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Ann Thorac Surg 2000;69:1216-1221
© 2000 The Society of Thoracic Surgeons

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ORIGINAL ARTICLES: CARDIOVASCULAR

Surgical myocardial revascularization without cardiopulmonary bypass

^a Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India

Address reprint requests to Dr Bhan, Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar 110 029, New Delhi, India
e-mail: shivmeet{at}medinst.ernet.in

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Though coronary artery bypass grafting (CABG) without cardiopulmonary bypass is being performed with increasing frequency, in the absence of adequate angiographic follow-up, safety, reproducibility, and efficacy of the procedure remain doubtful. In this prospective study, we report the results obtained by 100% angiographic follow-up of 96 consecutive patients.

Methods. A total of 96 patients (age range 33 to 76 years) underwent CABG without cardiopulmonary bypass. Single vessel disease was present in 46 (47.9%) patients, double vessel disease in 31 (32.3%), and triple vessel disease in 19 (19.8%) patients. All patients were operated through a standard midsternotomy and an optimal combination of pharmacological and mechanical methods were used to restrict cardiac movements during anastomosis. All patients underwent coronary angiography before discharge from the hospital.

Results. A total of 160 grafts were placed (range 1 to 4 grafts per patient, average 1.7 ± 0.3 grafts per patient). A single graft was placed in 46 patients, double grafts in 38, triple grafts in 10, and quadruple grafts in 2 patients. Various grafts included pedicled left internal mammary artery (LIMA) (n = 95), free LIMA (n = 1), right internal mammary artery (n = 14), radial artery (n = 24), right gastroepiploic artery (n = 5), and saphenous vein grafts (n = 21). Operative mortality was 1.0% (1 of 96). Two patients required reoperation for excessive bleeding. Mean hospital stay was 5.7 ± 1.2 days. Overall angiographic patency was 95.0% with LIMA patency of 97.9% (93 of 95). One patient with block in midsegment of LIMA was reoperated using cardiopulmonary bypass. Follow-up ranged from 4 to 17 months (mean 8.2 ± 3.1 months). Two patients (one with narrowed LIMA to left anterior descending artery anastomosis, and one with patent anastomosis) had residual angina.

Conclusions. Coronary artery bypass grafting without cardiopulmonary bypass is a reproducible, effective, and safe option in selected group of patients. A conscientious approach in patient selection and route of operation is required.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) is a frequently used technique. Various investigators [1–4] have reported excellent clinical results along with cost efficiency. It is of great value in patients who are at high-risk for CABG because of associated illnesses like chronic renal failure, significant carotid disease, pulmonary insufficiency, and incurable cancers. It also offers a viable option for the patients where angioplasty had failed or was unaffordable. However, some investigators [5–7] have expressed their concerns about technical limitations of the procedure and efficacy of the anastomoses. Moreover, there is paucity of the angiographic follow-up of the procedure [8, 9]. We have undertaken this prospective study to evaluate the feasibility, safety, reproducibility, and efficacy of the procedure.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Ninety-six consecutive patients who underwent CABG without CPB, from December 1996 through September 1998, formed the basis of this study. In 104 patients, CABG was attempted without CPB, but 8 patients (7.7%) required CPB to complete the procedure. All patients were operated upon by one of the authors (A.B.). The demographic and clinical profiles of patients are shown in Table 1.

Patient selection
Two subsets of factors favored CABG without CPB.

The first was morphological suitability. When the graftable vessels were situated suitably, and it was anticipated that those vessels could be tackled without excessive cardiac manipulation, CABG without CPB was planned. Usually these included isolated proximal left anterior descending artery (LAD) or right coronary artery (RCA) lesions, in which angioplasty was contraindicated (complex lesion); unsuccessful or restenosis occurred after angioplasty. A large ( 2 mm), noncalcified, totally occluded LAD with good collaterals to distal LAD, favored CABG without CPB. Presence of marked cardiomegaly disfavored the procedure.

The second subset included the conditions where CPB is frequently associated with high morbidity: namely chronic renal failure, cerebrovascular accident, and chronic obstructive pulmonary disease.

