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Ann Thorac Surg 2001;72:793-797
© 2001 The Society of Thoracic Surgeons

Original article: cardiovascular

Creative arterial bypass grafting can be performed on the beating heart

Robert L. Quigley, MD, PhDa, Steven J. Weiss, MDa, Richard Y. Highbloom, MDa, John Pym, FRCS(C)a

a Department of Surgery, Cardiothoracic Division, Albert Einstein Medical Center, Jefferson Health System, Philadelphia, Pennsylvania, USA

Accepted for publication May 15, 2001.

Address reprint requests to Dr Quigley, Division of Cardiothoracic Surgery, Albert Einstein Medical Center, 5501 Old York Rd, HB-3, Philadelphia, PA 19141
e-mail: quigleyr{at}aehn2.einstein.edu


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. To demonstrate that compromise is unnecessary in either the design or performance of beating heart surgery, we report our experience, over 1 year, of total arterial revascularization where composite or creative grafting was utilized.

Methods. We performed 321 off-pump coronary artery bypass operations, of which, 290 (90%) were done with only arterial conduits. The mean number of distal anastomoses was 2.48, with a range of 1 to 5. There were no aortic anastomoses. One hundred eighty-nine patients (65%) were male, and 101 (35%) were female, with a mean age of 67 years. Comorbidities included chronic renal failure (CRF), 21 (7%); diabetes, 92 (32%); obesity, 68 (23%); hypertension, 212 (73%); chronic obstructive pulmonary disease, 189 (65%); cerebral vascular accident (CVA), 39 (13%); smoking, 164 (56%); and hypercholesterolemia, 151 (52%). The mean ejection fraction was 56%, with a range of 21% to 71%. All procedures were performed with external stabilizers with or without vacuum assist. The complete arterial revascularizations included a T-graft (internal thoracic [ITA]/radial arteries [RA]), 130 (45%); a sequential graft (ITA ± RA), 118 (41%); a U-graft (coronary-coronary graft perfused by the ITA or right gastroepiploic artery), 5 (2%); an I-graft (ITA/RA), 4 (1%); an X-graft (ITA/RA), 2 (12); and a Y-graft (ITA/RA), 31 (10%).

Results. The postoperative incidence of atrial fibrillation was 80 of 290 (27%); CVA, 5 of 290 (2%); bleeding resulting in take-back, 5 of 290 (2%); CRF, 8 of 290 (3%); deep sternal infection, 4 of 290 (1%); and readmission (30-day) for angina, 4 of 290 (1%). The observed perioperative (30-day) mortality was 9 of 290 (3.1%), with the STS predicted rate of 3.82%.

Conclusions. Our experience indicates that once the operating surgeon has learned to safely expose the lateral and inferior walls of the heart, the type of conduit and the method of revascularization should be no different than that used with cardiopulmonary bypass. However, we still recommend conventional methods of revascularization (on-pump with saphenous vein conduits) for the ischemic patient.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
The morbidity and mortality of conventional (on-pump) coronary artery bypass grafting (CABG) have largely been attributed to cardiopulmonary bypass (CPB), cardioplegia/cardiac arrest, and hypothermia. On the other hand, off-pump CABG (OPCAB) significantly reduces oxidative stress and inflammation [1], preserves renal function [2], eliminates neuropsychologic impairment [3], and may be the preferred operation in the elderly [4].

Unfortunately, some clinicians remain skeptical about technical limitations of the OPCAB operation and the long-term patency of the anastomoses [5]. This skepticism has, in most centers, delayed progress in beating heart surgery, which typically is performed using the standard (historic) conduits (left internal thoracic artery [LITA] and reversed saphenous vein) in the routine configuration. In our program, not only did we question the use of CPB, but we also questioned the choice and configuration of our conduits.

New technology/skills for conduit harvest [6], potent vasodilators, and long-term patency data have resulted in a renewed interest in arterial conduits [7]. We share this interest, and over the last several years have developed unique methods to revascularize the myocardium using only arterial conduits. Here we report our recent series of OPCAB surgical procedures where total myocardial revascularization was performed with arterial conduits.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
In the calendar year 1999, four surgeons performed 321 OPCAB surgical procedures, of which, 290 (90%) were done with only arterial conduits. Total arterial revascularization was precluded in the remaining 31 patients (10%) due to demonstrable inadequate circulation in the hand. In these cases, the thigh saphenous vein was harvested using endoscopic technology. Diabetes mellitus or weight was not used as a contraindication to bilateral ITA harvest. The epidemiologic characteristics of this cohort of patients are listed in Table 1. During this calendar year, an OPCAB operation was considered in all cases of elective coronary revascularization unless the patient was unstable with ongoing ischemia. In this situation, CPB was employed with saphenous vein conduits. The ITAs and right gastroepiploic arteries (RGEA) were harvested using conventional techniques [8]. Radial arteries (RAs) were isolated by ultrasonic dissection (Harmonic Scalpel; Ethicon, Cincinnati, OH) and bathed in a standard solution (lactated Ringers, 450 mL; Verapamil, 7.5 mg; nitroglycerin, 3.75 mg; heparin, 750 units; sodium bicarbonate 8.4%, 0.3 mL). In all cases, nitroglycerin (0.5 to 1.0 µg · kg · min) was infused during the perioperative period. One surgeon, in addition, routinely used Diltiazem (0.5 to 1.0 µg · kg · min), and maintained his patients postoperatively on an oral regimen of this calcium channel blocker. Vasoconstrictors were used judiciously (epinephrine/norepinephrine), if at all, and were routinely infused in conjunction with the phosphodiesterase inhibitor Milrinone (0.1 to 0.4 µg · kg · min).


