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Ann Thorac Surg 2000;69:1383-1387
© 2000 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Beating heart versus conventional single-vessel reoperative coronary artery bypass

^a Division of Cardiac Surgery, Department of Surgery, Washington Hospital Center, and MedStar Research Institute, Washington, DC, USA

Address reprint requests to Dr Corso, Division of Cardiac Surgery, Washington Hospital Center, 106 Irving St NW, Suite 316, South Tower, Washington, DC 20010
e-mail: pjc{at}mhg.edu

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Reoperative (redo) coronary artery bypass grafting (CABG) with cardiopulmonary bypass (on-pump) is associated with a higher morbidity and mortality than first-time CABG. It is unknown, however, whether CABG without cardiopulmonary bypass (off-pump) may yield an improved clinical outcome over conventional on-pump redo CABG.

Methods. We compared the perioperative outcomes of patients with single-vessel disease who underwent on-pump (n = 41) versus off-pump (n = 91) redo CABG between April 1992 and July 1999. The two groups were similar with respect to baseline characteristics and risk stratification: mean Parsonnet scores were 26 ± 9 for on-pump versus 24 ± 8 for off-pump patients (p = nonsignificant).

Results. On-pump redo patients had a higher rate of postoperative transfusions (58% on-pump versus 27% off-pump, p = 0.001), prolonged ventilatory support (17% on-pump versus 4% off-pump, p = 0.03), and a higher rate of postoperative atrial fibrillation (29% on-pump versus 14% off-pump, p = 0.04). On-pump redo CABG was also associated with prolonged postoperative length of stay (8 ± 4 days on-pump versus 5 ± 2 days off-pump, p < 0.001). In-hospital mortality was significantly higher in on-pump than in off-pump patients (10% versus 1%, p = 0.03).

Conclusions. Single-vessel off-pump redo CABG can be performed safely with a lower operative morbidity and mortality than on-pump CABG and an abbreviated hospital stay compared with conventional on-pump redo CABG.

	Introduction

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Conventional reoperative (redo) coronary artery bypass grafting (CABG) has been associated with a relatively high early mortality (3.4% to 12.5%) compared with first-time CABG [1–6]. To lower mortality rates after redo CABG operation, alternative surgical practices have evolved such as the "no-touch technique" or minimal dissection before bypass, routine femoral artery and vein cannulation, antegrade and retrograde blood cardioplegia, and performance of all vascular anastomoses with a single aortic cross clamp. These techniques seem to improve outcome after redo CABG with cardiopulmonary bypass (on-pump CABG) [7].

The advent of minimally invasive techniques to perform CABG without cardiopulmonary bypass (off-pump CABG) may be of particular use in redo CABG operations. Compared with on-pump techniques, off-pump CABG has been associated with decreased foreign-surface/blood interactions and shear response [8], lower stroke rates, and improved perioperative outcomes [9]. Patients with atherosclerosis of the ascending aorta, who are at higher risk for atheromatous embolization during aortic cannulation, may particularly benefit from off-pump CABG [10].

The purpose of this study was to compare perioperative clinical outcomes and early mortality in patients who underwent off-pump single-vessel redo versus conventional on-pump CABG.

	Material and methods

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Patients
The computerized database of the Division of Cardiac Surgery of the Washington Hospital Center was queried to identify all patients who underwent redo CABG for single-vessel coronary artery disease between April 1992 and July 1999; 132 patients were so identified. Of these, conventional on-pump redo CABG was performed in 41 (31%) and off-pump redo CABG was performed in 91 (69%) patients. These 91 off-pump redo patients represented 11% of the total number of patients (848), who had off-pump CABG, during the period of study. Clinical events were source documented. Baseline demographics, procedural data, and perioperative outcomes were recorded on standardized data entry forms. Data were analyzed according to The Society of Thoracic Surgery National Cardiac Surgery Database guidelines and definitions (www.ctsnet.org/doc/230). Perioperative non-Q-wave myocardial infarction was defined as creatine phosphokinase (CPK)-MB enzyme elevation of more than 40 mg/dL within the first 48 hours after operation.

Risk stratification
Parsonnet [11] and Cleveland Clinic [12] risk stratification models were used to control for potential between-group imbalances in preoperative variables that could influence perioperative outcomes. Parsonnet scores are derived from 14 risk factors for mortality during open heart operation, with 0 being low risk and higher than 20 being extremely high risk [11]. Cleveland Clinic scores, derived from preoperative and perioperative measures of morbidity associated with CABG operation, ascend with increasing risk of operative morbidity and mortality, with 0 being low risk and higher than 6 being extremely high risk [12].

Selection criteria
Indications for off-pump redo CABG included patients who were considered high risk for on-pump redo CABG because of medical comorbidities such as renal failure, diffuse cerebrovascular and peripheral vascular disease, aortic atherosclerosis, chronic obstructive pulmonary disease, and religious convictions that precluded blood transfusions [13].