All patients who were scheduled to undergo CABG without CPB were reassessed at operation. After harvesting the desired conduits, the heart was gently lifted to bring the graftable vessel in view. If there was marked hypotension or serious arrhythmias, the endeavor to perform CABG on beating heart was abandoned and standard CPB was instituted. Other relative contraindications for this procedure included intramyocardial LAD or diffusely diseased and/or calcified LAD.

Surgical technique
A standard midsternotomy was used in all the patients. Pericardium was opened, and suitability for CABG without CPB was assessed. The conduits were harvested. The internal mammary artery (IMA) graft was subjected to gentle dilatation with dilute papaverine solution, and radial artery graft was dilated with papaverine and verapamil solution (10 mg papaverine, 10 mg verapamil, and 60 mL heparinized saline). Patients were heparinized (2 mg/kg) when IMA takedown was nearly complete. Pericardial stay sutures were fixed on the left side behind the left phrenic nerve and just in front of the left-sided pulmonary vein. These sutures, when pulled up, give a good lift to the heart, and hence the need for too many surgical sponges behind the heart is reduced.

The heart was gently lifted by placing adequate number of surgical sponges behind the heart. Significant hypotension was noticed in some patients with the initial lift. However, a sustained lift gradually stabilized their hemodynamics. Hemodynamic instability, if not severe, was managed by rapid administration of fluids and, if required, a small dose of dopamine.

The site of anastomosis was chosen. The preoperative angiographic evaluation gave a good idea about the likely site of anastomosis in the left anterior descending artery (LAD). The consideration was usually to exclude any major septal or diagonal branches of LAD. In most of the cases, it was possible to adhere to planning at the time of operation.

The target coronary artery was occluded, proximal, and distal to proposed arteriotomy site, by widely placing double-looped 5-0 Prolene (Ethicon, Somerville, NJ) sutures. These sutures were snugged and arteriotomy was made. In patients who had significant antegrade flow, we used a technique for preconditioning the myocardium. The proximal snare was snugged for a period of 2 to 3 minutes and then released. The cycle was repeated 3 to 4 times. After the preconditioning, complete occlusion of artery was tolerated much better. We have not used any intracoronary shunts.

We used an optimal combination of pharmacological and mechanical methods to reduce the coronary artery movement. Until January 1998, we used intravenous esmolol and diltiazem to reduce the heart rate and maintain the systemic systolic pressure at about 70 to 80 mmHg. Since the introduction of mechanical stabilization platform, we have stopped using too much pharmacological manipulation, and we do not target to drop the systemic systolic pressure. Mechanical stabilization was achieved by a modified cardiac stabilizer (Cardiothoracic Systems, Cupertino, CA). This stabilizer was originally devised for minimally invasive direct coronary artery bypass grafting (MIDCABG), and we modified it for the sternotomy incision.

After arteriotomy, the operative field was kept free from blood by saline squirts and blowing oxygen through an indigenously developed jet-blower. Recently, we have been using a blower-mister (Medtronic DLP, Grand Rapids, MI). This delivers a fine jet of an oxygen-saline mixture, and keeps the artery free of blood without drying it out.

The distal anastomosis was performed using a continuous 7-0 Prolene suture. After completion of the anastomosis, the target vessel snuggers were released and hemostasis achieved. In cases where free grafts were used, proximal anastomosis to the aorta was made on a punch aortotomy after applying a side clamp to the ascending aorta. To aid myocardial perfusion, the proximal anastomosis was made before the next distal anastomosis.

Heparin was reversed in all of the patients. Sternotomy was closed in a routine fashion after inserting drainage tubes. All patients were shifted to intensive care unit with mechanical ventilatory support. If there was no further significant blood loss, and if hemodynamics were stable, patients were weaned off the ventilator and extubated. Serial electrocardiograms and estimations of serum creatinine phosphokinase and its MB fraction were done to detect perioperative ischemia. All survivors were subjected to coronary angiography before discharge from the hospital.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Coronary artery bypass grafting without CPB was attempted in 104 patients, which constituted 23% of all patients (n = 452) in whom CABG was performed by the same surgeon during this period.

