infarction received thrombolysis (5.3% of the patients) and were operated on during the first week. In 54 patients (4.2%) the operation was performed while the patient had an evolving myocardial infarction, as determined by clinical status, electrocardiogram, and creatine kinase-MB level. Twenty patients (1.6%) received additional procedures during CABG without CPB: endarterectomy in 7, left ventricular aneurysm plication in 3, pacemaker implantation in 2, stellate ganglion resection in 1, Vineberg procedure (left interum mammary artery implantation) in 1, coronary artery fistula ligation in 1, bypass to brachiocephalic trunk in 1, correction of pericardial hernia in 1, thymectomy in 1, coronary artery aneurysm in 1, and pulmonary resection in 1.
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. The types of graft were as follows: saphenous vein, 1,175 (55.1%); LIMA, 916 (42.9%); saphenous vein/sequential, 9; ``free'' LIMA, 8; right mammary ``in situ'', 6; bovine mammary artery, 3; artificial Y saphenous vein, 6; sequential mammary, 5; gastroepiploic artery, 5; and Gore-Tex graft (W. L. Gore & Assoc, Flagstaff, AZ), 1. The LIMA was the most commonly used conduit for the LAD.
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, comparing CABG with and without CPB. Any arrhthymias perioperatively were recorded; there was significantly lower incidence in the group without CPB. Similarly, there were fewer pulmonary and neurologic complications in this group. There was no difference in the incidence of myocardial infarction, bleeding, and infarction in patients receiving CABG with or without CPB.
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). The mean hospital stay for patients operated on without CPB was 5.2 days versus 9.6 days for those operated on with CPB. The need for blood transfusion in this whole group was 0.6 units/patient.
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). There was no significant difference between the two groups, demonstrating the same patency rate with either techniques. Analyzing the last 5,838 patients undergoing myocardial revascularization procedures, we found that 20.3% were candidates to undergo operation without CPB. The technique is particularly suitable for patients with lesions in the LAD or right coronary artery, unsuccessful angioplasty, and reoperations.
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cases Undoubtedly the procedure is technically more demanding and there is a learning curve. However, we have experienced lower morbidity/mortality, less use of blood, and decreased costs due to savings of operating room equipment, such as oxygenators, cardioplegic sets, and cannulas.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Our on-going experience indicates that, with proper selection of patients, CABG without CPB is safe and effective. Arterial conduits, such as the LIMA, can be easily used, and most coronary arteries can be bypassed. The mortality rate was low (2.5%), and the incidences of serious complications such as arrhythmias, pulmonary sequelae, and neurologic sequelae were significantly lower than in patients undergoing CABG with CPB. The patency rate was similar to that in patients undergoing conventional CABG.
Further, at our institution, there was a cost saving of approximately US$3,000 per case due to decreased use of operating room equipment such as oxygenators, cardioplegic sets, cannulas, and others. There was also decreased stay in the intensive care unit and in the hospital. The management of these patients in terms of fluid, electrolyte, and respiratory care is simpler. In our institution, cardiologists currently favor CABG without CPB for single LAD lesions.
Undoubtedly the technique is more demanding, and there is a learning curve with this method of CABG. The surgeon, however, has the option of placing the patient on CPB should any problem occur.
