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Ann Thorac Surg 2000;70:1017-1020
© 2000 The Society of Thoracic Surgeons

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Supplement: cardiothoracic techniques & technologies

A review of 1,582 consecutive Octopus off-pump coronary bypass patients

^a Pinnacle Health System, Harrisburg, Pennsylvania, USA
^b Park Nicollet Heart Center, HealthSystem Minnesota, Minneapolis, Minnesota, USA
^c Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA
^d Cardiac Surgical Associates, Minneapolis, Minnesota, USA
^e Medical City Dallas, Dallas, Texas, USA
^f Utrecht University Hospital, Utrecht, The Netherlands

Address reprint requests to Dr Hart, Capital Area Cardiovascular Surgical Institute, 423 N 21st St, Camp Hill, PA 17011
e-mail: jchart51{at}earthlink.net

Presented at the Sixth Annual Cardiothoracic Techniques and Technologies Meeting 2000, Ft Lauderdale, FL, Jan 27–29, 2000.

	Abstract

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Background. Off-pump coronary bypass may provide a safer form of surgical revascularization by avoiding the unwanted complications of cardiopulmonary bypass, particularly in the increasingly complex patients being referred for operation. This study reviews the entire experience of the Medtronic Octopus System (Medtronic, Minneapolis, MN) for beating heart bypass from 7 surgeons. Demographics, operative procedures, early outcomes, and trends in usage were examined.

Methods. Patients were selected for off-pump procedures by the individual surgeons. Data were entered prospectively into locally maintained databases and then collected for collation and analysis.

Results. A total of 1,582 consecutive Octopus patients were entered, representing the entire Octopus experience of each surgeon. Proportions of off-pump procedures relative to standard bypass increased over time, as did the percentage of patients receiving three or more grafts, 24.6% in 1997 and 55.9% in 1999. A total of 3,653 anastomoses were performed, 1,905 to the left anterior descending system, 837 to the circumflex distribution, and 911 to the right coronary territory. Morbidity was low. Few patients required conversion to cardiopulmonary bypass (2.6%; 0.2% urgently). Permanent stroke occurred in 0.6% and myocardial infarction in 1.2%. Operative mortality was 1%.

Conclusions. Octopus off-pump bypass was demonstrated to be a safe procedure with widening applicability. With experience surgeons tend to apply the system to increasing proportions of their patients and are able to revascularize all coronary territories.

	Introduction

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Cardiopulmonary bypass (CPB) has been used for coronary artery bypass grafting (CABG) for three decades. Surgeons have required still and bloodless fields in which to perform a microvascular conduit to coronary anastomosis. Interventional cardiologists have applied percutaneous myocardial revascularization to an increasing proportion of the population with coronary artery disease, leaving surgeons with an increasingly complex group of patients for surgical revascularization. Cardiopulmonary bypass may be less well tolerated in these elderly patients who present with significant comorbidities. Interest in off-pump coronary artery bypass (OPCAB) has increased over several years. Avoiding the morbidity of CPB may provide safer surgical myocardial revascularization, particularly in the older age group or in patients with preexisting end organ dysfunction.

In 1998 Jansen and coworkers [1] reported the design, experimental evaluation, and the first clinical use of a novel suction-based mechanical coronary artery stabilizing system. In early to mid-1997 several North American surgeons became interested in using this Medtronic Octopus System (Medtronic, Minneapolis, MN). Following federal approval of the device they began clinical application of this stabilizer [2]. Early experience with the device was limited to vessels on the anterior surface of the heart, which were easily bypassed with excellent stabilization. Lateral and posterior vessels presented technical challenges, because hemodynamic tolerance to the cardiac displacement necessary for exposure was poor. Following experimental evaluation of the hemodynamic consequences of vertical cardiac displacement, techniques were developed and shared and gradually more surfaces of the heart could be approached safely [3]. Excellent stabilization with good hemodynamic tolerance allowed surgeons to offer complete revascularization to increasing proportions of their patients using Octopus OPCAB.

