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Ann Thorac Surg 2000;69:1725-1730
© 2000 The Society of Thoracic Surgeons

Original articles: Cardiovascular

Does multivessel, off-pump coronary artery bypass reduce postoperative morbidity?

Vibhu R. Kshettry, MDa, Thomas F. Flavin, MDa, Robert W. Emery, MDa, Demetre M. Nicoloff, MD, PhDa, Kit V. Arom, MD, PhDa, Rebecca J. Petersen, RNa

a Cardiac Surgical Associates, P.A., Minneapolis Heart Institute, Minneapolis, Minnesota, USA

Address reprint requests to Dr Kshettry, 920 East 28th St, Suite 420, Minneapolis, MN 55407

Presented at the Thirty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 31–Feb 2, 2000.


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. Off-pump coronary artery bypass (OPCAB) is an emerging procedure. It is assumed that elimination of cardiopulmonary bypass for coronary artery bypass grafting has the potential for reducing postoperative morbidity. This review evaluates the safety and impact of multivessel OPCABG as compared to CABG.

Methods. A retrospective review of 744 patients undergoing multivessel coronary artery bypass between January 1, 1997, and March 31, 1999, was done. The total population was divided into two groups: group A (n = 609 cardiopulmonary bypass) and group B (n = 135 OPCAB). This consecutive study cohort was elective status, full sternotomy with three or more distal anastomoses performed at a single institution.

Results. The mean risk adjusted predicted mortality was 2.3% in group A and 2.7% in group B (p = NS), with the mean number of distal anastomosis being greater in group A (3.8 vs 3.5/patient, p < 0.001). Major postoperative complications were similar but were not statistically significant between groups. Postoperative blood loss and use of blood transfusions were the only significant variables (p < 0.001).

Conclusions. Multivessel OPCABG can be safely performed in selected patients. Elimination of cardiopulmonary bypass did not significantly reduce postoperative morbidity. Prospective randomized trials and long-term follow-up are needed to better define patient selection and the role of OPCABG.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
A successful and reproducible surgical approach for coronary artery revascularization and relief of angina has evolved in the past three decades [1]. Cardiopulmonary bypass (CPB) and cardioplegic cardiac arrest have become the mainstays of coronary artery bypass grafting (CABG), providing still, bloodless, and accessible coronary artery sites for anastomosis. The high incidence of coronary artery disease along with the ease and safety of performing CABG have made this procedure common.

Cardiopulmonary bypass has long been recognized as one of the major causes of the systemic inflammatory response, which may contribute to postoperative complications and multiple organ dysfunction [2]. Refinement in CPB techniques have led to strategies to minimize these complications. Avoidance of CPB during CABG is believed to be associated with lower morbidity [3]. Recently there has been a resurgence of interest in performing CABG on the beating heart (OPCAB) [4–6]. Some of these surgical approaches were originally used to initiate the field of coronary artery surgery, but were abandoned with the advent of CPB. With improved technology and development of cardiac stabilizers, multivessel OPCABG is currently feasible in many patients. Indeed, there has been a "push" in the cardiac surgery community to "abandon" CPB for CABG. Decreased operative mortality, postoperative morbidity, shorter hospital stay, and reduced cost are often cited as reasons in favor of OPCABG [7, 8]. However, when comparing multivessel OPCABG to CABG, the intraoperative variables, postoperative complications, and follow-up are not well documented in the literature because of the shorter time span during which they have been performed. This report will detail the comparison between multivessel OPCABG and CABG performed by the authors at a single institution.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Patient selection
Our cardiac surgical registry was queried for a retrospective review of patients who underwent a CABG-only surgical procedure between January 1, 1997, and March 31, 1999. All patients signed a release of information for research purposes before their procedure. Inclusion criteria for the consecutive on- or off-pump CABG-only study cohort of 744 patients was presentation as an elective status, full median sternotomy approach, single institution, and patients with three or more distal anastomosis. The total population was divided into two groups for comparison: group A (n = 609 CPB) and group B (n = 135 OPCAB). Mean age of group A patients was 66 (± 10) years compared with 68 (± 11) years (p = 0.032). Incidence of reoperation was nonsignificant between groups, as was the number of women (group A, 24% and group B, 28%). All pre-, intra-, and postoperative clinical variables were reviewed and complied with the National Society of Thoracic Surgeons Cardiac Registry definitions. Patient demographics are listed in Table 1.


