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Ann Thorac Surg 1999;67:450-456
© 1999 The Society of Thoracic Surgeons
a Division of Cardiac Surgery, University G. D Annunzio, Chieti, Italy
b Division of Cardiology, Hospital of Pescara, Pescara, Italy
Accepted for publication July 8, 1998.
Address reprint requests to Dr Calafiore, Department of Cardiac Surgery, "G. D’Annunzio" University, "San Camillo de’ Lellis" Hospital, Via C Forlanini 50, 66100 Chieti, Italy
e-mail: calafiore{at}unich.it
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Abstract |
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Methods. From May 21, 1997, through February 1998, 227 patients underwent revascularization with two or more arterial conduits as the first operation: 122 without CPB (group A) and 105 with CPB (group B). Group A included a greater number of high-risk patients.
Results. Mean ± SD anastomoses per patient were 2.5 ± 0.6 in group A and 2.8 ± 0.8 in group B (p = NS). No patient died in group A, whereas 1 patient (0.9%) died in group B. The postoperative complication rate was low in both groups, but intensive care unit and in-hospital stays were shorter in group A than in group B (14.1 ± 7.1 versus 27.3 ± 36 hours, p < 0.001, and 4.1 ± 1.6 versus 5.4 ± 2.4 days, p < 0.001, respectively [group A versus group B]). Sixty-seven patients in Group A (54.9%) underwent postoperative angiography 33 ± 35 days after operation. The patency rate was 98.9% (98.2% for the marginal branches).
Conclusions. Arterial revascularization of the coronary arteries without CPB is feasible, with results similar to those obtained with CPB. The two techniques, in our opinion, are complementary, not antagonistic.
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Introduction |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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We describe our initial experience with CABG without CPB using a median sternotomy with two or more arterial conduits in patients who underwent a first coronary revascularization and analyze the evolution of the surgical techniques and assess the early clinical and angiographic results.
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Material and methods |
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In the first period (from January 1995 to May 20, 1997) only patients with favorable anatomy were considered. However, only in patients with high risk factors for CPB were the marginal branches or the posterior descending artery grafted. The remaining patients had only grafts to the LAD, diagonal branches, or the right coronary artery proximal to the crux.
During this period, 58 patients were operated on and represent 8.9% of the patients operated on during the same period with two or more arterial grafts.
In the second period (from May 21, 1997, through February 1998), after a new, improved technique for exposure of the lateral, posterior, and inferior walls of the heart was developed, surgical indications were expanded to include every patient who showed the following characteristics:
Need of multiple sequential grafts was considered a contraindication up to the end of December 1997 because we concentrated our attention in obtaining a good end-to-side anastomosis. Since January 1998, sequential grafts were routinary performed without CPB if necessary.
During the second period, 122 patients were operated on, 53.7% of those patients were operated on in the same period with two or more arterial grafts. The present report concerns this second group of patients because this group (group A) allowed a comparison with patients operated on with use of CPB during the same period (group B, n = 105). Only 1 patient was not included in any group, because the anastomoses were performed both without and with CPB. Table 1 shows the preoperative data.
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The mammary arteries are harvested skeletonized; the remaining conduits are harvested as previously described [4]. After partial heparinization (1 mg/kg body weight), all arterial grafts are prepared as previously reported [5]. The target coronary vessels are explored, and the surgical strategy is confirmed. Four slings (50 cm long, 3 cm wide) are enrolled and passed, two through the transverse sinus and two behind the inferior vena cava. The exposure of the lesions is obtained as follows.
The LAD is exposed by placing a laparathomic sponge behind the heart; the artery is gently moved medially and is easily accessible. This maneuver is well tolerated and takes seconds.
The diagonal branches are exposed in the same way. However, the two transverse sinus slings are moved so as to surround the lateral wall of the heart and are fixed to a towel in the right side of the sternotomy. This maneuver, well tolerated, moves the diagonal branches medially, making their position similar to the LAD (Fig 1A).
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After hemodynamic stabilization, the anastomotic site is presented. If the slings have to be moved, this is done slowly, a few millimeters each time, waiting 20 to 30 seconds before moving them again (Fig 1B).
Exposure of the inferior wall is obtained by pulling the heart upward in the vertical position, parallel to the diaphragm. Two slings (one from above and one from below) are crossed above the target vessel but near the apex to maintain the heart in position. The remaining slings are positioned near the others to better maintain the heart in a vertical position and to improve exposure as necessary. This maneuver is well tolerated by the heart, and hemodynamic stabilization is obtained in a few seconds (Fig 1C).
The right coronary artery proximal to the crux is exposed, pulling the acute margin up toward the aorta with 4-0 sutures. The two inferior vena cava slings are fixed to the left lateral portion of the sternotomy to improve exposure of the vessel.
The coronary arteries are occluded before the anastomoses, as described previously for the left anterior small thoracotomy (LAST) operation [6]. The LAD and the main right coronary artery are occluded proximally and distally and the other branches only proximally. An oxygen blower makes the operative field dry at the moment of the anastomosis.
Stabilization of the target vessel can be done pharmacologically or mechanically, or both. In the first part of our experience we used only diltiazem to reduce the movement of the heart; in September 1997 we began to use the MV stabilizer (CardioThoracic System, Cupertino, CA).
Once exposure and stabilization are obtained, the artery is incised, and the anastomosis is performed with a single suture. For the LAD and the diagonal branches, a Prolene or Sharpoint 8-0 suture is used. If a right gastroepiploic artery is used, an 8-0 suture is also used because of the characteristics of the graft. When a marginal branch or the RCA is grafted, when the radial artery is used, or when the coronary wall is thick, a 7-0 needle is used. For the marginal branches it is mandatory to use the 7-0 needle because a needle longer and thicker than 8-0 is needed. At the end of every anastomosis the flow in the graft is measured using a flowmeter (Cardiomed, Medi-Stim Oslo, Norway; Transonic System, Ithaca, NY).
