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Ann Thorac Surg 1996;62:945-946
© 1996 The Society of Thoracic Surgeons
uz Ta
demir, MD
Cardiovascular Surgery Department, Yüksek 
htisas Hospital of Turkey, Sihhiye 06100, Ankara Turkey
To the Editor:
We read with great interest the article by Buffolo and associates entitled "Coronary Artery Bypass Grafting Without Cardiopulmonary Bypass" [1]. We also perform "off-pump" coronary artery bypass grafting in our institution; our experience reached 2,000 cases by the end of February 1996, with a mortality rate of 1.8% and a perioperative myocardial infarction incidence of 2.9%. Our operative technique was previously described in detail [2]. We want to emphasize a few important points of our technique, which differs somewhat from the one applied by Buffolo and associates.
One of the most critical issues in off-pump coronary artery surgery is to obtain good exposure. After coronary arteriotomy, bleeding may interfere with surgical exposure. If profuse rinsing with warm saline solution is insufficient, bulldog clamps are applied to the coronary artery with its surrounding fat pad. Usually one proximal bulldog clamp is enough to obtain good vision. Backbleeding from the septal arteries or distal coronary bed may be overcome by gentle rinsing. Distal coronary clamping is avoided as far as possible; in practice, it is rarely needed. In the past, as in many previous reports including the study by Buffolo and associates, we used snares and polypropylene or silicone rubber stay sutures surrounding the coronary vessel to stop bleeding and to help fix the heart. Such maneuvers, however, could cause severe transmural or intimal damage to the coronary vessel and may cause either acute thrombosis or later intimal hyperplasia or atherogenesis as emphasized previously by others [3, 4]. We have abandoned using such materials.
We perform all the anastomoses with double-armed 7.0 or 8.0 polypropylene sutures with continuous suturing technique. After completion of the anastomosis, before the suture is tied, it is of vital importance to pass a 1-mm probe gently through the anastomosis both distally and proximally, not only to check the anastomosis, but also to dilate possible native coronary vessel obliterations caused by the temporary hemostatic bulldog clamp application that may persist after declamping. With this maneuver, perioperative ST-T changes, infarctions, and low output states after a successful bypass procedure can easily be avoided. Such obliterations cause ischemic septal regions upstream or downstream of the clamping sites, left internal mammary artery occlusion, or regression due to poor run-off. Also ischemia due to inadequate left internal mammary artery flows in the first minutes (caused by left internal mammary artery spasm or delayed adaptation) in a fully left internal mammary artery-dependent distal coronary flow state with the proximal obliteration of the native coronary vessel may occur.
If more than one vessel will be grafted, the sequence of revascularization is also important. We always begin by grafting the left anterior descending artery. We think that the left anterior descending artery is the most important vessel to be grafted, and retraction of the heart for grafting the right coronary artery (even one with a more critical lesion than the left anterior descending artery stenosis) could be tolerated poorly.
Maximum tolerable ischemia duration (ie, anastomosis time) for a right coronary artery with mild to moderate stenosing lesions is limited to a few minutes. After approximately 5 minutes, serious bradyarrhythmias, heart blocks, and even cardiac arrest may occur. In complete occlusions, however, such complications are uncommon, and the patients could tolerate longer periods of ischemia (even time-consuming endarterectomy and patch angioplasty procedures) well. The same is true for the left anterior descending artery system.
We had previously compared randomized groups with and without cardiopulmonary bypass [2] to determine whether there are meaningful differences in early outcomes, as stressed in the editorial by Ullyot [3]. As a result, in technically suitable cases, off-pump coronary artery bypass grafting was considered a safe and efficient technique. It is not a siren call of cost containment at all, and could be used in special circumstances in which cannulation, hypothermia, or cardiopulmonary bypass must be avoided. With these characteristics, this technique could take an important place in the cardiac surgeon's armamentarium.
References
demir O, Karagöz H, et al. Comparison of the early results of coronary artery bypass grafting with and without extracorporeal circulation. Thorac Cardiovasc Surg 1995;43:320–5.[Medline]
This article has been cited by other articles:
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  K. M. Vural, Z. H. Iscan, A. Kunt, E. Sener, and O. Tasdemir Off-Pump, In Situ Internal Thoracic Artery Grafting: A Durable Treatment for Single-Vessel Coronary Artery Disease Ann. Thorac. Surg., March 1, 2005; 79(3): 814 - 818. [Abstract] [Full Text] [PDF]
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 H. Posacioglu, Y. Atay, T. Yagdi, T. Calkavur, M. Cikirikcioglu, S. Buket, A. Hamulu, M. Yuksel, and O. Bilkay Simple and Cost-Effective Gas Jet for Non-Pump Coronary Bypass Surgery Asian Cardiovasc Thorac Ann, September 1, 1999; 7(3): 250 - 251. [Abstract] [Full Text] [PDF]
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A. J. Pfister, K. M. Vural, O. Tasdemir, H. Y. Karagoz, and K. Bayazit The Safety of CABG Without Cardiopulmonary Bypass Ann. Thorac. Surg., August 1, 1997; 64(2): 590 - 591. [Full Text]
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