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Ann Thorac Surg 2000;70:1021-1025
© 2000 The Society of Thoracic Surgeons
a Cardiac Surgical Associates, Minneapolis, Minnesota, USA
Address reprint requests to Dr Arom, Cardiac Surgical Associates, P.A., 920 East 28th St, Suite 420, Minneapolis, MN 55407
e-mail: csa{at}csa-heart.com
Presented at the Sixth Annual Cardiothoracic Techniques and Technologies Meeting 2000, Ft Lauderdale, FL, Jan 27–29, 2000.
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsCommentReferences |
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Methods. Between January 1, 1998, and June 30, 1999, 177 patients with ejection fractions of 30% or less underwent full sternotomy coronary artery bypass grafting at our institution. Of these patients, 45 underwent OPCAB procedures and 132 patients underwent CCAB. Pre-, intra-, and postoperative variables as identified by The Society of Thoracic Surgeons National Cardiac Surgery Database were compared using univariate and logistical regression analysis.
Results. Despite recognized hemodynamic derangement during cardiac displacement, these groups of OPCAB patients appeared to tolerate the procedure well. Univariate analysis of cardiac enzyme leak and blood loss was statistically significant in the OPCAB patients. Utilizing regression analysis, cardiopulmonary bypass was the only predictor for all postoperative complications.
Conclusions. Multivessel coronary artery bypass utilizing the OPCAB approach in patients with depressed left ventricular function of equal to or less than 30% is appropriate and applicable. Analysis of CCAB and OPCAB variables was nonsignificant except for operative and postoperative blood loss and peak cardiac enzyme leak. Attention to intraoperative detail and hemodynamic management could be credited for the success with OPCAB.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Off-pump coronary artery bypass (OPCAB) through a full median sternotomy has recently gained renewed interest for multivessel revascularization [5]. To bypass the circumflex system and the posterolateral branches of the right system the surgeon must expose the posterolateral aspect of the heart by displacing the heart vertically [6]. However, displacement of the beating heart in the animals [7] and in patients with good left ventricular function may be well tolerated [4]. In an ischemic heart or critically impaired left ventricle any hemodynamic instability may lead to increased complications or death.
The aim of this study was to: (a) analyze our own experience in patients with severely depressed left ventricular function (EF of 30% or less) who underwent off-pump multivessel CABG; (b) provide group comparisons of OPCAB with conventional CAB (CCAB) with impaired left ventricular function; and (c) determine through logistic regression analysis contributing variables of postoperative complications or death.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Preoperative, intraoperative, and postoperative variables were compared between these two groups using univariate analysis (
2, Fisher’s exact test) and Student’s t test. The CCAB group was deemed the control group in all statistical analysis. The variables were analyzed and only those with p values of equal to or less than 0.05 are discussed in detail. Logistic regression analysis for complications were analyzed and indicated that potential predictors for a poor outcome were CPB, gender, age, and percent predicted risk. The analysis of the independent variables for overall mortality, operative mortality, new renal failure, new atrial fibrillation, perioperative myocardial infarction, stroke, and confusion/delirium were carried out using models with multiple predictors and with CPB as an independent predictor.
Off-pump coronary artery bypass operation
Off-pump coronary artery bypass operation was carried out through a full sternotomy incision with or without takedown of the left internal mammary artery in the usual fashion. Three deep pericardial traction stitches were placed near the left upper and lower pulmonary veins and to the left of the inferior vena cava, thereby achieving vertical displacement of the apex of the heart. With perfectly placed stitches and aggressive traction, the apex of the heart should be elevated to approximately 90 degrees. To further assist in providing good presentation of the target arteries on the lateral and inferior aspect of the heart, patients were placed in a gentle right decubitus Trendelenburg position. Stabilization of the target arteries in the early phase of the study was accomplished using the CTS tissue stabilizer (CardioThoracic Systems, Inc, Cupertino, CA) and more recently with the Octopus II stabilizer (Medtronic, Minneapolis, MN). With the addition of suction capability on the Octopus II device, presentation and stabilization of the remote target arteries near the circumflex trunk were feasible. Occasionally, the quality of anastomosis was assessed at the time of operation utilizing a transonic flow meter (Transonic, Ithaca, NY).
On-pump coronary artery bypass operation
On-pump coronary artery bypass operation was carried out through a full sternotomy incision with or without the internal mammary artery taken down in the usual fashion. Institution of CPB was achieved by cannulating the ascending aorta and right atrium. Retrograde cardioplegia of either blood or crystalloid solution was delivered for myocardial protection of the arrested heart. All CPBs were accomplished with a centrifugal pump and membrane oxygenator.
Treatment of all patients in both groups followed the standard care and processes from operation through discharge. This time included admission to the intensive care unit from the operating room 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 was followed and targeted for 4 hours after return from the operative suite.
