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Ann Thorac Surg 2000;70:844-849
© 2000 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Midterm angiographic assessment of coronary artery bypass grafting without cardiopulmonary bypass

Suat Nail Ömerolu, MD^a, Kaan Kirali, MD^a, Mustafa Güler, MD^a, Mehmet Erdem Toker, MD^a, Gökhan pek, MD^a, Ömer Iik, MD^a, Cevat Yakut, MD^a

^a Department of Cardiovascular Surgery, Kouyolu Heart and Research Hospital, Istanbul, Turkey

Address reprint requests to Dr Kirali, Kouyolu Kalp Eitim ve Aratirma Hastanesi, 81020 Kadiköy, Istanbul, Turkey
e-mail: kosuyolu{at}superonline.com

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Coronary bypass surgery that provides good long-term graft patency can be performed on the beating heart as a viable alternative to conventional coronary artery bypass grafting (CABG).

Methods. From September 1993 to December 1996, 696 patients underwent CABG on the beating heart at the Kouyolu Heart and Research Hospital in Istanbul. Among them, 70 patients were chosen randomly for angiographic assessment of off-pump coronary artery bypass grafting.

Results. The interval from operation to angiography varied from 24 to 61 months (mean, 36.1 ± 10.9 months). The patency rate of left internal mammary–left anterior descending artery anastomoses was 95.59% (patency achieved in 65 of 68 patients) and of vein grafts was 47.06% (patency achieved in 16 of 34 patients) (p < 0.0001). The patency rates of grafts anastomosed to the left anterior descending artery were significantly higher than the rates of the grafts anastomosed to the other coronary arteries (95.71% versus 45.45%, p < 0.0001). Multivariate analysis showed that graft type (p < 0.0001) and hyperlipidemia (p = 0.023) were significant predictors for graft occlusion. Left ventricular function improved significantly after CABG (p = 0.04). Reintervention (using percutaneous transluminal cardiac angioplasty) and reoperation rates were 0.97% and 1.4%, respectively.

Conclusions. Off-pump coronary artery bypass grafting appears to produce midterm and long-term patency rates that are comparable to those of conventional techniques; that is especially true in cases of arterial conduits and of conduits anastomosed to the left anterior descending artery.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
The main strategy of coronary artery bypass grafting (CABG) is to obtain complete revascularization by bypassing all severe coronary artery stenoses (of at least 50% diameter reduction). The best way to accomplish this is to anastomose the graft with the highest patency rate to the most suitable coronary artery by using a successful technique. Long-term angiographic results in conventional CABG have shown that arterial grafts have excellent patency rates [1–4].

Because off-pump CABG is performed while the heart is beating in its own rhythm, it avoids the need for extracorporeal circulation and cardiac arrest. The most frightening aspect of this technique was the anastomotic failure caused by surgically inadequate exposure of coronary arteries. Because angiographic results of different off-pump techniques have been good, authors have begun to emphasize their advantages, and these techniques consequently have gained worldwide reputation [5–11]. Cost-effectiveness is another advantage of this technique [12].

It is well known that the long-term patency and survival rates in patients undergoing coronary bypass surgery are related to the choice of graft used for revascularization [13]. The patency rates of arterial grafts with no anastomotic failure are very high. That is the main reason for patients’ evident continuous recovery of quality of life. This justifies the use of the internal mammary artery, especially for left anterior descending artery (LAD) anastomosis.

Up to now any randomized long-term angiographic study following patients who have undergone off-pump CABG has not been conducted. The purpose of this paper is to present the angiographic results of off-pump bypass operations performed over a period of 5 years and to compare the results with those reported in the literature for both beating heart and conventional CABG.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
In the period from September 1993 to October 1999, a total of 2,063 patients underwent operations on the beating heart at Kouyolu Heart and Research Hospital. Of 696 patients operated upon by only two surgeons (C.Y. and Ö.I.) between September 1993 and December 1996, 70 were chosen randomly for the midterm and long-term angiographic assessment of off-pump procedures. Of those, 63 patients (90%) were male and 7 (10%) were female; their mean age was 53.21 ± 9.82 years (range, 36 to 76 years). All patients were considered to be at high risk because of the presence of various risk factors and associated diseases (Table 1).

Operative data are shown in Table 2. To prevent the irreversible injury of the heart segments by decreased reserve in cases of revascularization necessitating more than one bypass, priority was given to retrograde filling arteries. When a SVG was used, first distal anastomosis and then the proximal anastomosis were performed. Oxygen blowing was used to improve the visualization of the anastomotic region. Before the procedure, heparin (5,000 U) was administered to hold activated clotting time to between 200 and 250 seconds and the heart rate was slowed to less than 80 beats/min using a ß-blocker. In the absence of apparent drainage, the administrated heparin was not neutralized with protamine sulfate. Patients who underwent endarterectomy were treated with heparin for the first two days after the procedure and then with warfarin sodium for two months together with acetylsalicylic acid (150 mg/d), nitroglycerin, and diltiazem (90 to 180 mg/d). After two months all the medications except for acetylsalicylic acid were discontinued.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
The mean interval from operation to angiography was 36.11 plus or minus 10.88 months (range, 24 to 61 months).