In summary, in this large experience with CABG without CPB, the indications for operation with this method has been identified; the method can be used in approximately 25% of patients undergoing coronary revascularization. Arterial conduits can be used, and the patency rate is similar to that of conventional techniques. The mortality rate is acceptably low, and complication rates were lower compared with conventional techniques. In selected cases, the procedure is cost-effective due to lower use of hospital resources in the operating room, intensive care unit, and ward. The continuing use of this technique of coronary artery surgery is therefore justified.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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ao de Barros, 715, 3• Andar, São Paulo, SP, CEP 04024-002 Brazil. |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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R. Cartier, M. Leacche, and P. Couture Changing pattern in beating heart operations: use of skeletonized internal thoracic artery Ann. Thorac. Surg., November 1, 2002; 74(5): 1548 - 1552. [Abstract] [Full Text] [PDF]
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J. F. Sabik, A. M. Gillinov, E. H. Blackstone, C. Vacha, P. L. Houghtaling, J. Navia, N. G. Smedira, P. M. McCarthy, D. M. Cosgrove, and B. W. Lytle Does off-pump coronary surgery reduce morbidity and mortality? J. Thorac. Cardiovasc. Surg., October 1, 2002; 124(4): 698 - 707. [Abstract] [Full Text] [PDF]
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M. Caputo, A. J. Bryan, R. Capoun, B. Mahesh, F. Ciulli, J. Hutter, and G. D. Angelini The evolution of training in Off-Pump coronary surgery in a single institution Ann. Thorac. Surg., October 1, 2002; 74(4): S1403 - S1407. [Abstract] [Full Text] [PDF]
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W. Cheng, T. A. Denton, G. P. Fontana, S. Raissi, C. Blanche, R. M. Kass, K. E. Magliato, J. Mirocha, and A. Trento Off-pump coronary surgery: Effect on early mortality and stroke J. Thorac. Cardiovasc. Surg., August 1, 2002; 124(2): 313 - 320. [Abstract] [Full Text] [PDF]
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N. C. Patel, A. D. Grayson, M. Jackson, J. Au, N. Yonan, R. Hasan, B. M. Fabri, and on behalf of the North West Quality Improvement Pr The effect off-pump coronary artery bypass surgery on in-hospital mortality and morbidity Eur J Cardiothorac Surg, August 1, 2002; 22(2): 255 - 260. [Abstract] [Full Text] [PDF]
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B. Meyns, R. Autschbach, A. Boning, W. Konertz, K. Matschke, F. Schondube, K. Wiebe, and E. Fischer Coronary artery bypass grafting supported with intracardiac microaxial pumps versus normothermic cardiopulmonary bypass: a prospective randomized trial Eur J Cardiothorac Surg, July 1, 2002; 22(1): 112 - 117. [Abstract] [Full Text] [PDF]
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R. Ascione, K. Rees, K. Santo, M. H. Chamberlain, G. Marchetto, F. Taylor, and G. D. Angelini Coronary artery bypass grafting in patients over 70 years old: the influence of age and surgical technique on early and mid-term clinical outcomes Eur J Cardiothorac Surg, July 1, 2002; 22(1): 124 - 128. [Abstract] [Full Text] [PDF]
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 F. M. Fouad-Tarazi, J. Feldschuh, S. M. F. Malheiros, A. R. Massaro, E. Buffolo, D. Venes, W. T. C. Yuh, C. J. Knott-Craig, M. D. Tilak, D. van Dijk, et al. Cognitive Outcomes Following Cardiopulmonary Bypass JAMA, June 19, 2002; 287(23): 3077 - 3079. [Full Text] [PDF]
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M. H. Chamberlain, R. Ascione, B. C. Reeves, and G. D. Angelini Evaluation of the effectiveness of off-pump coronary artery bypass grafting in high-risk patients: an observational study Ann. Thorac. Surg., June 1, 2002; 73(6): 1866 - 1873. [Abstract] [Full Text] [PDF]
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M. Yeatman, M. Caputo, P. Narayan, A. Kumar Ghosh, R. Ascione, I. Ryder, and G. D. Angelini Intracoronary shunts reduce transient intraoperative myocardial dysfunction during off-pump coronary operations Ann. Thorac. Surg., May 1, 2002; 73(5): 1411 - 1417. [Abstract] [Full Text] [PDF]
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S. Al-Ruzzeh, S. George, M. Bustami, K. Nakamura, S. Khan, M. Yacoub, and M. Amrani The early clinical and angiographic outcome of sequential coronary artery bypass grafting with the off-pump technique J. Thorac. Cardiovasc. Surg., March 1, 2002; 123(3): 525 - 530. [Abstract] [Full Text] [PDF]