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  		Table 1. Patient Demographics

 
Through continued outcomes research studies, in our experience, patient selection and care processes have stabilized. A homogeneous patient population was therefore created. Table 2 reports similarities in preoperative risk factors. By limiting the review to one institution that has had considerable experience with open-heart surgery and fast-track care processes, intra- and postoperative practice variations are considered to be minimal. The selection of the off-pump versus on-pump approach was a surgeon-specific clinical decision dependent on patient presentation. The evolution of surgical experience and instrumentation for a multivessel off-pump approach is evident by the proportion of single vessel to multivessel procedures performed over the course of this retrospective review (Fig 1).


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  		Table 2. Preoperative Risk Factors

 


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  		Fig 1. Trend of off-pump multivessel procedures.

 
Off-pump coronary artery bypass
A median sternotomy was used in all cases. Internal mammary artery and saphenous vein were harvested as appropriate, using standard techniques. Deep pericardial sutures were placed to elevate the left posterior pericardium for exposure of the lateral and inferior walls. Traction to these sutures was serially applied to expose the desired coronary artery. To assist further in providing good presentation of the target arteries, especially the posterior and inferior walls, patients were placed in a gentle right decubitus Trendelenburg position. Stabilization of the target arteries was accomplished with either CTS Stabilizer (CardioThoracic Systems, Inc, Cupertino, CA) or Octopus stabilizer (Medtronic, Inc, Minneapolis, MN). Intravenous heparin (1 mg/kg) was given to maintain activated clotting time (ACT) between 200 and 300 seconds. A silicone elastomer retractor was placed proximal to the coronary anastomosis site for bleeding control. Distal snares around the coronary artery were avoided. Distal coronary anastomoses were done with a running 7-0 monofilament suture. Proximal anastomosis to the ascending aorta was done with a side biting clamp and using standard techniques. Good communication with the anesthesia team was maintained during the procedure to monitor carefully and to treat cardiac arrhythmias or hemodynamics using a Swan-Ganz or continuous cardiac output catheter.

Coronary artery bypass grafting with cardiopulmonary bypass
All procedures were performed through a median sternotomy. Internal mammary artery and other bypass conduits were harvested using standard techniques. After intravenous heparin (4 mg/kg, ACT > 400 s) cardiopulmonary bypass was instituted by cannulating the ascending aorta and right atrium with a two-stage venous cannula. Myocardial protection was achieved with moderate systemic hypothermia (mean core temperature 32° ± 2° C), topical cold saline, and delivery of intermittent retrograde cold blood or crystalloid cardioplegia (two of the investigators also used antegrade and retrograde cardioplegia). Cardiopulmonary bypass was accomplished with centrifugal pump and membrane oxygenator. Distal anastomoses were done first. Proximal anastomoses were done to the ascending aorta with a partially occluding clamp.

Postoperative care
Treatment of all patients followed standard care and processes from surgery until discharge. This included admission to an intensive care unit from the surgery suite, with subsequent transfer to an intermediate care ward within 24 hours or as dictated by the patient’s clinical status. A hospital-designed extubation protocol that targets extubation within 6 hours after surgery was followed.

Follow-up
At 6 months postprocedure, a registered research nurse clinician surveyed all patients by telephone. Multiple telephone calls were made to achieve a high percentage of complete follow-up. A standardized questionnaire was used that focused on quality of life, lifestyle activities, frequency and intensity of angina, and rehospitalization for cardiac reinterventions or medical treatment.

Probing for information pertaining to the occurrence of angina assisted in differentiating thoracic artery takedown chest wall pain and angina pectoris. Reporting of invasive or surgical reintervention or recurrent angina was not investigated to determine whether the cause was progressive native vessel disease or lesion of the graft site. There was no statistical significance between the groups for any of the follow-up categories collected. Complete follow-up at 6 months was 76% in group A and 92% in group B.

Data analysis
Data are presented as mean plus or minus standard deviation unless indicated otherwise. Comparisons between the group for statistical significance were performed using the {chi}2, Fisher’s exact, or Student’s t test when appropriate, and were considered significant when the p value was less than 0.05.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
A total of 609 patients had revascularization through a full mediam sternotomy and cardiopulmonary bypass support, whereas 135 patients were revascularized without CPB support. The total number of distal anastomosis performed was 2332 (mean 3.8/patient) in group A and 466 (mean 3.5/patient) in group B (p = 0.001). Individual graft locations for each group are reported in Table 3. No patient in group B required conversion to CBP because of limited exposure, conduit trauma, or hemodynamic instability. Using the National STS Logistical Regression Risk Model, the group A mean percent predicted risk was 2.3 (± 3.3) and Group B was 2.7 (± 2.6) with p = NS.