Hospital data
Only one patient (1.43%) had perioperative anteroseptal myocardial infarction, but the anastomoses were patent at the control angiography. The most frequently observed complication during the perioperative period was transient electrocardiographic changes, whereas transient arrhythmia was the most common morbidity during the early postoperative period. Morbidities are listed in Table 3.

Freedom from anginal symptoms
The number of angina-free patients was significantly higher in the postoperative period than in the preoperative period (p = 0.00001) (Fig 1).

View larger version (34K): [in this window] [in a new window]   Fig 1. Number of patients with or without angina in preoperative and postoperative periods (p = 0.00001).

View larger version (53K): [in this window] [in a new window]   Fig 2. Postoperative improvement of the left ventricular function (p = 0.04). (LVPS = left ventricular performance score)

Graft patency rate
The patency rate of arterial grafts was significantly higher than that of venous grafts (p < 0.0001).

Reintervention or reoperation
The reintervention rate was 2.85%. Two patients underwent postoperative percutaneous transluminal coronary angioplasty, one for severe stenosis in the native coronary artery and the other for graft stenosis. The reintervention rate for graft stenosis was 0.97% (1 patient of 103, including one case of SVG). Only one patient underwent a late reoperation, because of the occlusion of the LIMA and SVG. The reoperation rate was 1.4%.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Myocardial revascularization has become the standard therapy for ischemic coronary artery disease in patients who do not benefit from medical therapy, percutaneous transluminal coronary angioplasty, or other noninvasive cardiac interventions. Revascularization’s efficacy in relieving angina and prolonging life is well proved in certain subgroups of patients, and it can be performed with acceptable mortality and morbidity rates. On the other hand, although the adverse effects of cardiopulmonary bypass are minor and reversible, patients with significant functional impairment of various organ systems may not tolerate the deleterious additive effects of cardiopulmonary bypass, as some of those effects are irreversible and even fatal [14]. In an attempt to minimize such complications, many centers have started to use off-pump techniques, especially in high-risk patients [5, 10–11, 15]. In spite of the theorem that the coronary occlusion using a bulldog clamp or snare suture may injure the myocardium, left ventricular segmental wall motion has been found to be better in patients who underwent operations on the beating heart, compared with those who underwent cardiopulmonary bypass. This may result from the maintenance of the physiologic homeostasis during beating heart surgery [16, 17]. It can be presumed that during the stunning or hibernation phase, the ventricles benefit more from CABG on the beating heart than from cardiopulmonary bypass. We found that the left ventricular performance score decreased and left ventricular functions improved postoperatively. Although the perioperative myocardial infarction rate associated with off-pump CABG was reported as between 0% and 5.5% [5–8, 14–20], the rate for conventional CABG was found to be 4.4% to 7.7% [5, 15, 16]. The in-hospital mortality rate of off-pump CABG patients was also very low. Although no patient with normal left ventricular function suffered death, the mortality rate in patients with left ventricular dysfunction was 2.7% [7, 8, 15–20].

The patency rates of internal mammary artery grafts were significantly higher than the rates of vein grafts in both short-term and long-term angiographic investigations. In patients who underwent cardiopulmonary bypass, the long-term ( > 1 year) patency rate for LIMA was reported as 80% to 94% and for SVG as 45% to 75% [3, 9, 13, 21, 22]. The patency rate of grafts in off-pump CABG was found to be similar to that of grafts used in conventional techniques. The reported long-term patency rates for LIMA and SVG were approximately 93% and 62% to 84%, respectively [15, 22]. Gundry and colleagues emphasized that the 3-year patency rates for off-pump CABG grafts were lower than those of conventional technique. The patency rates of LIMA and SVG performed with conventional technique were reported as 92% and 54%, whereas the patency rates of LIMA and SVG in off-pump bypass were 41% and 23%, respectively [23].

In our study, 82 grafts (79.61%) were patent and 21 grafts (20.39%) were occluded. In the control angiographic studies performed approximately 3 years after operation, the patency rate of LIMA grafts was significantly higher than that of SVG. The patency rate of grafts anastomosed to LAD was significantly higher than the rate of the grafts anastomosed to the other coronary arteries. The decreased patency rate for SVG may result from not only the type of graft or presence of hyperlipidemia but also to exposure and quality of stabilization in the circumflex artery and branches of the right coronary artery. When assessing patients’ risk factors and associated diseases, we found that only hyperlipidemia affected the patency rates significantly. The patency rate in patients with fewer than two risk factors or associated diseases or both was significantly higher than in those with two or more risk factors or associated diseases or both.

The patency rate was higher in patients receiving single bypass operations than in those who underwent multiple bypassed patients, probably because LIMA was the only graft anastomosed to LAD in those undergoing single bypasses. The patency was not affected by endarterectomy, length of the anastomosed segment, or coronary artery structure. This finding is important in that it shows that these kinds of interventions may also be done in off-pump CABG. In multivariate analysis of possible determinants of graft occlusion, graft type and hyperlipidemia were the only significant risk factors.

In conclusion, off-pump CABG with good midterm and long-term patency rates appears to be comparable in outcome with conventional techniques, especially in cases of arterial conduits and of conduits anastomosed to LAD.

	References

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