The purpose of this multiinstitutional report was to analyze the entire Octopus-supported OPCAB experience of 7 surgeons with significant OPCAB interest. Demographics, operative details, and early outcomes were analyzed. Trends in usage were evaluated.

	Material and methods

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
The decision to proceed with Octopus OPCAB was made in the operating room after evaluation of coronary artery anatomy and the patient’s tolerance to cardiac displacement. All patients deemed suitable for OPCAB by the operating surgeon and in whom the Octopus was chosen were included in this study. Patients felt to be unsuitable for OPCAB following this intraoperative evaluation were not included. Some surgeons used other stabilizers for some procedures and these patients were not included in this analysis. All patients in whom the surgeons had attempted Octopus OPCAB from early 1997 through late 1999 were included as study patients. Start and finish dates varied by a few months among institutions. The patients from Utrecht included those from 1995 and 1996 as well, to allow for completeness. These patients represent the entire Octopus experience of each of the participating surgeons.

Data were entered prospectively into locally maintained databases and were then reviewed retrospectively and reported to the central reporting institution for analysis. Attempts were made to standardize definitions of terms. Each institution reported its population divided into cohorts by the year of operation to allow for analysis of trends in usage.

	Results

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
A total of 1,582 patients underwent attempted Octopus OPCAB. The distribution of patients by center is shown in Table 1. The yearly percentage of CABG patients completed using Octopus OPCAB is also shown. Table 2 demonstrates this percentage to have been a demographically typical cohort of CABG patients with little variation among centers. Mean left ventricular ejection fraction averaged 55.4% (range 15% to 80%).

Of 1,500 patients operated on from 1997 through 1999, 395 (26.3%) had single bypass, 468 (31.2%) double, 498 (33.2%) triple, and 139 (9.3%) quadruple or quintuple bypass. The trend was to perform more bypasses per patient in the later part of the study time period. In 1997, 75.4% of patients had one or two bypasses and 24.6% had three or more bypasses. By 1999 this ratio had reversed with 44.1% of patients receiving single or double bypass whereas 55.9% had three or more grafts. There was also some institutional variation in this trend.

A total of 3,653 distal anastomoses were performed on the total population of 1,582 patients, an average of 2.31 grafts per patient. Excluding the single bypass patients, the multiple graft patients averaged 2.8 distal anastomoses per patient. The average number of grafts tended to increase during the time of the study (Fig 1). There were 1,905 grafts to the left anterior descending artery system, 837 to the circumflex distribution, and 911 to the right coronary artery territory (Table 3).

View larger version (19K): [in this window] [in a new window]   Fig 1. Average number of grafts per patient by year.

Complication rates were gratifyingly low. Reoperation for bleeding was necessary in 19 patients (1.2%; range 0.6% to 2.3%) and deep sternal wound infection developed in 5 (0.3%; range 0.0% to 1.1%). Perioperative myocardial infarction was identified in 20 patients (1.3%; range 0.0% to 3.0%) and postoperative stroke with permanent deficit was noted in 9 (0.6%; range 0.0% to 2.0%). New renal failure requiring dialysis postoperatively was present in 14 patients (0.9%; range 0.0% to 3.9%). Mechanical ventilation was required for more than 24 hours in 2.2% of patients (range 0.0% to 8.0%) and depended on practice patterns. Transfusion of blood products was necessary in 28.1% of patients (range 15.7% to 39.1%). New atrial fibrillation requiring treatment was seen in 14.9% of patients (range 11.2% to 25.3%) during their hospitalization. Patients readmitted for atrial dysrhythmias were not captured for analysis.

In-hospital or 30-day mortality was also low at 1.0% (range 0.0% to 3.7%). Statistical analysis of observed versus predicted mortality for the entire population was not possible but individual center statistics are shown in Table 4. Postoperative length of stay averaged 5.8 days (range 4.9 to 7.6 days).

