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Ann Thorac Surg 1997;64:590-591
© 1997 The Society of Thoracic Surgeons
Washington Hospital Center, 1706 New Hampshire Ave, Nw, Washington Dc 20009
To the Editor:
Recently our article [1] reporting coronary artery bypass without cardiopulmonary bypass has been used by a number of authors in reference sections for a case report, letter to the editor, and editorial.
Pathi and associates [2] state, "The greatly improved conditions provided by cardioplegic techniques, together with some reports of late stenoses at the sites of the anastomoses and encircling sutures used to exclude blood from the operative field, have led to abandonment of this method by many centers." This statement is misleading at best, and is not supported by any part of our article.
More troublesome are the recent examples in which our article, or more accurately, the discussion of our article by Dr Gundry, has been used as a reference to support statements made. Vural and associates [3] stated, " ... stay sutures surrounding the coronary vessel [were used] 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."
Ullyot [4] in his recent editorial stated, " ... at least one surgeon familiar with the technique warns that a number of his patients operated on without CPB died unexpectedly or had recurrent angina, and an inordinate number had graft stenoses at anastamotic sites, and stenoses at the site of the stay sutures or loops placed around vessels."
I have great respect for Dr Gundry, and I appreciated his comments during my presentation of the paper in 1992. However, those comments for the most part lacked objective data, and were punctuated with phrases like "a number," "unfortunately large number," and "inordinate." To take an anecdote and use it to support an opinion puts the author on very shaky ground.
The entire point of our report was to establish the safety and efficacy of performing selected cases of coronary bypass without cardiopulmonary bypass and cardioplegia. We continue to perform the technique, and since the presentation of that paper have operated on close to an additional 200 patients with results even better than presented in the original report. We continue to be convinced that there is a subpopulation of patients who clearly do better by having their coronary revascularization performed off pump.
With the advent of minimally invasive direct coronary artery bypass grafting, I fully expect that more, rather than fewer, coronary artery bypass grafting procedures will be done off bypass. Faulty anastamoses and restenosis at the sites of snares may be theoretic concerns for some. Many others do not share these concerns.
The decision to perform beating heart operations must be made by each individual surgeon. Our experience would suggest that excellent results can be obtained using such techniques.
References
demir O, Karagöz HY, Bayazit K. Avoiding early or late failure in "off-pump" coronary artery bypass grafting [Letter]. Ann Thorac Surg 1996;62:945–6.
uz Tademir, MD
N. Tandoan Cad 5/6, Kavaklidere 06540, Ankara, Turkey, e-mail:kvural{at}tr-net.net.tr
Reply To the Editor:
We greatly appreciated the comments of Dr Pfister. We agree that, in technically suitable cases, off-pump coronary artery bypass grafting is considered a safe and efficacious technique [1]. It is not only practical and economical, but also very useful in situations in which there is some major risk associated with cannulation, hypothermia, or cardiopulmonary bypass. We performed more than 2,000 such cases in our institution, and we believe this technique will become more and more important in the future with its potential advantages.
However, the procedure is somewhat technically demanding. As previously reported, one of the most critical issues in off-pump coronary artery surgery is to obtain good exposure and fixation of the field. During anastomosis, bleeding may interfere with surgical exposure. After observing a relatively high rate of early ST-T segment changes, as well as elevations in the myocardial-specific isoenzyme of creatine kinase in our early experience, we abandoned using snares and polypropylene or silicone rubber stay sutures surrounding the coronary vessel as the measures for achieving good exposure, as well as for fixing the heart. Any possible intimal or transmural damage to the native coronary vessel, which may result in either acute occlusion by spasm or thrombosis, or provocation of intimal hyperplasia, was our main concern. After changing our technique to a less invasive one [2], we encountered a substantial decrease in the incidence of early failure represented by electrocardiographic and enzymatic changes, as well as low-output state. We currently are studying the midterm angiographic assessment of our patients who have previously undergone off-pump coronary operations. Preliminary data of this study strongly support this observation.
At the moment, we use the following technique to obtain good exposure: If profuse rinsing with warm saline solution is insufficient, we apply an atraumatic bulldog clamp about 1.5 cm proximal to the coronary artery to be grafted, together with a bulk of surrounding fat pad. Usually one proximal bulldog clamp is enough to obtain a good vision. Back-bleeding from the septal arteries or distal coronary bed can be overcome by gentle rinsing with warm saline solution. Distal coronary clamping is avoided as far as possible; in practice, it is rarely needed. During the passage of the needle through the native coronary vessel, the first assistant holds tight the adjacent epicardium with slightly hanging pick-ups to obtain a relatively motionless operative field. After completing the anastomosis, before tying the suture, we always pass a 1- or 1.5-mm probe gently through the anastomosis both distally and proximally, not only to check the anastomosis, but also to dilate possible native coronary vessel spasm caused by the temporary hemostatic bulldog clamp application, which may persist after declamping.
Considering minimally invasive direct coronary artery bypass grafting procedures, we think that standard median sternotomy rather than a minithoracotomy may be necessary, not for the anastomosis, but for precise harvesting of the internal mammary artery. With the minithoracotomy techniques, harvesting of the internal mammary artery may be difficult and cumbersome. Damage to this invaluable graft due to excess manipulation may be anticipated. Further, with a limited thoracotomy technique, the distal muscular part of the internal mammary artery, which is of poor quality to be a bypass conduit, is used. Undivided proximal branches also may cause a steal phenomenon. We think that grafting the left anterior descending artery with an internal mammary artery is perhaps the most efficient therapeutic intervention currently available for coronary artery disease, regarding both early and late results and its superiority in terms of event-free survival. Any event that may reduce the efficacy of this procedure must strictly be avoided. We are agree that more, rather than fewer, coronary artery bypass grafting operations will be performed with off-pump technique in the future, and we think that we all benefit from contemplation of options in the field.
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]
demir O, Karagöz HY, Bayazit K. Avoiding early or late failure in off-pump coronary artery bypass grafting [Letter]. Ann Thorac Surg 1996;43:320–5.This article has been cited by other articles:
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  O. E. Dapunt, M. R. Raji, S. Jeschkeit, S. Dhein, F. Kuhn-Regnier, M. Sudkamp, J. H. Fischer, and U. Mehlhorn Intracoronary shunt insertion prevents myocardial stunning in a juvenile porcine MIDCAB model absent of coronary artery disease Eur J Cardiothorac Surg, February 1, 1999; 15(2): 173 - 179. [Abstract] [Full Text] [PDF]
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 A. G. Jayakrishnan, T. Rameshwara, G. A. Pillai, H. D. Waikar, V. L. Pathi, G. A. Berg, and K. J. D. MacArthur Emergency Coronary Bypass on a Beating Heart Ann. Thorac. Surg., August 1, 1997; 64(2): 591 - 592. [Full Text]
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