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Ann Thorac Surg 1999;67:1653-1658
© 1999 The Society of Thoracic Surgeons

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Original Articles

Technical aspects of total revascularization in off-pump coronary bypass via sternotomy approach

^a St. Vincent Medical Center, Los Angeles, California, USA
^b Providence Saint Joseph Medical Center, Burbank, California, USA
^c St. John’s Regional Medical Center, Oxnard, California, USA>

Accepted for publication December 14, 1998.

Address reprint requests to Dr Baumgartner, Pacific Cardiothoracic Surgery Group, 2200 W Third St, Suite 300, Los Angeles, CA 90057–1904

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. Cardiopulmonary bypass and cardioplegic arrest result in known physiologic inflammatory, coagulopathic, and embolic states that may result in end-organ damage. Interest in off-pump complete coronary revascularization using sternotomy exposure is therefore increasing.

Methods. Using specific surgical and anesthetic techniques, we have been able to achieve total revascularization using off-pump coronary artery bypass grafting procedures (OP-CAB) through a sternotomy approach. Exposure techniques and local stabilization are tailored to individual vessels and cardiac regions. Vascular control is achieved with silicone-elastomer loops, occluders, and shunts. Poor ventricular function, advanced age, and other comorbid conditions, in and of themselves, were not considered contraindications to OP-CAB. Cardiomegaly or situations of small, intramyocardial, or heavily calcified vessels were relative contraindications to OP-CAB.

Results. Of 141 sternotomy OP-CAB cases, 132 (93.6%) were completely off-pump. The mean number of OP-CAB grafts per patient in the cases that were completely off-pump was 3.3 (range, 1 to 6). The 30-day operative mortality was 0%. There were four instances of intraoperative cardiac arrest, precipitated by vascular occlusion of the right coronary artery or manipulating a cardiomegalic heart. Advanced age ( 80 years) or profound ventricular dysfunction (ejection fraction 0.25) was present in a considerable percentage of patients (10.6% and 9.9%, respectively).

Conclusions. Off-pump coronary artery bypass grafting is successful for total revascularization in large numbers of patients. Anatomic factors, including cardiomegaly and small, intramyocardial, or heavily calcified vessels are possible contraindications to OP-CAB. Patients at highest risk for undergoing cardiopulmonary bypass, including those of advanced age and having ventricular dysfunction, are precisely the ones in whom OP-CAB may be the most useful.

	Introduction

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
The feasibility of off-pump coronary artery bypass graft procedures (OP-CAB) has been well demonstrated [1, 2]. Off-pump grafting of the circumflex branches by median sternotomy can be difficult and was either not done [1, 3] or done in limited numbers [2]. A limited thoracotomy [4–6] has been used to perform direct coronary artery bypass (MIDCAB) without cardiopulmonary bypass (CPB) to graft, predominantly, the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD). The use of a stabilizer platform has been reliable in limiting regional wall motion at the point of anastomosis [7]. This technique does not address circumflex artery disease, which is not easily accessible with a limited thoracotomy and is, therefore, applicable to only a minority of patients undergoing coronary artery bypass grafting (CABG) in whom complete surgical revascularization is the goal. Interest is increasing in the area of total, multivessel OP-CAB. We herein describe our technique with a median sternotomy approach.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Patient selection
Unless a patient is in shock at the time of sternotomy, no patient has been considered to have an absolute contraindication to OP-CAB. The ideal patient selected for OP-CAB is actually one who is elderly with other comorbid conditions (severe cardiac dysfunction, pulmonary or renal failure, prior stroke, or prior gastrointestinal bleed). In situations in which small or intramyocardial vessels or possibility of endarterectomy are suspected on the basis of the preoperative angiograms, we have been wary of performing OP-CAB, and usually use CPB in these patients. Ejection fraction is not used as a basis to reject a patient from OP-CAB. Cardiomegaly is a relative contraindication because of the technical difficulty of reaching the obtuse marginal and right coronary artery branches. When a simultaneous valve procedure is performed, we have not done OP-CAB.

Anesthetic management
Anesthetic induction is performed with a bias toward intermediate-acting agents and muscle relaxants, and avoidance of high-dose narcotic techniques to facilitate early awakening and extubation. Temperature homeostasis is achieved using adequate room temperature, forced-air warming blankets, warm circulating water mattresses, warm infusion solutions, and low-flow anesthetic gas and oxygen delivery systems.

