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Ann Thorac Surg 2001;71:165-169
© 2001 The Society of Thoracic Surgeons

Original article: cardiovascular

Complete revascularization in coronary artery bypass grafting with and without cardiopulmonary bypass

Martin Czerny, MDa, Harald Baumer, MDa, Juliane Kilo, MDa, Andreas Zuckermann, MDa, Georg Grubhofer, MDb, Orest Chevtchik, MDa, Ernst Wolner, MDa, Michael Grimm, MDa

a Department of Cardiothoracic Surgery, University of Vienna Medical School, Vienna, Austria
b Department of Cardiothoracic and Vascular Anesthesia, University of Vienna Medical School, Vienna, Austria

Accepted for publication July 19, 2000.

Address reprint requests to Dr Grimm, Währinger Gürtel 18-20, A-1090 Vienna, Austria
e-mail: michael.grimm{at}akh-wien.ac.at


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
Background. The feasibility of complete revascularization on the beating heart without cardiopulmonary bypass (CPB) as compared with the standard operation with CPB in elective low-risk patients with multivessel disease has not been clearly demonstrated in a prospective trial.

Methods. Eighty selected low-risk patients were enrolled. In preoperative study with coronary angiography, the decision was made whether complete revascularization without CPB could be performed. Patients were randomly assigned to receive CABG either with (n = 40) or without CPB (n = 40). Randomization criteria were age, sex, and left ventricular ejection fraction. Completeness of revascularization as well as short- and mid-term clinical outcome in a 13.4 ± 6.5 month follow-up period were monitored.

Results. Twenty-six of 40 (65%) patients undergoing CABG without CPB underwent complete revascularization. In 5 of these patients (12.5%) suitable vessels were discarded for technical reasons and 9 patients (22.5%) were switched to CABG with CPB owing to the deeply intramyocardial course of target vessels (n = 5) or to hemodynamic instability (n = 4). In the group of patients operated on with CPB, 34 of 40 patients (85%) received complete revascularization. In 6 patients (15%) suitable vessels were discarded for technical reasons. Mean number of bypass grafts was 3.1 ± 0.8 with CPB and 2.6 ± 0.5 without CPB (p = 0.043). Clinical outcome and hospital stay were comparable in both groups. No patient died during the study period. No myocardial infarction was observed. Three patients undergoing CABG without CPB underwent successful PTCA 3 months after surgery.

Conclusions. CABG without the use of CPB is effective for complete revascularization in the majority of selected low-risk patients. Nevertheless, it has to be stated that the rate of incomplete revascularization in this early series of CABG without CPB is higher, and compromises the basic principle of complete revascularization.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
Coronary artery bypass grafting (CABG) on the beating heart without cardiopulmonary bypass (CPB) is being used for an increasing number of patients [1, 2]. New technical devices have made the operation easier resulting in a better quality of anastomoses especially at the anterior wall [2]. However, exposure of the posterior wall is more problematic resulting in a drop in cardiac output and left ventricular stroke volume [3]. Hemodynamic instability may even prevent grafting of the posterior wall, thus compromising the basic principle of complete revascularization. Although the concept of complete revascularization is logical and has been strongly advocated, its feasibility is not always given in patients with multivessel disease. This usually reflects the interactions among the luminal diameter of native coronary arteries, left ventricular ejection fraction, and myocardial viability, as well as the degree of distal disease [4].

CABG with CPB is a routine and safe procedure in selected low-risk patients [5] and complete revascularization with CPB is the surgical standard, improving symptomatic outcome and survival [4]. The beneficial effects of complete revascularization, as defined as grafts to three or more vessels, on event-free survival were shown in the early 1980s and confirmed by others later on [4, 6, 7]. Although complete revascularization on the beating heart provides long-term results comparable with complete revascularization with CPB, a threefold increase of reinterventions has been found after an observation period of 7 years as compared with CABG with CPB [8].

