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Ann Thorac Surg 1998;66:1068-1072
© 1998 The Society of Thoracic Surgeons
a Carlyle Fraser Heart Center, Crawford Long Hospital of Emory University, Atlanta, Georgia, USA
Address reprint requests to Dr Puskas, Carlyle Fraser Heart Center, Crawford Long Hospital, Emory University, 550 Peachtree St, NE, Suite 7700, Atlanta, GA 30365
e-mail: (jpuskas{at}emory.edu)
Presented at "Facts and Myths of Minimally Invasive Cardiac Surgery: Current Trends in Thoracic Surgery IV", New Orleans, LA, Jan 24, 1998.
Abstract
Background. In an attempt to avoid the deleterious effects of cardiopulmonary bypass, off-pump coronary artery bypass grafting has been rediscovered and refined. The purpose of this study was to compare clinical outcomes, length of stay, and hospital costs with coronary artery bypass grafting on cardiopulmonary bypass.
Methods. Coronary artery bypass was performed on 51 patients without cardiopulmonary bypass. Patients were selected on the basis of coronary anatomy, with significant stenoses in the left anterior descending, ramus intermedius, diagonal, right coronary, acute marginal, or posterior descending territories. Outcomes were compared with those of a computer-generated matched control group having coronary artery bypass grafting on cardiopulmonary bypass (n = 248) during the same time period.
Results. No preoperative differences were noted between groups. There were no deaths in the off-pump group and a mortality rate of 1.6% (4/248) in the control group. There was no incidence of stroke, myocardial infarction, or reentry for bleeding among patients in the off-pump group. There was a reduction in length of stay by 3 days (p = 0.01), blood transfusions by 50% (p = 0.0001), and hospital charges by one third (p = 0.05) in the off-pump group. Twenty-six patients had repeat coronary angiography before discharge; 41/43 grafts were widely patent, 1/43 was totally occluded, and 1/43 was narrowed by more than 50%. All internal mammary artery grafts were widely patent.
Conclusions. Off-pump multivessel cardiopulmonary bypass grafting is a safe and effective means of revascularization for patients with coronary stenoses in the anterior or inferior regions, with excellent short-term patency rates and minimal morbidity.
In an attempt to avoid the deleterious effects of cardiopulmonary bypass (CPB), off-pump coronary artery bypass grafting (CABG) has been rediscovered and refined. Coronary artery bypass grafting was first performed without the use of CPB in the late 1960s [1], but this technique was largely abandoned after the use of CPB and cardioplegic arrest became routine [2].
Blood contact with artificial surfaces on the CPB circuit produces a well-documented diffuse inflammatory response that affects multiple organ systems. Specific deleterious effects of the inflammatory response have been documented in the heart, lungs, central nervous system, kidneys, and gastrointestinal tract. Activated neutrophils, free oxygen radicals, and cytotoxins lead to myocardial edema and decreased contractility, thus directly contributing to cardiac dysfunction after CPB. The inflammatory response impairs pulmonary function through the degradation of surfactant and activation of complement and neutrophils, with resultant capillary permeability, interstitial edema, atelectasis, and decreased pulmonary compliance. Stroke after coronary surgical procedures is usually embolic and related to CPB, cannulation, or surgical manipulation of the aorta. Subtle neurologic and cognitive deficits can be detected through psychologic testing and have been reported in up to 50% of patients after CPB. Virtually all detrimental effects of this diffuse inflammatory response increase with longer durations of CPB [3]. Also associated with increased CPB time are increased length of stay and hospital costs [4]. Use of corticosteroids, use of protease inhibitors, surface modification of the circuit, and leukocyte depletion have been proposed to decrease, but not eliminate, the inflammatory response [4].
Previous groups [2, 5, 6] have reported series of off-pump CABG operations. Although the mortality rates obtained have been excellent, concern has been raised about a decrement in graft patency rates [7]. Other concerns have centered on the limited exposure provided by a small thoracotomy for safe internal mammary artery (IMA) harvest and precise coronary anastomosis, on incomplete immobilization of target vessels, and on possible injury to vessels by temporary occlusion sutures.