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T.-P. Tsai, K.-C. Ueng, J.-M. Yu, Y.-C. Chang, and Y.-L. Wu Comparison of the Postoperative Blood Flow Waveforms of the Bypassing Grafts in Patients Following Minimally Invasive Direct Coronary Artery Bypass Chest, March 1, 2002; 121(3): 951 - 956. [Abstract] [Full Text] [PDF]
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Q.-B. Do, C. Goyer, O. Chavanon, P. Couture, A. Denault, and R. Cartier Hemodynamic changes during off-pump CABG surgery Eur J Cardiothorac Surg, March 1, 2002; 21(3): 385 - 390. [Abstract] [Full Text] [PDF]
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B. T. Lorenz and K. M. Coyte Coronary Artery Bypass Graft Surgery Without Cardiopulmonary Bypass: A Review and Nursing Implications Crit. Care Nurse, February 1, 2002; 22(1): 51 - 60. [Full Text] [PDF]
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M. Riha, M. Danzmayr, G. Nagele, L. Mueller, D. Hoefer, H. Ott, G. Laufer, and J. Bonatti Off pump coronary artery bypass grafting in EuroSCORE high and low risk patients Eur J Cardiothorac Surg, February 1, 2002; 21(2): 193 - 198. [Abstract] [Full Text] [PDF]
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S. Eryilmaz, T. Corapcioglu, N. T. Eren, L. Yazicioglu, K. Kaya, and H. Akalin Off-pump coronary artery bypass surgery in the left ventricular dysfunction Eur J Cardiothorac Surg, January 1, 2002; 21(1): 36 - 40. [Abstract] [Full Text] [PDF]
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S. Al-Ruzzeh, S. George, M. Yacoub, and M. Amrani The clinical outcome of off-pump coronary artery bypass surgery in the elderly patients Eur J Cardiothorac Surg, December 1, 2001; 20(6): 1152 - 1156. [Abstract] [Full Text] [PDF]
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M. Capdeville and J. H. Lee Off-Pump Coronary Artery Bypass Surgery: Revival of an Old Technique Seminars in Cardiothoracic and Vascular Anesthesia, November 1, 2001; 5(4): 345 - 361. [Abstract] [PDF]
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W. B. M. Gerritsen, W. J. P. van Boven, A. H. G. Driessen, F. J. L. M. Haas, and L. P. H. J. Aarts Off-pump versus on-pump coronary artery bypass grafting: oxidative stress and renal function Eur J Cardiothorac Surg, November 1, 2001; 20(5): 923 - 929. [Abstract] [Full Text] [PDF]
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R. Ascione, G. Iannelli, K. H.H. Lim, H. Imura, and N. Spampinato One-stage coronary and abdominal aortic operation with or without cardiopulmonary bypass: early and midterm follow-up Ann. Thorac. Surg., September 1, 2001; 72(3): 768 - 774. [Abstract] [Full Text] [PDF]
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M. J. Magee, T. M. Dewey, T. Acuff, J. R. Edgerton, J. F. Hebeler, S. L. Prince, and M. J. Mack Influence of diabetes on mortality and morbidity: off-pump coronary artery bypass grafting versus coronary artery bypass grafting with cardiopulmonary bypass Ann. Thorac. Surg., September 1, 2001; 72(3): 776 - 781. [Abstract] [Full Text] [PDF]
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T. M. Dewey, M. J. Magee, J. R. Edgerton, M. Mathison, D. Tennison, and M. J. Mack Off-pump bypass grafting is safe in patients with left main coronary disease Ann. Thorac. Surg., September 1, 2001; 72(3): 788 - 792. [Abstract] [Full Text] [PDF]
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G. Asimakopoulos Systemic inflammation and cardiac surgery: an update Perfusion, September 1, 2001; 16(5): 353 - 360. [Abstract] [PDF]
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P. P. Brown, M. J. Mack, A. W. Simon, S. L. Battaglia, L. G. Tarkington, S. D. Culler, and E. R. Becker Comparing clinical outcomes in high-volume and low-volume off-pump coronary bypass operation programs Ann. Thorac. Surg., September 1, 2001; 72(3): S1009 - S1015. [Abstract] [Full Text] [PDF]
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H. Niinami, Y. Takeuchi, S. Ichikawa, and Y. Suda Partial median sternotomy as a minimal access for off-pump coronary artery bypass grafting: feasibility of the lower-end sternal splitting approach Ann. Thorac. Surg., September 1, 2001; 72(3): S1041 - S1045. [Abstract] [Full Text] [PDF]
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A. M. Calafiore, M. Di Mauro, M. Contini, G. Di Giammarco, M. Pano, G. Vitolla, A. Bivona, R. Carella, and S. D'Alessandro Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease: impact of the strategy on early outcome Ann. Thorac. Surg., August 1, 2001; 72(2): 456 - 462. [Abstract] [Full Text] [PDF]
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M. E. Plomondon, J. C. Cleveland Jr, S. T. Ludwig, G. K. Grunwald, C. I. Kiefe, F. L. Grover, and A. L. Shroyer Off-pump coronary artery bypass is associated with improved risk-adjusted outcomes Ann. Thorac. Surg., July 1, 2001; 72(1): 114 - 119. [Abstract] [Full Text] [PDF]