The aim of this study was to evaluate the feasibility of CABG without CPB to achieve complete revascularization as compared with the standard operation with CPB in selected low-risk patients. We studied a series of 80 patients with multivessel coronary artery disease and normal left ventricular ejection fraction undergoing CABG either with or without CPB.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
Patients
After the study protocol was approved by the ethics comitee of the University of Vienna, 80 elective low-risk patients were enrolled. Inclusion criteria were a normal or almost unimpaired left ventricular ejection fraction and presence of coronary multivessel disease. Only patients lacking diffuse disease, ventricular hypertrophy, and cardiac enlargement were included in the study protocol. In preoperative study of coronary angiography, the decision was made whether complete revascularization without CPB could be performed. Primary target vessels were the left anterior descending (LAD) artery, diagonal branches and right coronary artery. Patients with diseased circumflex branches were only enrolled when the marginal branches looked feasible to access without CPB at the state of our experience when the study was performed. Patient demographics are shown in Table 1.


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  		Table 1. Patient Demographics According to Randomization

 
Anesthesia and surgical procedure
Patients were premedicated with midazolam. Additional midazolam in 1-mg increments was administered intravenously as needed for sedation during placement of monitors and invasive catheters. All patients received a standard general anesthesia with midazolam, etomidate, fentanyl, and pancuronium. Patients were ventilated with oxygen in air, ventilation was set to a tidal volume of 8 mL/kg and a respiratory rate of 12 breaths per minute, positive end-expiratory pressure 5. The transesophageal echocardiography (TEE) probe was placed after anesthetic induction in all patients. The TEE views used to assess regional wall motion abnormalities included the transesophageal four-chamber and two-chamber views and the transgastric short-axis and long-axis views.

CABG with CPB
In all patients surgical access was gained through a median sternotomy. After harvesting the arterial and venous bypass grafts the patients received heparin (300 U/kg). In patients undergoing CABG with CPB a standard technique was used. We performed normothermic CPB in all patients. Core temperature was assessed by a nasopharyngeal probe.

Myocardial preservation during aortic cross clamping was achieved by 4°C cold intermittent antegrade and retrograde blood cardioplegia. Heparin was antagonized with protaminsulfate. The cardiopulmonary bypass circuit consisted of a hollow-fiber oxygenator (Bard HF 5701; C. R. Bard Inc, Haverhill, PA) primed with Ringer’s lactate solution 2,000 mL, mannitol 20 g, heparin 8,000 IU (Immuno, Vienna, Austria), and aprotinin 1,000,000 IU (Trasylol Bayer, Leverkusen, Germany). Flow during CPB was maintained at 2.5 L · min-1 · m-2. Blood cardioplegia in a 4:1 ratio was used. Hematocrit level was kept higher than 20% with donor blood if necessary. After weaning from CPB, mean arterial pressure was maintained above 60 mm Hg with fluid loading and appropriate vasoactive drugs. Treatment in the intensive care unit (ICU) was defined by institutional standards.

CABG without CPB
A myocardial coronary artery stabilizer system (Cardio Thoracic Systems, Cupertino, CA) was used in all cases. In the majority of cases the LAD was revascularized first. The vessel was stabilized, surrounded distally and proximally to the chosen anastomotic site by two 5-0 polypropylene sutures and was snared. No test of the tolerance for regional ischemia was performed. Afterwards the left internal mammary artery (LIMA)–LAD anastomosis was performed on the beating heart. Thereafter, further distal anastomoses were performed using the same myocardial coronary artery stabilizer system. If venous bypass grafts had been used, proximal anastomoses were performed on the partially clamped ascending aorta. Heparin was antagonized with protaminsulfate.

Completeness of revascularization and parameters of clinical outcome
Revascularization was considered incomplete when a territory was judged surgically nonreconstructable or when a suitable vessel was discarded for technical reasons. In-hospital death, myocardial infarction, and stroke were defined as major adverse outcome. Minor adverse outcome was defined as wound infections and postoperative atrial fibrillation. We also recorded the number of bypass grafts, requirement for blood units, intubation time, in-ICU stay, and in-hospital stay. Mean follow-up was 13.4 ± 6.5 months with regard to major and minor adverse outcome as well as to recurrence of angina. Completion coronary angiography was performed in 9 patients 3 months after surgery.