Surgical techniques
For on-pump redo CABG, standard anesthesia and surgical techniques, extracorporeal circulation, and myocardial protection methods were used [14]. Off-pump redo CABG was performed using one of three surgical approaches: minimally invasive direct coronary artery bypass (MIDCAB), median sternotomy, or left posterolateral thoracotomy. Main indications for MIDCAB included isolated proximal disease of the left anterior descending or first diagonal artery, whereas a median sternotomy approach was favored in grafting of the right coronary artery or posterior descending branch. The principal indication for left posterolateral thoracotomy was bypass regrafting of the circumflex system. The three off-pump surgical techniques are described briefly.

MIDCAB
A left anterolateral thoracotomy approach was used. After a 6 to 9 cm incision was made, the fourth intercostal space was entered without removing the rib. The costal cartilage was not routinely excised. The left internal mammary artery was harvested under direct vision from the fifth intercostal space to the left subclavian vein, then it was clipped and divided. The pericardium was incised close to the internal mammary artery pedicle and parallel to the midline and suspended by traction sutures. After the diseased artery was located, a silicone elastomer suture bolstered with a pledget encircling the entire artery, epicardial fat, and veins was placed proximally to the anastomotic site to achieve coronary artery occlusion. No ischemic preconditioning was used for myocardial protection. A compression stabilizer was used to stabilize the coronary artery. The anastomosis was performed using continuous 7-0 Prolene (Ethicon, Somerville, NJ) sutures. A blower device (Aries CO₂ Blower, CardioThoracic Systems, Inc) was used to keep the field clear of blood and the incised edges of the coronary artery separated during the anastomosis. After the anastomosis was completed, the internal mammary pedicle was fixed to the epicardium with three 6-0 silk sutures.

Median sternotomy
After a median sternotomy, the left internal mammary artery was harvested using a specialized internal mammary artery access retractor (Rultract, Rultract Inc, Cleveland, OH). Two or three lap tapes or, alternatively, a glove injected with normal saline through a Foley catheter, were placed beneath the left ventricle to bring the left anterior descending, first diagonal, or ramus marginal to the surface and to achieve better exposure. Distal anastomoses were done as in the MIDCAB technique using a compression or a stabilizer suction. The inferior and posterolateral arteries were approached using pericardial traction sutures placed anterior to the pulmonary veins and fixed to the drapes on the patient’s left side. Two traction sutures were placed through the acute margin of the right ventricle to approach the right coronary arteries.

Posterolateral thoracotomy
Single-lung ventilation, lateral decubitus positioning of the patient, and a fifth intercostal space approach were used as appropriate. After retraction of the lung, the pericardium was opened posterior to the phrenic nerve. The radial artery or saphenous vein were used as conduits to graft the second or third marginal arteries The proximal anastomosis was usually placed on the descending thoracic aorta with this approach.

Anesthesia and intraoperative monitoring
Routine hemodynamic, electrocardiographic, and arterial blood gas monitoring were routinely performed during the procedures. External defibrillator pads were used on all patients and a primed cardiopulmonary bypass machine and a perfusionist were available at all times. Heparin, in a bolus dose of 10,000 IU, was routinely administered intravenously in all patients. Activated clotting time was kept within a range of 300 to 350 seconds. If a radial artery conduit was used, Diltiazem (10 mg/h) or nitroglycerin (30 µg/min) was infused intravenously. Before performing the anastomoses, intravenous doses of lidocaine (200 mg bolus) and magnesium sulfate (2 g) were routinely given to all patients. Patients were extubated in the intensive care unit. Intercostal blocks with bupivacaine were used for pain control after left posterolateral thoracotomy or MIDCAB. Postoperative pain control was achieved with intravenous doses of propofol (50 mg/kg) and morphine (2 mg) as needed.

Statistical analysis
Primary comparisons were performed between the on-pump and off-pump redo CABG groups. Data were expressed as percentages or as means ± standard deviation. Categorical variables were compared using two-tailed Fisher’s exact test. Continuous variables were compared using a two-tailed, unpaired Student’s t test for variables with normal distributions and a two-tailed Mann-Whitney U test for variables with nonnormal distributions.

A multivariate, stepwise forward logistic regression analysis was conducted to determine the independent predictors of postoperative stay of more than 5 days. Values of p less than or equal to 0.05 were considered significant. All statistical analyses were performed using SPSS 8.0 for Windows 95 (SPSS Inc, Chicago, IL).

	Results

Top Abstract Introduction Material and methods Results Comment References

 
An increase in the number of redo patients operated off-pump with a subsequent decrease in the percentage of on-pump redo patients was noted during the course of the study period (Fig 1). No patient who was operated off-pump needed a conversion to on-pump CABG. The different approaches for off-pump CABG included median sternotomy (n = 51, 56%), MIDCAB (n = 19, 21%), and left posterolateral thoracotomy (n = 21, 23%). Ventricular tachyarrhythmias were not observed in any of our patients when the distal anastomoses were performed.

