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Ann Thorac Surg 2000;70:1034-1036
© 2000 The Society of Thoracic Surgeons

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Supplement: cardiothoracic techniques & technologies

Off-pump surgery for anterior vessels in patients with severe dysfunction of the left ventricle

^a Cardiovascular Institute, University of Dresden, Dresden, Germany

Address reprint requests to Dr Schüler, Cardiovascular Institute, University of Dresden, Fetscherstrasse 76, D-01307 Dresden, Germany
e-mail: monika.weber.hkz_dd{at}t-online.de

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

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Coronary artery revascularization in patients with severe dysfunction of the left ventricle remains a high-risk procedure due its high mortality and morbidity. Off-pump operation seems to be particularly attractive for this patient group. We report our experience with off-pump coronary revascularization in patients with severe dysfunction of the left ventricle.

Methods. Between June 1997 and December 1999, 31 patients with left ventricle ejection fraction less than or equal 30% (mean left ventricle ejection fraction 24 ± 12%, range from 12% to 30%) underwent off-pump coronary artery bypass grafting without the use of cardiopulmonary bypass. There were 29 men (93.5%) and 2 women (6.5%). The Patients’ ages ranged from 55 to 77 years (61 ± 10 years).

Results. Mean number of grafts was 2 ± 0.7 (range from 1 to 3). The internal mammary artery was used in 28 patients (90.3%). The hospital survival rate was 93.5%, in the 6-month follow-up the survival was 90%.

Conclusions. Off-pump coronary revascularization seems to be an alternative concept for the treatment of patients with severe dysfunction of the left ventricle.

	Introduction

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Despite major advances in coronary artery bypass surgery (CABG) the treatment of patients with coronary artery disease and severe left ventricle (LV) dysfunction still presents a particular challenge with a perioperative mortality up to 37% and high morbidity in this patient group [1]. On the other hand several studies have demonstrated favorable results from surgical revascularization in this patient group [2]. The impaired clinical outcome in comparison with patients who have normal LV function may be partially related to deleterious effects of cardiopulmonary bypass (CPB) and the use of cardioplegic solutions on the myocardium that may lead to a poor clinical course for the patient. Therefore the application of other surgical concepts in this patient group has been advocated. Beating heart operation has become an accepted surgical strategy in selected patients without various risk factors with good early and midterm results [3]. Perioperative course, graft patency, and convalescence of these patients are promising; however, patients with serious risks factors such as severe dysfunction of the LV are rarely included.

We report our experience with beating heart operation in patients with severe dysfunction of the LV.

	Material and methods

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Patients
Between June 1997 and December 1999, 31 patients with left ventricle ejection fraction (LVEF) less than or equal 30% (mean LVEF 24 ± 12%, range from 12% to 30%) underwent off-pump coronary artery bypass grafting (OPCAB) without the use of CPB. There were 29 men (93.5%) and 2 women (6.5%). The patients’ ages ranged from 55 to 77 years (61 ± 10 years). Overall beating heart procedures in our institution included 278 patients with 101 patients having a minimally invasive direct coronary artery bypass graft and 177 patients having an OPCAB procedure.

Concerning the patients with an LVEF less than 30% the clinical staging revealed 1 patient (3.2%) to be in Canadian Cardiovascular Society (CCS) stage I, 11 patients (35.5%) in stage II, 16 patients (51.6%) in stage III, and 3 patients (9.7%) in stage IV. There was 1 patient (3.2%) in New York Heart Association (NYHA) class I, 13 patients (41.9%) in NYHA class II, and 17 patients (54.8%) in NYHA class III. Preoperative angiography revealed a single-vessel disease in 5 patients (16.1%), double-vessel disease in 7 patients (22.6%), and triple-vessel disease in 19 patients (61.3%).

Comorbidity in this patient group included previous cardiac decompensation (n = 7, 22.6%), previous myocardial infarction (n = 21, 67.7%), chronic obstructive lung disease (n = 4, 12.9%), cerebrovascular disease (n = 4, 12.9%), liver cirrhosis (n = 1, 3.2%), renal insufficiency (n = 4, 12.9%), diabetes mellitus (n = 11, 35.5%), hypertension (n = 18, 58.1%), and smoking (n = 13, 41.9%).

Perioperative data such as postoperative ventilation, intensive care unit (ICU) stay, and hospital stay were monitored and retrospectively compared with the clinical outcome of beating heart CABG in patients with an LVEF of more than 30%. Clinical follow-up was performed after hospital discharge and 6 months postoperatively.

Surgical technique
All procedures were performed using the Octopus stabilizing system (Medtronic, Minneapolis, MN) through median sternotomy. Left internal thoracic artery (LIMA) preparation was performed in the usual manner. Heparin was administered in a dose of 2 to 3 mg/kg body weight. After opening of the pericardium a catheter was introduced into the left atrium (LA) for LA pressure blood monitoring. The temporary pacemaker electrodes were attached to the right atrium and right ventricle. Two to three stay sutures were placed on the left side of the pericardium, below the phrenic nerve, and one to two sponges were placed under the heart. Positioning maneuvers were used such as tilting the operating table to the right and applying the Trendelenburg position for assuring hemodynamic stability and improving access to the target vessels. For exposure of the coronary vessels of the posterior and lateral wall additional sponges or slings were used. After placement of the Octopus paddles, the blood flow through this vessel was temporary interrupted by snaring with vessel loops or tourniquets. Graft anastomosis was performed in the usual manner. For preservation of a bloodless anastomotic field we used a CO₂ blower.

In case of hemodynamic instability related to interrupted flow through the operated vessel a temporary coronary shunt was inserted for the anastomosis time.