Statistical analysis
Demographic, medical, angiographic, operative, and postoperative data were collected on all patients. All clinical data are expressed as mean and standard deviation. Data processing and statistical analysis were performed using SAS statistical software (Cary, NC). The nonparametric Mann-Whitney U test was used to calculate differences between the two groups. The {chi}2 test was used to compare categorical variables. A p value less than 0.05 was considered significant.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
Completeness of revascularization
Clinical outcome is summarized in Table 2. The use of arterial and venous conduits was comparable in both groups (Table 3). The average number of grafts as well as the distribution of myocardial territories grafted are shown in Table 4. In the group without CPB, 26 of 40 patients underwent revascularization (65%) of all target vessels, as intended preoperatively. Of the remaining 14 patients, in 5 patients (12.5%) the intention of complete revascularization without CPB could not be accomplished because the vessel was judged surgically nonreconstructable due to a small luminal diameter (diagonal branch n = 2, marginal branch n = 2, posterior descending branch n = 1). Nine patients (22.5%) were switched to CABG with CPB. The reasons for switch to CPB were deeply intramyocardial course of target vessels (n = 5, 12.5%) and hemodynamic intolerability during the exposure of the posterior wall (n = 4, 10%).


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  		Table 2. Clinical Outcome

 

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  		Table 3. Distribution of Arterial and Venous Conduits

 

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  		Table 4. Coronary Territories Grafted

 
In the group of patients operated with CPB 34 out of 40 patients (85%) received complete revascularization of all target vessels as intended preoperatively (Fig 1). In 6 patients (15%) intraoperative decision was made that the target vessels were not suitable for anastomosis (diagonal branch n = 2, marginal branch n = 3, posterior descending branch n = 1) due to a small luminal diameter. Mean CPB time was 102 ± 27 minutes and mean cross-clamp time was 64 ± 19 minutes.



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  		Fig 1. Achievement of revascularization (Left, with CPB; right, without CPB).

 
Clinical outcome
In this series of elective low-risk patients there was neither a perioperative death nor a postoperative myocardial infarction. One reexploration occurred because of bleeding in a patient without CPB and 2 reexplorations occurred in patients with CPB. All patients were extubated within 48 hours. The mean ICU stay was 1.2 ± 0.96 days in patients without CPB and 2.0 ± 2.8 days in patients with CPB. One patient after CABG without CPB underwent reoperation for acute LIMA occlusion on the fifth day after surgery. The incidence of minor adverse outcome (wound infections and postoperative atrial fibrillation) and clinically relevant neurologic events is shown in Table 2. All patients were discharged from hospital within 14 days.

Follow-up and need for reintervention
The mean follow-up period was 13.4 ± 6.5 months. Death was not observed. Nine patients undergoing CABG without CPB underwent completion coronary angiography 3 months after surgery. All grafts were patent except in 1 patient a vein graft to RCA was occluded. In 2 patients hemodynamically significant anastomotic stenoses were revealed in postoperative completion angiography (LIMA–LAD and vein-marginal circumflex branch). All 3 patients underwent successful percutaneous transluminal coronary angioplasty. No patient in either group experienced early or late recurrence of angina.


   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
CABG without the use of CPB is effective to achieve complete revascularization in the majority of selected low-risk patients. Nevertheless, the rate of incomplete revascularization in these patients undergoing CABG without CPB is higher. The rate of incomplete revascularization due to a small luminal diameter of target vessels is comparable in patients undergoing CABG either with or without CPB. However, in a certain number of patients, the deeply intramyocardial course of vessels or hemodynamic intolerability due to nonuniformal myocardial perfusion during the exposure of the posterior wall prevents grafting, thus compromising the basic principle of complete revascularization.