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  		Table 3. Distal Anastomoses and Conduits

 
Procedural time in minutes (incision to closure) for group A was 194 (± 43) and for group B was 202 (±42) (p = 0.059). The Group A CPB time was 86 (±28) minutes with a mean cross-clamp time of 51 (±17) minutes. Estimated blood loss in first 24 hours for group A was 894 ml (± 503) and 729 ml (±325) for group B, p < 0.001. Mean blood product use within the first 24 hours was statistically significant between the groups: red blood cells (RBC), 0.99 versus 0.59 units per patient, p < 0.001; fresh frozen plasma (FFP), 0.40 versus 0.10 units per patient, p < 0.001; platelets (PLT), 0.98 versus 0.12 units per patient, p < 0.001 (Table 4).


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  		Table 4. Intraoperative Demographics

 
Time to extubation was targeted for less than 6 hours after return from the surgical suite. Mean ventilation time in hours for group A was 14.8 (±72) hours, with range of 1 to 1000 hours, compared with 7.1 (±24.6) hours, with a range of 0 to 268 hours in group B (p = 0.021). Ventilation time categories are reflected in Table 5. We found no statistical difference between either group in the length of stay for intensive care unit hours (p = 0.323) or in hospital stay (mean surgery to discharge in days for group A [7.3] and for group B [7.0], p = 0.536). The overall operative mortality for group A was 13 of 609 (2%) and for group B 1/135 (1%) (p = 0.484, NS).


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  		Table 5. Ventilation Intervals

 
The major postoperative complications acknowledged as indicators for OPCAB benefits did not result in a significant difference except for reoperation for bleeding (p = 0.056) in this retrospective review (Table 6).


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  		Table 6. Postoperative Complications

 
At the time of 6-month follow-up, both groups had comparable frequency for readmission to the hospital since discharge (group A 23% and Group B 24%; p = NS). Reasons for readmission focused on specific cardiac disease indications: recurrent angina (2% vs 1.6%), percutaneous transluminal coronary angioplasty (1.5% vs 1.6%), congestive heart failure (1.8% vs 1.6%), repeat surgery (0.2% vs 0.8%), and arrhythmias (4.2% vs 3.3%) for groups A and B, respectively; all were nonsignificant. Additionally, patient-reported quality of life and lifestyle activities were similar (Table 7).


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  		Table 7. Six-Month Follow-up Telephone Responses

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
In recent years, new surgical strategies in the treatment of coronary artery disease have generated controversy and debate [9, 10]. The standard CABG ensures optimal conditions for safe and reproducible results in a wide range of cardiac surgical practices. However, with interest in performing less invasive CABG and experience gained in many centers with minimally invasive direct coronary bypass (mainly left internal mammary artery to left anterior descending artery) OPCABG seems to be the next step in offering multiple vessel bypass to select patients [11]. Long-term results of such procedures are not available at present. Off-pump coronary bypass surgery is a more demanding procedure than conventional CABG; more attention to detail is required for performing technically good anastomosis. Despite the availability of cardiac stabilizers, continuous motion of the heart and the potential for hemodynamic derangement during manipulation and elevation continues to be a concern, especially in performing posterior coronary artery anastomosis. In an experimental porcine model of a beating heart, exposure of the circumflex branches with anterior displacement caused primarily right heart dysfunction.

It has been found that right heart bypass normalized stroke volume and mean arterial pressure by increasing left ventricular preload; in contrast, left heart bypass failed to restore systemic circulation [12]. These studies may provide a platform for future technological development in refining OPCABG.

The main reason for less invasive CABG has been the steadily increasing evidence that CPB contributes to some degree of end-organ dysfunction, especially neurologic. For the majority of patients this results in clinically undetectable sequelae; for a minority, the results can be devastating [13]. Refinements in CPB techniques, especially use of membrane oxygenators and arterial line microfilters, have demonstrated a lowered incidence of postoperative neurologic dysfunction [14]. Many factors contribute to neurologic dysfunction after CABG, especially age greater than 70 years, duration of CPB, pre-existing atherosclerosis of aorta, and cerebrovascular circulation. A recent study showed similar patterns of early decline and late recovery of cognitive function in patients undergoing CABG with and without CPB, suggesting that CPB may not be the major cause of postoperative cognitive impairment [15]. Others, however disagree [16].

This retrospective study compares the perioperative and postoperative course of multivessel coronary artery bypass patients operated on either with or without CPB. Preoperative demographics and comorbidities as analyzed showed little variation between the two patient groups. In contrast to previously published studies, the number of grafts was three or more in both groups. The Society of Thoracic Surgeons data show that currently the mean number of grafts for CABG patients is approximately 3.4 per patient (mortality risk 0 to 5%) [17].