Of these 104 patients, 8 (7.7%) required CPB. In 6 patients, CPB was instituted as patients developed marked hypotension or serious arrhythmias during the manipulation of the heart. In one patient, the LAD was intramyocardial and in another patient significant bleeding from anastomosis necessitated CPB. In the remaining 96 patients, 160 grafts were placed (range 1 to 4 grafts per patient, average 1.7 ± 0.3 grafts per patient). The frequency and distribution of various types of grafts are shown in Table 2.

Eighteen patients required inotropic support for 1 to 3 days. None of the patients required mechanical circulatory assistance. Two patients required reoperation for excessive bleeding. In both of these patients, the bleeding was from IMA bed. Homologous blood transfusion was required in 12 patients. Two patients who had preoperative renal dysfunction did well. Most of the patients were ventilated for 4 to 12 hours. Two patients, who were reexplored for excessive bleeding, required ventilation for more than 24 hours. There were 4 episodes of minor wound related sepsis. Serial electrocardiograms and cardiac enzyme assays did not reveal new onset ischemia in any of the patients. Mean hospital stay was 5.7 ± 1.2 days (range 5 to 11 days).

The postoperative angiography done before discharge showed a graft patency rate of 95% (151 of 159), with the LIMA patency of 97.9% (93 of 95) (Table 3) (Fig 1). One patient had narrowing of LIMA to LAD anastomosis (Fig 2). Immediate reoperation was refused and the patient continued to be symptomatic. Stress thallium performed after 6 weeks was positive for inducible ischemia in the LAD territory. Reoperation was recommended, but the patient refused the same. He is presently under medical follow-up. In the other patient, the LIMA was blocked in midsegment (Fig 3). This patient had an episode of severe chest pain during internal mammary angiogram, and we are not certain if there was any catheter-induced injury to LIMA. This patient was reoperated as he developed unstable angina after angiographic procedure.

View larger version (77K): [in this window] [in a new window]   Fig 1. (A) Coronary angiogram with selective injection into LIMA showing patent LIMA-LAD anastomosis (LIMA = left internal mammary artery; LAD = left anterior descending artery). (B) Coronary angiogram with selective injection into radial artery showing patent radial artery to obtuse marginal anastomosis.

View larger version (77K): [in this window] [in a new window]   Fig 2. Coronary angiogram with selective injection into LIMA showing narrowing of LIMA-LAD anastomosis. (A) Left anterior oblique view. (B) Right anterior oblique view (LIMA = left internal mammary artery; LAD = left anterior descending artery).

View larger version (151K): [in this window] [in a new window]   Fig 3. Selective injection into left internal mammary artery showing complete cut-off in midsegment.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Though described as early as 1973 by Garret and coworkers [10] only few sporadic reports [11, 12] of CABG without CPB appeared in the 1980s. However, in the current decade, encouraging reports appeared [13–16] and with the advent of MIDCABG in early 1990s, CABG without CPB was established as a popular alternative technique of myocardial revascularization [1–4, 17–19]. These investigators showed distinct advantages of the procedure in terms of reduced morbidity, rapid recovery, short hospital stay, and faster return to routine activity [1–4, 17–19]. Reduced cost of operation was an added advantage [2, 20, 21]. The morbidity and mortality of CABG have largely been attributed to the use of CPB, global cardiac arrest, and hypothermia [9, 22]. Adverse cerebral outcome is also a frequent complication of CPB [23]. Absence of CPB, obviously, contributes to reduced morbidity and mortality. However, there is concern about safety and efficacy of the procedure [5–7, 24], more so, when compared to excellent results obtained with standard CPB. Furthermore, due to lack of angiographic follow-up in consecutive patients [8, 9] the safety, reproducibility, and efficacy of the procedure remained doubtful.

In our series of 96 consecutive patients, patency rate of LIMA to LAD anastomosis was 97.9%, with an overall patency rate of 95%. The results were comparable to the results obtained with CPB, as in our own experience [25], and also reported in the literature [26, 27]. Others have also shown comparable patency rates [3, 4, 18–20]. A lower patency rate has been reported in earlier reports [1, 2], but with advent of better support systems, superior results are obtained [18]. Subramanian and associates [18] demonstrated much superior results with use of mechanical immobilization in later part of their experience, as compared to conventional methods of immobilization in their early experience (LIMA-LAD patency rate 97% vs 84% p = 0.05).