CABG without CPB has gained increasing acceptance for selected patients with single-vessel disease. Introduction of stabilizers made complete revascularization feasible even in multivessel disease [9]. Complete revascularization in multivessel disease without CPB can be performed with low morbidity and mortality and excellent early angiographic results even in high-risk patients [3]. However, so far not all patients seem to be eligible for this procedure. In a certain group of patients with multivessel disease, the intramyocardial course of vessels or hemodynamic instability due to nonuniformal myocardial perfusion during the exposure of the posterior wall will prevent complete revascularization on the beating heart without CPB.

The rate of complete revascularization in patients without CPB in our series is lower and the rate of conversion to CPB is higher when compared with recent reports from other groups [9, 23]. Cartier and coworkers [9] reported a rate of complete revascularization greater than 90% in the group without CPB and a conversion rate to CPB of less than 1%. Bedi and coworkers [23] achieved complete revascularization in all patients undergoing CABG without CPB, with a conversion rate to CPB of 1%.

This series represents our initial experience with off-pump surgery in patients with multivessel disease. In more recent cases the success rate of complete revascularization in patients undergoing CABG without CPB steadily increased and has now reached more than 90%. The procedures at our institution were performed by five different surgeons and not by only one surgeon as in the other mentioned series. Therefore the learning curve of each surgeon may to some extent affect our results. Additionally in the series of Cartier and associates [9], patients with a deeply intramyocardial LAD artery were primarily not considered for the procedure. If we would have excluded this patient group from analysis, our rate of complete revascularization would rise to 78%.

Patients who undergo CABG without CPB are considered to have a smoother early postoperative period and a shorter hospital stay as compared with patients undergoing conventional CABG with CPB [9, 10]. Gundry and coworkers [8] found that multivessel CABG without CPB appears capable of producing similar longevity and symptomatic status even years after surgery as compared with a matched group of patients receiving CABG with CPB. However, twice as many repeat coronary angiographies and three times as many reinterventions predominantly at distal snare sites were required in patients having undergone CABG without CPB [8]. Our 3-month reintervention rate of 10% in patients after CABG without CPB is well in line with reported reintervention rates of other series [8, 9, 23]. Nevertheless, our concept of surrounding the artery distally and proximally to the chosen anastomotic site by two 5-0 polypropylene sutures and snaring has changed, although our completion angiograms did not reveal any late stenoses at distal snare sites. We now surround coronary vessels with smooth silicone elastomer tapes and then snare the artery extremely careful in a stepwise procedure.

It is widely accepted that complete revascularization with the use of CPB remains the surgical gold standard [4, 6, 7]. Interestingly in the Coronary Artery Surgery Study (CASS) registry in patients with CCS class I and II there was no difference in major event-free survival nor in freedom from angina irrespective of the number of vessels bypassed after 5 years [4]. However, patients with complete revascularization were more likely to be free from severe angina than patients with incomplete revascularization, especially patients with CCS class III and IV. From the recent surgical experience, it seems likely that differences in clinical and neurologic outcome—with or without CPB—will only be seen in high-risk patients, eg, the very elderly in whom in-hospital mortality rates after conventional CABG with CPB may be as high as 11.5% and postoperative cognitive brain dysfunction may be as high as 79% [11, 12, 19–21]. Morphologic evidence for cognitive brain dysfunction was provided by Harris and associates [22] who observed significant brain swelling in the first hours after CABG with CPB.