The purpose of this study was to describe the evolution of the off-pump coronary bypass operation at our institution and to compare outcomes with a computer-matched control group to determine the safety and efficacy of off-pump CABG.
Material and methods
The off-pump group included 51 patients who were seen from November 1996 through December 1997 and underwent off-pump CABG by a single surgeon at Crawford Long Hospital, Emory University. The comparison group was a computer-matched control group. For each off-pump patient, the computer generated 5 control patients matched for age, sex, and preexisting disease who had primary CABG by a group of four surgeons at the same institution during the same period. Preexisting disease variables included history of hypertension, diabetes, renal insufficiency (serum creatinine level higher than 2 ng/dL), previous stroke, chronic obstructive pulmonary disease, peripheral vascular disease, and previous myocardial infarction (MI).
The surgical technique evolved over time in the off-pump group. During the first few months (9 patients), the procedure was accomplished through a thoracotomy. A left anterior minithoracotomy (approximately 10 cm) was made in the fourth intercostal space. The left IMA was harvested through this incision with a commercially available retractor (Cardiothoracic Systems, Cupertino, CA). Heparin sodium (5,000) units) was given prior to the division of the left IMA. The artery was treated with intraluminal administration of papaverine hydrochloride and lidocaine (2 mL of papaverine [30 mg/mL] plus 8 mL of lidocaine 1%). Ischemic preconditioning for 5 minutes was accomplished by using a loop of silicone elastomer for proximal occlusion of the left anterior descending coronary artery. A 5-minute period of reperfusion preceded the construction of the anastomosis. A "no-touch" technique was used for the target vessel distal to the anastomosis. A humidified, sterile carbon dioxide "blower" was used to clear the surgical field of blood. A mechanical stabilizer was employed during the anastomosis. The distal anastomosis was sewn with 7-0 nonabsorbable monofilament suture under direct vision.
The surgical technique evolved from a minithoracotomy to a median sternotomy. This was prompted by concern about precision and safety with the limited exposure afforded by a minithoracotomy and by the very limited number of patients referred for surgical management of single-vessel disease at our institution. Moreover, there was no indication that the thoracotomy was less painful than a sternotomy. Multiple vessels can be bypassed off-pump through a median sternotomy. This incision offers excellent exposure for safe IMA harvest and precise coronary anastomosis and allows rapid conversion to CPB if necessary. The remaining 42 patients underwent the off-pump operation through a median sternotomy. The IMA (right or left) was harvested under direct vision. Heparin (15,000 units) was administered prior to division of the IMA. The rest of the operation was as described for the first 9 patients with the addition of a half-reversal dose of protamine sulfate (750 mg) and the use of the miniCABG retractor (United States Surgical Corp, Norwalk, CT) for stabilization of the coronary target or targets on the beating heart. Proximal anastomoses were sewn to the aorta under a partial occlusion clamp with 5-0 suture.
Data reflecting intraoperative and postoperative variables were collected for comparisons. These data included number of distal grafts, use of the IMA as a conduit, use of an intraaortic balloon pump, inotropic support for more than 48 hours postoperatively, intubation for greater than 48 hours after operation, postoperative MI, stroke, sternal would infection (defined as mediastinitis necessitating readmission and debridement), leg wound infection (defined as deep soft-tissue infection necessitating readmission and debridement), renal failure (defined as postoperative elevation of a previously normal serum creatinine level to a level greater than 2 ng/dL), reexploration for bleeding, transfusion requirements, atrial arrhythmia (defined as supraventricular tachycardia or fibrillation requiring treatment), ventricular arrhythmias, postoperative length of stay, and hospital costs associated with the operation.