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K.-B. Kim, C. Lim, H. Ahn, and J.-K. Yang Intraaortic balloon pump therapy facilitates posterior vessel off-pump coronary artery bypass grafting in high-risk patients Ann. Thorac. Surg., June 1, 2001; 71(6): 1964 - 1968. [Abstract] [Full Text] [PDF]
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J. D. Puskas, V. H. Thourani, J. J. Marshall, S. J. Dempsey, M. A. Steiner, B. H. Sammons, W. M. Brown III, J. P. Gott, W. S. Weintraub, and R. A. Guyton Clinical outcomes, angiographic patency, and resource utilization in 200 consecutive off-pump coronary bypass patients Ann. Thorac. Surg., May 1, 2001; 71(5): 1477 - 1484. [Abstract] [Full Text] [PDF]
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L. L. Creswell and R. J. Damiano Jr Postoperative atrial fibrillation: An old problem crying for new solutions J. Thorac. Cardiovasc. Surg., April 1, 2001; 121(4): 638 - 641. [Full Text] [PDF]
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M. Caputo, M. H. Chamberlain, F. Ozalp, M. J. Underwood, F. Ciulli, and G. D. Angelini Off-pump coronary operations can be safely taught to cardiothoracic trainees Ann. Thorac. Surg., April 1, 2001; 71(4): 1215 - 1219. [Abstract] [Full Text] [PDF]
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C. Detter, H. Reichenspurner, D. H. Boehm, M. Thalhammer, A. Schutz, and B. Reichart Single vessel revascularization with beating heart techniques - minithoracotomy or sternotomy? Eur J Cardiothorac Surg, April 1, 2001; 19(4): 464 - 470. [Abstract] [Full Text] [PDF]
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M. Yeatman, M. Caputo, R. Ascione, F. Ciulli, and G. D. Angelini Off-pump coronary artery bypass surgery for critical left main stem disease: safety, efficacy and outcome Eur J Cardiothorac Surg, March 1, 2001; 19(3): 239 - 244. [Abstract] [Full Text] [PDF]
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D. Varghese, M. H. Yacoub, R. Trimlett, and M. Amrani Outcome of non-elective coronary artery bypass grafting without cardio-pulmonary bypass Eur J Cardiothorac Surg, March 1, 2001; 19(3): 245 - 248. [Abstract] [Full Text] [PDF]
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 L. W. Tang, G. D'Ancona, J. Bergsland, A. Kawaguchi, and H. L. Karamanoukian Robotically Assisted Video-Enhanced-Endoscopic Coronary Artery Bypass Graft Surgery Angiology, February 1, 2001; 52(2): 99 - 102. [Abstract] [PDF]
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M. Guler, K. Kirali, M. E. Toker, N. Bozbuga, S. N. Omeroglu, E. Akinci, and C. Yakut Different CABG methods in patients with chronic obstructive pulmonary disease Ann. Thorac. Surg., January 1, 2001; 71(1): 152 - 157. [Abstract] [Full Text] [PDF]
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D. A. Bull, L. A. Neumayer, J. C. Stringham, P. Meldrum, D. G. Affleck, and S. V. Karwande Coronary artery bypass grafting with cardiopulmonary bypass versus off-pump cardiopulmonary bypass grafting: does eliminating the pump reduce morbidity and cost? Ann. Thorac. Surg., January 1, 2001; 71(1): 170 - 175. [Abstract] [Full Text] [PDF]
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M. P. R. Watters, R. Ascione, I. G. Ryder, F. Ciulli, A. A. Pitsis, and G. D. Angelini Haemodynamic changes during beating heart coronary surgery with the 'Bristol Technique' Eur J Cardiothorac Surg, January 1, 2001; 19(1): 34 - 40. [Abstract] [Full Text] [PDF]
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E. Ovrum, G. Tangen, C. Schiott, and S. Dragsund Rapid recovery protocol applied to 5,658 consecutive "on-pump" coronary bypass patients Ann. Thorac. Surg., December 1, 2000; 70(6): 2008 - 2012. [Abstract] [Full Text] [PDF]
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 M. G. Gamoso, B. Phillips-Bute, K. P. Landolfo, M. F. Newman, and M. Stafford-Smith Off-Pump Versus On-Pump Coronary Artery Bypass Surgery and Postoperative Renal Dysfunction Anesth. Analg., November 1, 2000; 91(5): 1080 - 1084. [Abstract] [Full Text] [PDF]
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R. Ascione, M. Caputo, G. Calori, C. T. Lloyd, M. J. Underwood, and G. D. Angelini Predictors of Atrial Fibrillation After Conventional and Beating Heart Coronary Surgery : A Prospective, Randomized Study Circulation, September 26, 2000; 102(13): 1530 - 1535. [Abstract] [Full Text] [PDF]
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Omeroglu S. N., K. Kirali, M. Guler, M. Erdem Toker, and C. Yakut Midterm angiographic assessment of coronary artery bypass grafting without cardiopulmonary bypass Ann. Thorac. Surg., September 1, 2000; 70(3): 844 - 849. [Abstract] [Full Text] [PDF]
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