There are certain areas of concern regarding CABG without CPB. First is the possibility of ischemia of the territory supplied by the recipient artery. The recipient artery is completely occluded during the anastomosis, and thus can lead to myocardial ischemia. However, angioplasty experience with regional ischemia during balloon inflation has made the investigators understand the consequences of interruption of blood flow during the anastomosis [24]. In presence of well-developed collaterals, this interruption of coronary flow is well tolerated [1, 2, 18]. Secondly, there is a possibility of coronary injury due to traction on proximal and distal occluding snares. Too much traction may damage the coronary artery, and can result in intimal hyperplasia leading to focal stenosis [7, 8, 28, 29]. However, long-term angiographic evaluation is required to evaluate the risk. Thirdly, a procedure performed on a beating heart, carries the risk of suboptimal anastomosis suturing [9, 18, 29–31]. Multiple intimal tears in coronary artery and graft during anastomosis, in presence of beating heart, can lead to thrombus formation, and finally vascular occlusion [18]. With availability of better mechanical assistance to immobilize the hearts, this risk has been reduced to minimum [18–21].

We have performed the procedure through a standard midline approach with full sternotomy in all patients. Apart from cosmetic drawback, this approach offered several advantages. In our patients, institution of CPB did not require any additional incision as has been in 6% to 8% cases of other investigators [3, 18–20]. In addition, other approaches required more than one incision if right coronary or posterior descending artery revascularization was required. Even in some patients with MIDCABG, a midsternotomy was required for right coronary grafts [18]. Furthermore, Subramanian and colleagues [18] have reported high block rate (20%), if right IMA is anastomosed to RCA by a MIDCABG approach. However, Subramanian [18] and Calafiore [19] and their colleagues have advocated MIDCABG as preferential approach for graft to LAD. It is postulated that during limited thoractomy the intactness of the mediastinal and pericardial attachment to undersurface of the sternum brings the LAD close to the surface and places the LAD underneath the pericardial opening [18]. Secondly, in MIDCABG, the heart moves up and down, and thus moves the LAD towards the surgeon during contraction. In contrast to this, in midsternotomy procedure, heart rotates with every beat and LAD moves away from the surgeon [19]. In our experience, we have found the pericardial traction suture placed behind left phrenic nerve very helpful. When pulled up along with slight rotation of operating table towards the surgeon, it permits good exposure of LAD and marginal vessels. However, if only LAD graft is required, minithoracotomy approach may be a suitable alternative because of its superior cosmetic results.

There is a possibility of steal phenomenon if all the proximal branches of IMA are not divided. Though some investigators deny its existence [19], some have expressed their concern about it [9, 18, 32]. However, with midsternotomy the possibility of steal phenomenon is completely abolished. Furthermore, the limited access obtained during minithoracotomy precluded adequate mobilization of LIMA and required lengthening with inferior epigastric artery [3]. Though with improved techniques this is not required [18], midsternotomy always ensures proper length of LIMA which not only improves quality of anastomosis but can also prevent catastrophic complication of LIMA-LAD anastomotic disruption due to short IMA, as has been reported [18, 30].

Incomplete revascularization has been clearly identified as a main contributor to higher hospital mortality and morbidity and early return of angina [22, 33–35]. Our goal was to achieve complete revascularization. Only in those patients where angiographic findings were suitable for complete revascularization without CPB, was the procedure attempted. This was possible in 23% of our patients. When angiographic findings did not meet the prerequisites for CABG without CPB, a standard procedure with CPB was carried out. In recent reports [3, 18–20] of MIDCABG, incomplete revascularization resulted in significant reoperations and angioplasties. Thus, we feel that complete revascularization should be the goal of the procedure and it can be obtained in only selected group of patients when CPB is kept at abeyance. Furthermore, accepting incomplete revascularization solely for cosmesis does not seem appropriate.

In conclusion, CABG without CPB is a reproducible, effective and safe option in selected group of patients with results comparable to conventional technique. A conscientious approach in patient selection and route of operation is required.

	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): Anil Bhan Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bhan, A. Articles by Venugopal, P. Search for Related Content PubMed PubMed Citation Articles by Bhan, A. Articles by Venugopal, P.