In the early experience, any patient with a postoperative complaint remotely suggestive of angina underwent angiography. Later, all patients were asked to consent to postoperative angiography for study purposes. Patients with preoperative renal insufficiency were excluded from postoperative angiography. Twenty-six of the off-pump patients had coronary angiography to document graft patency prior to hospital discharge.
Measures of central tendency and inferential and multivariate statistics were used for the data analysis. The frequency, mean, and standard deviation were calculated for the independent and dependent variables. The Student t test was used for two-group comparisons with continuous variables. Comparisons between the two groups were made using logistic regression for the dichotomous dependent variables. Multiple regression was used as a means to identify independent predictors of length of stay and hospital costs. An alpha level of 0.05 was used to determine significance [8].
Results
Group comparisons were made on the basis of morbidity, mortality, postoperative length of stay, and hospital costs. For the purpose of this study, two-group comparisons were made. All off-pump patients (thoracotomy and sternotomy approaches) were considered together and compared with patients having CABG on CPB. The off-pump group consisted of 51 patients and the control group included 245 patients, for a total sample of 296 patients. Forty-nine off-pump patient were matched; 2 underwent operation after the computer request was made. The two groups were compared on the basis of age, sex, and all seven comorbidities already listed to ensure that the two groups were appropriately matched. There were no preoperative differences between groups (Table 1). The mean age for the off-pump group was 59.8 years (37% female, 63% male) and for the control group, 60.9 years (32% female, 68% male).
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Dramatic differences in total postoperative length of stay and hospital costs were found between groups (Table 5). Length of stay was reduced by 50%, and hospital costs fell by 30% for the off-pump group. Cardiopulmonary bypass was found to be an independent predictor of increased hospital costs and increased postoperative length of stay.
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Pioneered by Benetti and associates [9] and Buffolo and colleagues [10] in South America almost 20 years ago, CABG without CPB has recently been rediscovered and continues to be refined. Techniques of off-pump CABG have also evolved at Crawford Long Hospital. Several important practical lessons have been learned. First, the sternotomy approach allows the surgeon to offer the benefits of avoiding CPB to a much larger group of patients than does minimally invasive direct coronary artery bypass through a minithoracotomy. This is determined by cardiology referral patterns and rests on the fact that few patients with single-vessel disease are referred for operation regardless of the surgical approach taken. Second, off-pump CABG through a sternotomy can be performed for lesions in the left anterior descending coronary, ramus intermedius, diagonal, right coronary, acute marginal, and posterior descending coronary arteries with currently available instrumentation and with a high degree of patient safety and surgeon comfort. The clinical and angiographic results we describe support this statement. Surgical management of lesions in the left circumflex territory requires CPB in this institution at the present time. No patient in the off-pump group had to be converted to CPB during the procedure.
Patients having single-vessel CABG through a thoracotomy had a statistically lower transfusion requirement that those having multivessel CABG off-pump through a sternotomy. However, the magnitude of the difference in transfusion requirement was much smaller than that between the off-pump sternotomy and on-pump control groups. Postoperative length of stay was only trivially shorter for thoracotomy patients having single grafts than for sternotomy patients with multivessel disease, who were on average 7 years older. There was no significant difference in costs between thoracotomy and off-pump sternotomy. Thus, during the hospital stay, there was no apparent advantage for thoracotomy over sternotomy for off-pump CABG.
As changes in the clinical practice of surgery are increasingly driven by economic considerations, the emphasis in minimally invasive cardiac surgery is on techniques that may decrease costs, length of hospital stay, and overall morbidity associated with cardiac operations. As older, sicker patients are referred for CABG, an increasing proportion of patients may have a relative contraindication to CPB. The results presented here support our belief that eliminating CPB in patients with suitable coronary anatomy while accomplishing complete revascularization off-pump is safe, effective, and economically advantageous.
Acknowledgments
It is with gratitude and appreciation that we acknowledge the team effort required for this project. Specifically we thank Lisa Satterwhite for secretarial support and Jean Walker for expertise with the Cardiac Data Bank.
References
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