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Results |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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0.03) and first 24-hours postoperative blood loss (CCAB 1,050 ± 713 versus OPCAB 705 ± 379 mL, p = 0.001). The significance of skin-to-skin times should be considered in relationship to the mean number of distal anastomosis performed within each group (CCAB 3.3 ± 1.1 grafts/patient versus OPCAB 2.7 ± 1 grafts/patient, p 0.01). Eliminating CPB cannulation, rewarming and termination has consistently saved 45 to 60 minutes of expensive operating room utilization with the OPCAB procedure. The details of peri- and postoperative factors are listed in Table 2.
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Comment |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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To be able to allow for complete revascularization in the OPCAB patient, the heart must be elevated. The degree of displacement varies with the location of the target vessels. A more gentle displacement is adequate to achieve left anterior descending and diagonal artery anastomosis. Revascularization on the branches of the circumflex and right coronary artery systems require a more vertical displacement that is even more pronounced in the posterolateral system. To accomplish this displacement, insertion of three deep pericardial traction stitches is critical. With proper placement of these three stitches, the vertical displacement of the apex of the heart can be achieved without using a sling or other supporting device. It has been shown that a 90-degree displacement of the animal heart causes hemodynamic derangement characterized by a major drop in stroke volume, cardiac output, and mean arterial pressure despite elevation of right side volume overload [7]. In another study using flow probe and a microsphere perfusion study, Grundeman and coworkers [12] showed that coronary blood flow (CBF) was decreased in all coronary arteries with a more pronounced effect in the circumflex system. The pathophysiology of CBF on displacement of the heart is complex. The decrease in CBF is likely to be reflected through autoregulation and a decrease in myocardial work and wall tension reduction when afterload is decreased. The assumption that cardiac work was decreased during displacement resulting in a drop in arterial pressure is supported by the observation that left ventricular myocardial oxygen consumption is diminished [12]. Extrapolation of these results to clinical practice must be carefully considered. Off-pump revascularization of the posterior wall is feasible while the heart is displaced vertically and the patient placed in the Trendelenburg position.
Our own observation has been a decline in the cardiac index, a decline in arterial pressure, and a fluctuating heart rate. The preload of both left and right sides fluctuated, although fluctuation was more pronounced on the right. In this clinical setting it is very difficult to interpret whether these changes were related to the findings as shown in the animal studies alone or in combination with aggressive intravenous treatment with Neosynephrine and a short-acting beta blocker. We have learned that hemodynamic instability is minimized when the three deep pericardial traction stitches were perfectly placed and vertical displacement of the heart accomplished without the addition of a sling or sponge pad inside the cradle. Hemodynamic instability was minimized with the patient in a Trendelenburg position, which creates bilateral filling pressures to reach 20 mm Hg or higher. Waiting approximately 2 to 3 minutes allows for normalization of the parameters so application of the stabilizing device and completion of the anastomosis can then be accomplished. We have also learned that it is easier to reach the posterolateral aspect of a large dilated heart than the heart with a concentric hypertrophied left ventricle.
The limitations of this study are that it is nonrandomized comparing two markedly different surgical approaches to cardiac revascularization. It is also a retrospective review of a small cohort of patients. During the same study period 2,302 patients underwent CABG by our group with 177 of them having an EF of less than 30%. However, all of the patients included in this study were consecutive. The selection of which surgical approach to apply was strictly a surgeon decision based on the patient’s clinical presentation and not existing comorbidities. For the OPCAB approach, we prefer no calcified vessels, no intramuscular arteries, and the size of the target artery should not be smaller than 1.5 mm. Also, we preferred not to offer OPCAB in the patient with severe left ventricular hypertrophy. The nonsignificant reporting of comparative preoperative demographics, comorbidities, and preoperative predicted risk according to the STS National Cardiac Surgery Database Module supports this statement.
Arguably, the mean number of distal anastomoses between groups was significant and may suggest an unmatched comparison or represent incomplete revascularization in the OPCAB group. As experience was gained in the 1999 population, the discrepancy between mean number distal anastomosis neared uniformity. Table 5 details the graft location and frequency of anastomosis performed in each vessel. A more recent review of patients whose surgical procedure was performed between October 1, 1999, and December 31, 1999, with an overall sample population of 376, indicates that the number of grafts per patient for CCAB (n = 255) was 3.3 ± 0.93 and for OPCAB was 3.17 ± 0.98 (n = 121), p = 0.219. Therefore, the OPCAB approach does allow for possible complete revascularization.
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Conclusions
With the continued rise in patient age and multiple system impairment secondary to acute or chronically depressed ventricular function, evaluation of various surgical treatment modalities for this high-risk population is warranted. Our ultimate goal should be to continue to achieve complete revascularization, providing for long-term survival and enhancement of the quality of life. This review supports the feasibility of multivessel OPCAB for patients with left ventricular function of equal to or less than 30%. The immediate results are satisfactory and long-term follow-up is mandatory. Additionally, our findings could prompt the question as to whether or not right or left heart support devices for partial CPB will be necessary for this OPCAB subset in the future. The commitment of the surgeons, the attention to every detail, and the assistance of a highly trained and experienced cardiac surgical and anesthesia team play an important role in this success.
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