Blood lost during the procedure is reinfused in the patient using a cell saver (Dideco, Mirandola, Modena, Italy). Protamine is reversed 1:1, and the wound is closed in the usual manner.
Coronary artery bypass grafting with cardiopulmonary bypass
The technical aspects of the operation were as follows: Warm systemic perfusion was used together with intermittent antegrade warm blood cardioplegia [7]; all proximal anastomoses were performed during a single cross-clamping time.
Hemodynamic data
To evaluate the hemodynamic changes related to cardiac manipulation, mean systemic pressure and cardiac output (thermodilution method; Baxter Explorer, Irvine, CA) were recorded in 10 patients before any maneuver and during the anastomosis.
Postoperative course
The patients were admitted to the intensive care unit, where they remained until extubation and clinical stabilization; intravenous diltiazem was given. Patients were transferred to the ward (generally on the same day as the operation or in the first postoperative day); diltiazem (60 mg, three times a day) was given orally and was continued for 4 weeks. On the morning of the first postoperative day, all infusion lines and drainage tubes were removed, and the patients were ambulatory. If the patient agreed, control angiography was performed before hospital discharge in group A; if, for practical reasons, this was not possible, angiography was performed a few days or weeks later. One, 3, and 6 months postoperatively, all the patients were seen in the outpatient clinic and were asked to perform a stress test.
Statistical analysis
Results are expressed as mean value ± SD, unless otherwise indicated. Statistical analysis comparing two groups was performed with an unpaired two-tailed t test for mean values or a 
2 test for categoric variables. Survival and event-free survival curves were obtained with the Kaplan-Meier method (BMDP 1L software). Statistical significance was calculated using the Mantel-Cox and z tests. A p value less than 0.05 was considered significant.
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Results |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Technical details
Most patients in both groups achieved total arterial myocardial revascularization (78.3% in group A, 69.4% in group B, p = NS). Arterial conduits, distal anastomoses, and associated operations are shown in Table 2, whereas different conduit arrangements are shown in Table 3. Two arterial conduits were used in 95 patients in group A and 84 patients in group B, three in 26 patients in group A and 21 patients in group B, and four only in 1 patient in group A. The mean anastomoses per patient were 2.5 in group A but increased to 2.8 in the last 2 months.
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Postoperative course
Postoperative data are shown in Table 5. The intensive care unit stay was lower in group A than in group B, and 26.2% of patients were discharged by the first 6 hours. Postoperative complications were lower in both groups. Only 1 patient in group B (0.9%) had a cerebrovascular accident and died late of complications related to residual deficit. The postoperative in-hospital stay was significantly less in group A than in group B (4.1 ± 1.6 versus 5.4 ± 2.4 days, p < 0.001; median, 4 and 5 days, respectively).
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Postoperative angiography
After a mean period of 33 ± 35 days after operation, 67 patients (54.9%) in group A underwent angiography (23 during the same hospital period) (Figs 2–4); the details are shown in Table 6. Three sequential grafts and 14 Y grafts were restudied; all anastomoses, including the intermediate one in the Y grafts, were perfectly patent (grade A). According to the classification of Fitzgibbon and colleagues [8], the patency rate (grade A plus B) was 98.9% (183 of 185); the perfect patency rate (grade A) was 98.4% (182 of 185). However, subsequent angiography, performed 44 days after the first angiography, showed a reversal to normal of the conduit shape (Fig 5) in only the grade B anastomosis, making the perfect patency rate equal to the patency rate (98.9%). Only 4 patients in group B underwent postoperative angiography, 12 anastomoses were checked (four on the LAD, one on the diagonal branch, four on the obtuse marginal branch, three on the posterior descending coronary artery), and all were grade A.
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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We compared our early results with those obtained in patients who had two or more arterial conduits during CPB. The present study was not randomized because the two strategies are, in our opinion, complementary, not antagonist. Postoperative mortality and morbidity were absent or low in both groups. The major difference was intensive care unit stay, which was significantly lower in group A than in group B. In group A, 26.2% of patients were discharged in the first 6 hours, allowing the use of a single intensive care unit bed for 2 patients. Also, hospital stay was significantly lower in group A, especially when the 23 patients who underwent angiography during this period, prolonging hospital stay 1 or 2 days more, are considered.
Angiographic studies in group A showed good results. There was a high incidence of grade A anastomoses (98.9%). In particular, LAD grafts were patent in 100% of patients; in a single patient in this group a grade B anastomosis was present but reversed to grade A 44 days after operation, confirming our observations after the left anterior small thoracotomy operation [6]. Marginal branch grafts had a high patency rate (98.2%). This is a very important finding because lateral wall grafting is a major problem in myocardial revascularization without CPB.
In conclusion, we demonstrated by carefully carried out angiographic studies that arterial revascularization of all the arteries of the heart is possible without use of CPB in selected patients, with results similar to those obtained with CPB. Technologic advances facilitated the procedure and may simplify the technique in the future. Our early clinical results indicate that the procedure is safe. Our angiographic studies demonstrate a satisfactory patency rate. Even if some loss of patency, still related to perioperative technical inadequacies, occurs during the first year, this is true for every coronary anastomosis, independent of surgical technique.
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A. L. Iaco, M. Contini, G. Teodori, M. Di Mauro, G. Di Giammarco, G. Vitolla, T. Iovino, and A. M. Calafiore Off or on bypass: what is the safety threshold? Ann. Thorac. Surg., October 1, 1999; 68(4): 1486 - 1489. [Abstract] [Full Text] [PDF]
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