The LIMA was grafted to the left anterior descending artery in 27 patients (87%) and to the diagonal branch in 2 patients (6.5%). Additional vein grafts were performed to the circumflex system in 2 patients (6.5%), to the right coronary system in 11 patients (35.5%), and to a diagonal branch in 3 patients (9.8%).

	Results

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Survival
The hospital survival was 93.5% (n = 29). One patient died on day 21 due to pneumonia leading to multiorgan failure. One patient died due to urinary sepsis on day 36. In the 6 month follow-up the survival was 90% (n = 28). A further patient died on day 150 from myocardial infarction.

Intraoperative results
The mean number of grafts was 2 ± 0.7 (range 1 to 3). Complete revascularization was possible in 21 patients (67.8%). Incomplete revascularization due to nongraftable coronary arteries occurred in 7 patients (22.6%). Incomplete revascularization due to limited access occurred in 3 patients (9.6%).

Morbidity
Nine patients (29%) required inotropic support, which was defined as the use of any inotropic agent postoperatively. A postoperative intraaortic balloon pump was inserted in 1 patient (3.2%). There were no additional events of perioperative myocardial infarction and no perioperative stroke. Further complications included conversion to CPB (n = 1, 3.2%), intraaortic balloon pump implantation (n = 1, 3.2%), pneumonia (n = 2, 6.4%), and atrial fibrillation (n = 7, 22.6%).

Clinical course
The vast majority of patients were extubated within 6 hours (6 ± 2.9), which was equal to patients with higher ejection fraction (5 ± 2 hours). The ICU stay (3 ± 2 days) was significantly longer in patients with severe dysfunction of the LV in comparison with the other group (1.5 ± 1 day). The ICU stay had no influence on the hospital stay, which was similar in both groups (8 ± 7 days versus 6 ± 2 days).

Clinical follow-up
A clinical follow-up was obtained from 23 patients. Sixteen patients (69.6%) were in CCS class I, 6 patients (26.1%) in CCS class II, and 1 patient (4.3%) in class III. Twelve patients (52.2%) were in NYHA class I, 10 patients (43.5%) in NYHA class II, and 1 patient (4.3%) in NYHA class III. An improvement of the NYHA class was found in 15 patients (65%) and of the CCS class in 17 patients (74%).

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
The use of beating heart operation in patients with severe dysfunction of the LV seems to be particularly attractive due to the avoidance of the deleterious effects and complications of CPB such as induction of a systemic inflammatory response, stroke and neurocognitive defects, renal insufficiency, or pulmonary insufficiency. Although sophisticated protocols of myocardial protection in CPB have led to improved results in myocardial revascularization in patients with severe dysfunction of the LV, the use of extracorporal circulation is still associated with a significant morbidity [4].

In accordance with other researchers our clinical experience with beating heart operation in in patients with severe dysfunction of the LV indicates that this technique offers an alternative concept to conventional CABG with CPB [5]. The advantages refer to mortality and in particular to morbidity, which was relatively low in our patient group: in comparison to our patients with higher LVEFs the ICU stay was longer and the need for catecholamines was significantly higher for patients with low LVEF, but this had no influence on the total hospital stay and was partially related to a more cautious observation of these patients.

Our clinical experience has made evident limitations of the beating heart operation in this high-risk patient group. The limitations include incomplete revascularization, which is of major importance in this patient group as prognosis is determined by the degree of complete revascularization and coronary vessel quality [6]. Although efforts were made to perform complete revascularization in all cases, surgical anatomy, coronary vessels, or inadequate exposure or stabilization of the anastomosis site led to incomplete revascularization. This is in particular true for revascularization of posterior vessels, which was uncommon in our patient group. More experience will increase the numbers of complete revascularization, specifically of posterior vessels, but patient selection and choice of the surgical procedure still remains a major challenge. The surgeon must always consider the quality of the coronary vessels, which should be selected according to the best feasibility of complete revascularization.

We conclude that in patients with severe dysfunction of the LV early results of OPCAB are promising, in particular in patients with additional risk factors. Despite these encouraging results a prospective, randomized trial comparing the off-pump operation with conventional CPB-based CABG will allow safe decision making in this high-risk patient group.

	References

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1. Christakis G.T., Weisel R.D., Fremes S.E., et al. Coronary artery bypass grafting in patients with poor ventricular function. J Thorac Cardiovasc Surg 1992;103:1083-1092.[Abstract]
2. Kaul T.K., Agnihotri A.K., Fields B.L., Riggins L.S., Wyatt D.A., Jones C.R. Coronary artery bypass grafting in patients with an ejection fraction of twenty percent or less. J Thorac Cardiovasc Surg 1996;111:1001-1012.[Abstract/Free Full Text]
3. Spooner T.H., James C.H., Pym J. A two year, three institution experience with the Medtronic Octopus. Ann Thorac Surg 1999;68:1478-1481.[Abstract/Free Full Text]
4. Ascione R., Lloyd C.T., Underwood M.J., Gomes W.J., Angelini G.D. On pump versus off-pump revascularization. Ann Thorac Surg 1999;68:493-498.[Abstract/Free Full Text]
5. Moshkowitz Y., Sternik L., Yoav P., et al. Primary coronary artery bypass grafting without cardiopulmonary bypass in impaired left ventricular function. Ann Thorac Surg 1997;63:44-47.
6. De Carlo M., Milano A., Borzoni G., et al. Predicting outcome after myocardial revascularization in patients with left ventricular dysfunction. Cardiovasc Surg 1998;6:58-66.[Medline]

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This Article Abstract Full Text (PDF) Correction (v70,p1766) 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): Vassilios Gulielmos Romuald Cichon Klaus Matschke Michael Knaut Stephan Schüler Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tugtekin, S. M. Articles by Schüler, S. Search for Related Content PubMed PubMed Citation Articles by Tugtekin, S. M. Articles by Schüler, S.