Oximetric pulmonary artery catheters are used routinely and provide continuous evaluation of end-organ tissue perfusion during periods of maximal hemodynamic instability and low cardiac output states secondary to surgical manipulation. During grafting of the right coronary artery branches and circumflex arteries, which typically require significant myocardial manipulation, mixed venous oxygen saturations and cardiac output may decline as much as 20% to 30% and 30% to 40% from preoperative baseline values, respectively. Restoration to baseline levels typically occurs within 1 to 2 minutes of surgically unrestricted myocardial function, provided serum pH balance is maintained within the normal physiologic range (7.35 to 7.45). Transesophageal echocardiography is used to detect subtle but significant hemodynamic as well as ischemic changes within the myocardium.

Systemic anticoagulation with heparin is established using one third of the CPB loading dose and periodically supplemented to maintain an activated clotting time between 200 and 300 seconds at all times until revascularization is complete. Reversal with protamine is individualized but is done for most patients.

Ischemic prophylaxis is accomplished using intravenous nitroglycerin infusion and short acting ß-blockers such as esmolol to control heart rate and minimize myocardial oxygen consumption. Although stroke volume may be compromised during myocardial manipulation, cardiac output may become increasingly rate-dependent. Mean arterial blood pressure and therefore tissue perfusion pressure can be maintained using -agonists such as phenylephrine both as infusions and timely intravenous boluses during periods of induced hypotension. Volume loading with infusions and placing the patient in Trendelenburg position optimize cardiac output during cardiac manipulations.

Lidocaine boluses and maintenance infusions are frequently necessary prophylactically or as treatment for ventricular tachycardia or fibrillation during manipulation or coronary occlusion. These episodes are particularly prevalent during right coronary artery grafting.

Although extubation in the operating room was performed in several cases, we have not made a special effort to do so. Most patients undergo early extubation within 3 hours of returning to the critical care unit. These patients are more awake during this time than those undergoing CPB, and attention to pain management during this time is an important priority.

Surgical technique
The defibrillator paddles are placed on the field. A median sternotomy approach is used. The LIMA is harvested in the vast majority of patients.

Exposure
The Cardiothoracic Systems retractor (Cardiothoracic Systems, Inc, Cupertino, CA) is placed in position with the connecting bar placed inferiorly. The pericardium is opened, and a transverse slit is made to accommodate the LIMA without tension. A single pursestring suture is placed in the aorta and right atrium in case rapid cannulation becomes necessary. After grafting the LAD with the LIMA, the LIMA is anchored to the epicardium to prevent avulsion in subsequent manipulations. A LIMA to LAD anastomosis is under the greatest tension during exposure of the ramus intermedius or high obtuse marginal arteries (while the heart is torqued inferiorly and toward the right).

Anterior pericardial traction sutures are placed. Deep pericardial sutures are next placed in strategic locations (Fig 1) to facilitate pericardial retraction for cardiac elevation and exposure. This is a variant of a described procedure for obtaining direct exposure of the circumflex [8]. Care is taken to avoid injury to the pulmonary veins or phrenic nerve during this maneuver. Varying amounts of traction on these sutures will elevate the heart in different ways, eg, lift the cardiac apex up and out of the sternotomy (anteriorly and superiorly) or roll the lateral aspect of the heart toward the surgeon. Trendelenburg positioning further elevates the apex out of the chest. Care is taken that the deep suture adjacent to the left superior pulmonary vein does not ensnare or lacerate the left atrial appendage. Rubber snares on these sutures are used to prevent such injury. Laparotomy packs can be placed behind the heart to further elevate the heart from the chest. Alternatively a saline-filled glove (accomplished with an inflated Foley catheter tied within the glove) can be used as a soft buttress. Opening the right pleura may improve exposure of the lateral heart vessels.

View larger version (51K): [in this window] [in a new window]   Fig 1. Deep pericardial sutures (arrows) placed to elevate the left posterior pericardium for exposure of lateral and inferior walls. Exposure of the ramus intermedius, obtuse marginals (OM), and posterior descending artery (PD) are best achieved by tension on sutures 1-2, 2-3, and 3-4, respectively. The Trendelenburg position further elevates the apex (A).