The strengths of this study were the similarity of the patient population and multivessel revascularization procedures that included posterior distal anastomosis. It has been assumed and, in some cases, documented that the OPCAB population has fewer and less dramatic postoperative complications. Early experience with OPCAB technology and patient characteristics described single or double vessel disease populations. Multivessel cardiac disease patients present more frequently with multifactorial disease processes such as renal, pulmonary, neurologic, and peripheral vascular disease. Therefore, one would hypothesize that without the physiologic insult of extracorporeal circulation, postoperative multiorgan complications would be minimized. In a recent review from our practice comparing OPCABG with CABG patients, of the three risk groups (low 0 to 2.5%, medium 2.51% to 5.0%, high > 5.1%), a reduction of reported complications was significant only in the high-risk group undergoing OPCABG [18].

In this study the differences in major complications of new renal failure, permanent or transient cerebrovascular events, new atrial fibrillation, and operative mortality were nonsignificant between the two groups. Perioperative bleeding and transfusion-related complications are among the major risks associated with open heart surgery. Avoidance of CPB has been reported to be beneficial in reducing blood product use [19]. In the present study, postoperative bleeding and blood transfusion were significantly lower with OPCABG.

The questions that continue to be raised and challenged are, What are the contributing factors for rapid recovery: the elimination of CPB, median sternotomy, or underlying patient factors? Is there a select subset of patients for whom OPCAB is, or should be, the recommended approach? As minimally invasive bypass surgery has developed, the issue of anastomotic patency when surgery is performed on the beating heart has been subject to intense scrutiny. Short-term results have been favorable [7, 20]. However, long-term results of patency, especially of posterior coronary anastomoses, are still awaited. Thus, how do we currently define the role of OPCAB with the pressures to embracing new technology, public opinion, and healthcare demand for cost containment?

In summary, within the limitations of this nonrandomized retrospective review, multivessel off-pump coronary bypass can be safely performed. However, the incidence of stroke, transient ischemic neurologic attack, new renal failure, atrial fibrillation, length of stay, and readmission rate were similar and statistically nonsignificant between the groups. Nonetheless, OPCAB remains an emerging and developing surgical technique, and continued reevaluation is warranted. Prospective randomized trials are needed to define better patient selection and long-term benefits of OPCAB.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Favalaro R. Critical analysis of coronary artery bypass graft surgery. J Am Coll Cardiol 1998;31(Suppl B):1-63B.[Abstract/Free Full Text]
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  3. Wan S., Izzat M.B., Lee T.W., et al. Avoiding cardiopulmonary bypass in multivessel CABG reduces cytokine response and myocardial injury. Ann Thorac Surg 1999;68:52-57.[Abstract/Free Full Text]
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  5. Jansen E.W., Borst C., Lahpor J.R., et al. Coronary artery bypass grafting without cardiopulmonary bypass using the Octopus method. J Thorac Cardiovasc Surg 1998;116:60-67.[Abstract/Free Full Text]
  6. Baumgartner F.J., Gheissari A., Capouya E.R., Panagiotides G.P., Katouzian A., Yokoyama T. Technical aspects of total revascularization in off-pump coronary bypass via sternotomy approach. Ann Thorac Surg 1999;67:1653-1658.[Abstract/Free Full Text]
  7. Calafiore A.M., Teodori G., Di Giammarco G., et al. Multiple arterial conduits without cardiopulmonary bypass. Ann Thorac Surg 1999;67:450-456.[Abstract/Free Full Text]
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  12. Grundeman P.F., Borst C., Verlaan C.W.J., Meijburg H., Mouës C.M., Jansen E.W.L. Exposure of circumflex branches in the tilted, beating porcine heart. J Thorac Cardiovasc Surg 1999;118:316-323.[Abstract/Free Full Text]
  13. Roach C.W., Kanchuger M., Mangano C.M., et al. Adverse cerebral outcomes after coronary bypass surgery. N Engl J Med 1996;335:1857-1863.[Abstract/Free Full Text]
  14. Pugsley W., Klinger L., Paschalis C., Treasure T., Morrison M., Newman D.P. The impact of micro-emboli during cardiopulmonary bypass on neuropsychological functioning. Stroke 1994;25:1393-1399.[Abstract]
  15. Taggart D.P., Browne S.M., Halligan P.W., Wade D.T. Is cardiopulmonary bypass still the cause of cognitive dysfunction after cardiac operations?. J Thorac Cardiovasc Surg 1999;118:414-421.[Abstract/Free Full Text]
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  17. The Society of Thoracic Surgeons Cardiac Registry Eighth Annual Report, December 1998; 195.
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Magnesium infusion dramatically decreases the incidence of atrial fibrillation after coronary artery bypass grafting
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