View larger version (14K): [in this window] [in a new window]   Fig 1. The number of patients who underwent single vessel on-pump redo CABG has been decreasing over time: 58% in 1992 to 1995, 15% in 1996 to 1998, and 5% in 1999 (January to July).

Predictors of prolonged postoperative hospital stay
Off-pump patients had a shorter mean postoperative hospital length of stay (LOS) compared with on-pump patients. In the multivariate analysis, on-pump redo CABG emerged as an independent predictor of prolonged hospital LOS (odd ratio [OR] = 10, 95% confidence interval [CI] = 2.3 to 3.3, p = 0.001).

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Repeated coronary revascularization remains a source of significant morbidity and mortality in patients suffering from ischemic cardiomyopathy [2]. Although the mortality associated with redo CABG operations has declined significantly in past years, morbidity remains significant [1–8]. Replacement of a diseased vein graft in patients with already limited cardiac reserve is believed to pose a greater risk for the myocardium than is bypass of native coronary disease [10].

Operative complications might be mitigated by avoiding the hemodynamic and cerebral effects of cardiopulmonary bypass [8, 9]. Allen and associates [8] have reported a decreased incidence of postoperative myocardial infarctions, cerebrovascular accidents, and less need for transfusions in patients who underwent minimally invasive CABG compared with on-pump CABG. Although an important criticism of off-pump (beating heart) operation focuses on the accuracy of anastomosis [8, 15], previous reports [11, 16, 17] document excellent results and an 84% to 95% graft patency rate with off-pump CABG.

In the present study, we found off-pump redo CABG to improve morbidity and mortality in comparison with conventional on-pump redo CABG. Specifically, off-pump redo CABG was associated with shorter operative times and less need for intraoperative and postoperative blood transfusions, in accordance with previous reports [8]. Interestingly, on-pump redo CABG patients had a fourfold higher rate of prolonged ventilatory support than off-pump patients. Echoing reports in previous studies, conventional on-pump redo CABG was associated with a twofold higher incidence of postoperative new-onset atrial fibrillation [8, 18] and can be potentially explained by the effects of systemic hypothermia, manipulation of the atria, and greater surgical trauma patients undergoing on-pump CABG [19]. Similarly, Koh and colleagues [20] have reported higher levels of cardiac troponin T after on-pump compared with off-pump CABG, which reflects the greater heart trauma associated with on-pump CABG. In addition, cross clamping of the aorta during on-pump CABG has been demonstrated to produce myocardial injury and decrease heat shock protein 70 expression in the myocardium, suggesting a defective adaptive response of the heart muscle to this type of surgical stress [21]. Wan and coworkers [22] have similarly reported reduced cytokine responses and myocardial injury after off-pump compared with conventional on-pump CABG.

An interesting trend documented during the course of our study was the increased use of off-pump approaches in redo patients with single-vessel coronary artery disease and the concomitant decrease of on-pump CABG. Interestingly, during the years 1992 and 1995 only 42% of redo patients were operated off-pump, whereas for the first 7 months of 1999 more than 95% of single-vessel disease redo patients were operated off-pump (Fig 1), reflecting a general trend in our cardiac surgery practice during the last years, as well as the general surgical trend toward minimally invasive techniques.

Off-pump redo CABG appears to significantly shorten hospital LOS. In the present study, use of cardiopulmonary bypass emerged in the multivariate analysis as an independent predictor of prolonged hospital LOS. This finding is in agreement with previous reports [23, 24], thus favoring beating heart operation as a potential means for reducing use of hospital resources and health care cost.

Despite the small number of deaths in our study and the short period of follow-up, a significantly higher mortality rate was documented in the on-pump than in the off-pump patients. However, larger prospective studies are required to properly investigate mortality differences between the two techniques and validate the results of this study.

The limitations of our study include the drawbacks inherent in any retrospective analysis, the small number of patients, and the inability to conduct a reliable multivariate analysis of predictor variables of early mortality because of the small number of deceased patients. Moreover, the short period of clinical follow-up was another limitation, along with the absence of angiographic follow-up that would enable a comparison of the early and late graft patency between the two groups. Further, the number of patients in the two groups was too small to allow valid statistical comparisons between the on-pump versus off-pump median sternotomy subgroup. Theoretically, off-pump redo CABG may benefit patients through the avoidance of median sternotomy, although it might not be critical in patients with single-vessel disease. These issues should be investigated in larger, prospective randomized studies and set the indications and contraindications of beating heart approaches.

In conclusion, off-pump redo CABG can be performed safely in patients with single-vessel coronary artery disease and reduce postoperative morbidity and (potentially) health care cost in comparison with on-pump redo CABG.

	References

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