	Comment

Top Footnotes Abstract Introduction Material and methods Results Comment References

During the course of this experience individual surgeons tended to use Octopus OPCAB in increasing proportions of their CABG populations and also tended to perform more grafts per patient in the last year of analysis. These trends likely reflect surgeons’ advancing ability to reach all target arteries as well as their growing confidence in the success rates seen in their individual practices. The ratio of OPCAB to total CABG among centers varied based on individual surgeons’ preferences. Reasons to avoid OPCAB included, but were not limited to, unfavorable coronary anatomy, intolerance to cardiac displacement, clinical instability, and time-related surgical inexperience.

The gratifyingly low rates of morbidity and mortality demonstrated in this large group of OPCAB patients compare favorably with the early outcomes described in recent reports of CPB-supported CABG [5]. Direct comparisons cannot be made, however, because this study was retrospective and observational only. Patient selection for OPCAB was at the discretion of the operating surgeon and therefore selection bias cannot be excluded. In the latter half of the study period, however, several of the surgeons utilized this technique for the large majority of their patients. Higher risk patients were often selected for OPCAB because of surgeons’ bias that it was likely a safer procedure in these patients with significant risk factors for CPB.

Many issues remain regarding the proper positioning of beating heart CABG within the 21st century cardiac surgeon’s armamentarium. Studies are ongoing to investigate what impact OPCAB may have in the prevention or minimization of complication rates seen in the central nervous system, renal system, the myocardium, the pulmonary system, the hematological system, and so on [6–8]. Studies are also underway to assess early graft patency rates following beating heart CABG, a concern many cardiac surgeons and cardiologists rightly have. Lastly, longitudinal studies of return of symptoms, the need for reintervention, and long-term survival will be necessary to demonstrate whether the excellent early clinical outcomes demonstrated in studies such as this one will lead to sustained clinical benefit for patients.

	Footnotes

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
All authors of this paper are consultants for Medtronic, Inc, of Minneapolis, MN, serving as training physicians for the use of the Octopus device.

	References

Top Footnotes Abstract Introduction Material and methods Results Comment References

 

1. Jansen E.W.L., Borst C., Lahpor J.R., et al. Coronary artery bypass grafting without cardiopulmonary bypass using the Octopus method. J Cardiovasc Thorac Surg 1998;116:60-67.[Abstract/Free Full Text]
2. Spooner T., Hart J.C., Pym J. A two-year, three institution experience with the Medtronic Octopus. Ann Thorac Surg 1999;68:1478-1481.[Abstract/Free Full Text]
3. Grundeman P.F., Borst C., Verlaan C.W.J., et al. Exposure of circumflex branches in the tilted, beating porcine heart. J Thorac Cardiovasc Surg 1999;118:316-323.[Abstract/Free Full Text]
4. Hart J.C., Spooner T., Edgerton J., et al. Off-pump multivessel coronary artery bypass utilizing the Octopus tissue stabilization system. Heart Surg Forum 1999;2:15-28.[Medline]
5. Sundt T.M., III, Barner H.B., Gay W.A. Total arterial revascularization with an internal thoracic artery and radial T graft. Ann Thorac Surg 1999;68:399-405.[Abstract/Free Full Text]
6. 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]
7. Ascione R., Lloyd C.T., Underwood M.J., et al. On-pump versus off-pump coronary revascularization. Ann Thorac Surg 1999;68:493-498.[Abstract/Free Full Text]
8. Murkin J.M., Boyd W.D., Ganapathy S., et al. Postoperative cognitive dysfunction is significantly less after coronary revascularization without cardiopulmonary bypass. Ann Thorac Surg 1999;68:1469.[Free Full Text]

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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): James C. Hart Ted H. Spooner John Pym Thomas F. Flavin James R. Edgerton Michael J. Mack Erik W.L. Jansen Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hart, J. C. Articles by Jansen, E. W.L. Search for Related Content PubMed PubMed Citation Articles by Hart, J. C. Articles by Jansen, E. W.L.