All distal anastomoses are generally completed first. A partial occlusion clamp is applied once to the aorta and proximal anastomoses are performed. In a minority of cases, proximal anastomoses have been done before the distal anastomoses. In general, no more than two proximal anastomoses are done, as sequential bypasses are liberally performed. In a few instances, to permit revascularization of an important artery, a proximal anastomosis may be done before completing all distal anastomoses. In a few instances we have Y-grafted a saphenous vein onto the previous graft to prevent multiple partial aortic occlusion clampings.

Immobilization
The cardiothoracic systems immobilizer footplate is placed straddling and parallel to the target vessel. The immobilizer is usually best positioned aimed superiorly from the inferiorly placed retractor bar (Fig 2). The blades of the footplate may themselves be swiveled in any position. Generally for the LAD and diagonal arteries, the tips of the footplate aim cephalad and are positioned on the right side of the retractor (Fig 2).

View larger version (62K): [in this window] [in a new window]   Fig 2. Retractor and stabilizer in position over the left anterior descending artery, the easiest target to graft. The retractor bar is placed inferiorly; the footplate points cephalad.

View larger version (144K): [in this window] [in a new window]   Fig 3. Exposure of the obtuse marginal (OM) as viewed from the head of the table (CE = cephalad). Two deep pericardial suture snares (S) are used to elevate the left pericardium and tilt the apex out of the chest. The stabilizer bar (B) further exposes, positions, and immobilizes the OM. A vessel loop is seen around the proximal OM. The left internal mammary artery (L) has already been grafted to the left anterior descending coronary artery.

View larger version (158K): [in this window] [in a new window]   Fig 4. Exposure of the posterior descending artery as viewed from the surgeon’s perspective. A suture snare (S) in the diaphragmatic pericardium elevates the apex anteriorly and cephalad (CE), as does the Trendelenburg position. The stabilizer bar (B) further exposes, positions, and immobilizes the target. A vessel loop is seen around the proximal posterior descending artery.

View larger version (132K): [in this window] [in a new window]   Fig 5. Cruciate side-to-side sequential anastomosis between the radial artery (R) and ramus intermedius. The distal limb of the radial artery has been grafted to the obtuse marginal. The heart is torqued inferiorly and toward the right, resulting in the greatest chance of tension on the left internal mammary artery to left anterior descending coronary artery anastomosis (arrowhead). The handle of the vascular occluder is seen (O) as well as the loosened silicone-elastomer snare. Note the maneuverability of the stabilizing bar (B), which is nearly parallel with the footplate.

View larger version (38K): [in this window] [in a new window]   Fig 6. FloCoil shunt inserted into opened coronary artery. Internal vascular occlusion is achieved while maintaining perfusion.

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

Conduits have included LIMA, right internal mammary artery, radial artery, greater and lesser saphenous vein, and cryopreserved vein. There were five instances of intraoperative cardiac arrest, three occurring during or immediately after anastomoses to the right coronary artery, one during anastomosis to an endarterectomized diagonal artery, and one while manipulating a cardiomegalic heart. Of those patients sustaining an intraoperative cardiac arrest, one required emergent CPB. One 67-year-old man who sustained a short ventricular fibrillation episode during grafting of an endarterectomized diagonal artery sustained a unilateral occipital infarct resulting in a homonymous hemianopia. There were no other strokes in our series. One 83-year-old male patient who was confused preoperatively developed worsening, persistent postoperative confusion without computed tomographic or magnetic resonance imaging evidence of stroke.

The overall 30-day operative mortality was 0%. There were 5 redo cases. The mean age was 68 years (range, 40 to 87 years) and mean ejection fraction was 0.50 (range, 0.15 to 0.7). Profound ventricular dysfunction (ejection fraction 25%) was present in 14 patients (9.9%). Advanced age ( 80 years) was present in 15 patients (10.6%).