Cardioplegic cardiac arrest is safe and effective for protecting the myocardium during CABG with CPB and the clinical relevance of myocardial injury related to cardioplegic cardiac arrest is acceptably low [13]. Nevertheless, a certain number of patients will suffer from postoperative myocardial injury undergoing CABG with CPB [14]. This ischemic injury may be caused by incomplete distribution of cardioplegia in the heart and by unexpected aortic regurgitation, which results in nonuniform myocardial perfusion [16–18]. For patients undergoing CABG without CPB, recent data suggest that temporary coronary occlusion on the beating heart causes less myocardial injury than cardioplegic cardiac arrest in CABG with CPB [17, 18]. Nevertheless it is known that hemodynamic intolerability during the exposure of the posterior wall is the result of nonuniform myocardial perfusion. Avoidance of ischemia by using an intraluminal shunt or by retrograde coronary sinus perfusion by arterial blood from the ascending aorta may enable complete revascularization to a greater extent than without these techniques [23, 24]. In our early series we did not use any of these techniques. This may contribute to the 10% conversion rate due to hemodynamic intolerability in our series.

Limitations of the study
The primary limitation of our study is that this study was probably done at a too-early stage of performing CABG without CPB for multivessel disease. As is the rest of the surgical community, we are continuously gaining experience in patient selection and intraoperative hemodynamic management—in none of the patients in this series were pericardial stay sutures used for the exposure of the posterior wall, which certainly affected outcome. And finally, data from this study may not be extrapolated to patients with depressed ventricular function, diffuse coronary artery disease, and ventricular hypertrophy.

Despite the several limitations of our early experience with multivessel off-pump grafting, CABG without the use of CPB is effective for achieving complete revascularization in the majority of selected low-risk patients. Nevertheless, it has to be stated that patients undergoing CABG without CPB have a higher rate of incomplete revascularization. Deeply intramyocardial vessel course and hemodynamic intolerability during exposure of the posterior wall were the main limiting factors of this early study [15].


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

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D. N. Wijeysundera, W. S. Beattie, G. Djaiani, V. Rao, M. A. Borger, K. Karkouti, and R. J. Cusimano
Off-Pump Coronary Artery Surgery for Reducing Mortality and Morbidity: Meta-Analysis of Randomized and Observational Studies
J. Am. Coll. Cardiol., September 6, 2005; 46(5): 872 - 882.
[Abstract] [Full Text] [PDF]

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 Ann. Thorac. Surg.Home page
T. Fukui, S. Takanashi, Y. Hosoda, and S. Suehiro
Total Arterial Myocardial Revascularization Using Composite and Sequential Grafting With the Off-Pump Technique
Ann. Thorac. Surg., August 1, 2005; 80(2): 579 - 585.
[Abstract] [Full Text] [PDF]

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 SEMIN CARDIOTHORAC VASC ANESTHHome page
D. Novitzky
Reducing the Risk of Myocardial Revascularization: Relevance of Multimodal Brain Monitoring
Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2005; 9(2): 131 - 137.
[Abstract] [PDF]

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 Eur. J. Cardiothorac. Surg.Home page
A. J. Rastan, H. B. Bittner, J. F. Gummert, T. Walther, C. V. Schewick, E. Girdauskas, and F. W. Mohr
On-pump beating heart versus off-pump coronary artery bypass surgery--evidence of pump-induced myocardial injury
Eur. J. Cardiothorac. Surg., June 1, 2005; 27(6): 1057 - 1064.
[Abstract] [Full Text] [PDF]

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D. Bainbridge, J. Martin, and D. Cheng
Off Pump Coronary Artery Bypass Graft Surgery Versus Conventional Coronary Artery Bypass Graft Surgery: A Systematic Review of the Literature
Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2005; 9(1): 105 - 111.
[Abstract] [PDF]

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 Ann. Thorac. Surg.Home page
F. Onorati, M. De Feo, P. Mastroroberto, L. Cristodoro, F. Pezzo, A. Renzulli, and M. Cotrufo
Determinants and Prognosis of Myocardial Damage After Coronary Artery Bypass Grafting
Ann. Thorac. Surg., March 1, 2005; 79(3): 837 - 845.
[Abstract] [Full Text] [PDF]