Three OP-CAB patients had evidence of postoperative ischemia or infarction during follow-up ranging from 2 to 13 months. One 64-year-old man who had undergone an off-pump LAD endarterectomy with saphenous grafting sustained an early (< 12 hours) postoperative anterior myocardial infarction with occlusion of his LAD. He was successfully managed medically. A 78-year-old man re-presented 2 weeks postoperatively with inferior ischemia and congestive heart failure. He was found at angiography to have occluded his posterior descending artery graft. He underwent uneventful angioplasty of the native right coronary artery. A 66-year-old woman experienced anginal symptoms and a positive stress test 2 months postoperatively and was found to have a 95% narrowing of an off-pump LIMA to LAD anastomosis. She successfully underwent angioplasty of this anastomosis. An 83-year-old woman had no autologous usable vein, and a cryopreserved vein was used for the posterior descending artery anastomosis. The radial artery was taken from the hood of this vein to graft the first and second obtuse marginal arteries, and the LIMA was used for the LAD. Three months postoperatively, the patient experienced angina at rest, and angiography confirmed closure of the cryopreserved vein and the radial artery grafts. She underwent successful atherectomy of the circumflex system. Other than these four cases, no patient has had evidence of postoperative ischemia or infarction in terms of symptoms or electrocardiographic change. We did not routinely study creatine kinase-MB or troponin levels in our OP-CAB patients. We did not perform routine postoperative angiography.

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Cardiopulmonary bypass and cardioplegic arrest are in and of themselves nonphysiologic and inflict a total-body invasion. Pathophysiologic changes occur from systemic inflammatory, coagulopathic, high vascular resistance, low output states; neuropsychiatric phenomena; and outright stroke [9–13]. Although the majority of patients undergoing coronary artery bypass grafting tolerate CPB well, certain patient subgroups have a higher incidence of adverse outcomes from CPB, including the elderly and patients with profound ventricular dysfunction, prior stroke, and pulmonary and renal dysfunction. It is these types of high-risk patients who may benefit the most from OP-CAB compared with standard CPB. In our series, we intentionally did not preselect better-risk patients for OP-CAB, since it is the higher-risk patient who would be expected to benefit the most from OP-CAB. A substantial number of our patients had profound ventricular dysfunction and advanced age. The ideal patient for OP-CAB may paradoxically be the worst operative candidate.

It was clear that the greatest risk of intraoperative cardiac arrest arose from vascular isolation of the right coronary artery. If at all possible, grafting of the posterior descending artery or posterior ventricular branch is preferable to grafting the right coronary artery itself. When grafting of the right coronary artery directly is necessary, an occluder that simultaneously maintains perfusion may be of the most benefit. If CPB is necessary, cardioplegic arrest may still be avoided, and this may still afford substantial benefit for the patient [10].

Certain subsets of patients may be suboptimal candidates for OP-CAB. These include those whose preoperative angiograms demonstrate small, intramyocardial, or heavily calcified vessels that may require endarterectomy. Cardiomegalic hearts are particularly difficult to position for OP-CAB grafting and usually represent a contraindication to the procedure. Hemodynamically unstable patients are clearly not OP-CAB candidates.

We believe the sternotomy approach has advantages over the small anterior thoracotomy approach. In multivessel disease, exposure of all vessels is feasible with sternotomy but not limited thoracotomy, but even for single-vessel disease, a sternotomy approach may be preferred to thoracotomy. With the sternal approach, harvesting of the internal mammary artery is simplified, identification of the LAD done with greater confidence, and access for cannulation is readily available should problems arise. Furthermore, it is not apparent to us that postoperative pain is reduced by a minithoracotomy compared with sternotomy. One real advantage of a small anterior thoracotomy may be in reoperative situations in which adhesion takedown necessary through a sternotomy may be obviated.

Active, vigilant participation by the anesthesiologist using anticipatory, as well as reactive, strategies is essential to achieve a safe and successful outcome. There is no question that complete OP-CAB revascularization is technically far more demanding for both the anesthesiologist and surgeon than working on an arrested heart. If the procedure cannot be done safely and efficiently, it should not be done. However, the elimination of CPB and cardioplegic arrest in a high-risk patient undergoing OP-CAB may have important implications from the standpoint of neurologic recovery and operative morbidity.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
The assistance of Cardiothoracic Systems, Inc, in the preparation of the figures is gratefully acknowledged.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Fritz J. Baumgartner Ali Gheissari Eli R. Capouya Taro Yokoyama Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Baumgartner, F. J. Articles by Yokoyama, T. Search for Related Content PubMed PubMed Citation Articles by Baumgartner, F. J. Articles by Yokoyama, T.