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 Clin Med ResHome page
J. Pepper
Controversies in Off-pump Coronary Artery Surgery
Clin. Med. Res., February 1, 2005; 3(1): 27 - 33.
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 J. Thorac. Cardiovasc. Surg.Home page
N. C. Patel, N. U. Patel, D. F. Loulmet, J. C. McCabe, and V. A. Subramanian
Emergency conversion to cardiopulmonary bypass during attempted off-pump revascularization results in increased morbidity and mortality
J. Thorac. Cardiovasc. Surg., November 1, 2004; 128(5): 655 - 661.
[Abstract] [Full Text] [PDF]

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 Eur. J. Cardiothorac. Surg.Home page
T. Athanasiou, O. Aziz, O. Mangoush, S. Al-Ruzzeh, S. Nair, V. Malinovski, R. Casula, and B. Glenville
Does off-pump coronary artery bypass reduce the incidence of post-operative atrial fibrillation? A question revisited
Eur. J. Cardiothorac. Surg., October 1, 2004; 26(4): 701 - 710.
[Abstract] [Full Text] [PDF]

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L. Aklog and D. H. Adams
Invited commentary
Ann. Thorac. Surg., August 1, 2004; 78(2): 684 - 685.
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 Eur. J. Cardiothorac. Surg.Home page
G. J.M.G. van der Heijden, H. M. Nathoe, E. W.L. Jansen, and D. E. Grobbee
Meta-analysis on the effect of off-pump coronary bypass surgery
Eur. J. Cardiothorac. Surg., July 1, 2004; 26(1): 81 - 84.
[Abstract] [Full Text] [PDF]

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J. D. Puskas, W. H. Williams, E. M. Mahoney, P. R. Huber, P. C. Block, P. G. Duke, J. R. Staples, K. E. Glas, J. J. Marshall, M. E. Leimbach, et al.
Off-Pump vs Conventional Coronary Artery Bypass Grafting: Early and 1-Year Graft Patency, Cost, and Quality-of-Life Outcomes: A Randomized Trial
JAMA, April 21, 2004; 291(15): 1841 - 1849.
[Abstract] [Full Text] [PDF]

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E. D. Peterson and D. B. Mark
Off-Pump Bypass Surgery--Ready for the Big Dance?
JAMA, April 21, 2004; 291(15): 1897 - 1899.
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 Ann. Thorac. Surg.Home page
L. R. Gerola, E. Buffolo, W. Jasbik, B. Botelho, J. Bosco, L. A. Brasil, and J. N. R. Branco
Off-pump versus on-pump myocardial revascularization in low-risk patients with one or two vessel disease: perioperative results in a multicenter randomized controlled trial
Ann. Thorac. Surg., February 1, 2004; 77(2): 569 - 573.
[Abstract] [Full Text] [PDF]

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 J. Thorac. Cardiovasc. Surg.Home page
M. Pocar and F. Donatelli
Abdominal tumors with cavoatrial extension
J. Thorac. Cardiovasc. Surg., January 1, 2004; 127(1): 301 - 302.
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A. Boening, C. Friedrich, J. Hedderich, J. Schoettler, S. Fraund, and J. T. Cremer
Early and medium-term results after on-pump and off-pump coronary artery surgery: a propensity score analysis
Ann. Thorac. Surg., December 1, 2003; 76(6): 2000 - 2006.
[Abstract] [Full Text] [PDF]

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J. T. Reston, S. J. Tregear, and C. M. Turkelson
Meta-analysis of short-term and mid-term outcomes following off-pump coronary artery bypass grafting
Ann. Thorac. Surg., November 1, 2003; 76(5): 1510 - 1515.
[Abstract] [Full Text] [PDF]

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 Eur. J. Cardiothorac. Surg.Home page
D. L. Ngaage
Off-pump coronary artery bypass grafting: the myth, the logic and the science
Eur. J. Cardiothorac. Surg., October 1, 2003; 24(4): 557 - 570.
[Abstract] [Full Text] [PDF]

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 HeartHome page
R A Archbold and N P Curzen
Off-pump coronary artery bypass graft surgery: the incidence of postoperative atrial fibrillation
Heart, October 1, 2003; 89(10): 1134 - 1137.
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