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  		Table 1. Epidemiologic Characteristics (n = 290)

 
All procedures were performed using external stabilizers with (Medtronic, Minneapolis, MN) or without (CTS/Guidant, Cupertino, CA) vacuum assist. Shunts or arterial blockers were used at the discretion of the operating surgeon. The complete arterial revascularizations included a T-graft (ITA/RA), 130 (45%); a sequential graft (ITA ± RA), 118 (41%); a U-graft (coronary-coronary graft perfused by the ITA or RGEA), 5 (2%); an I-graft (ITA/RA), 4 (1%); an X-graft (ITA/RA), 2 (1%); and a Y-graft (ITA/RA), 31 (10%). The mean number of distal anastomoses was 2.48, with a range of 1 to 5. There were no aortic anastomoses in this series. All patients were given heparin systemically (a loading dose of 10 to 15,000 U followed by a maintenance dose of 5,000 U/hr to maintain the activated clotting time (ACT) between 300 and 400 seconds). This was reversed upon completion of the case with Protamine sulphate (the dose required to return the ACT to baseline). None of these planned 290 OPCAB cases were converted to CPB.

Arterial revascularization was achieved using either a sequential graft(s) (Fig 1), or a composite graft (Figs 2 to 6). The principles and technique of sequential grafting were extrapolated from our previous series of sequential vein grafting [9]. Two hundred seventy-eight of the operations were performed via a median sternotomy, six through a left lateral thoracotomy, and six through an anterior thoracotomy (MIDCAB) incision.



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  		Fig 1. A standard sequential graft. The left internal mammary artery (LIMA) is anastomosed to the diagonal (Dx) and left anterior descending (LAD) coronary arteries (CABG = coronary artery bypass grafting).

 


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  		Fig 2. A standard composite graft. The radial artery (RA) serves as a coronary-coronary graft, which can be supplied by the right gastroepiploic arteries (RGEPA) (A), the left internal mammary artery (LIMA) (B), and the right internal mammary artery (RIMA) (C) (RIMA = RITA).

 


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  		Fig 3. A standard composite graft. The left internal mammary artery (LIMA) is anastomosed to the left anterior descending (LAD). A segment of radial artery (RA) or right internal mammary artery (RIMA) is anastomosed to the LIMA in a "T" configuration with the other end anastomosed to a diagonal (Dx). Data from Tector and associates [13]. (CABG = coronary artery bypass grafting.)

 


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  		Fig 4. A standard composite graft. The left internal mammary artery (LIMA) is anastomosed in an end-to-end "I" configuration with the distal end anastomosed to the left anterior descending (LAD). (CABG = coronary artery bypass grafting.)

 


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  		Fig 5. A standard composite graft. The radial artery (RA) serves as a coronary-coronary graft that is supplied by the left internal mammary artery (LIMA) (side-side), which is ultimately anastomosed to the left anterior descending (LAD) in an "X" configuration. (CABG = coronary artery bypass grafting.)

 


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  		Fig 6. A standard composite graft. The left internal mammary artery (LIMA) is anastomosed to the left anterior descending (LAD). A segment of radial artery (RA) is anastomosed to the LIMA in a "Y" configuration with the other end anastomosed to a marginal branch of the circumflex system. Data from Barner [14]. (CABG = coronary artery).

 

   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
The observed and expected morbidity/mortality are outlined in Table 2. The morbidity data listed in Table 2 indicate generally similar values for the observed and expected results. The observed incidence of atrial fibrillation, however, was significantly higher than the expected, despite the lack of great vessel instrumentation.


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  		Table 2. Mortality and Morbidity Data (n = 290)

 
Eight patients developed chronic renal failure (CRF) postoperatively (serum creatinine > 2.0), however, only 2 required permanent dialysis. Five (2%) of the patients suffered a permanent stroke with residual neurologic deficits. None of these were hemorrhagic, and 2 involved the brainstem as indicated on CAT scan.

Only four of the deaths were in-hospital, and they were all severely moribund at the time of operation and each succumbed to multisystem organ failure. Although there was no evidence of cardiac ischemia postoperatively, they all suffered from states of low cardiac output. Three of the other five mortalities were sudden and occurred either at home or in convalescent homes. In the absence of autopsy data, it is unclear whether these represented fatal cardiac dysrhythmias or pulmonary emboli. The remaining two had cerebral vascular accidents (CVAs) from which they did not recover.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Our results clearly indicate that creative and complete arterial bypass grafting can successfully and safely be performed on the beating heart. Furthermore, we have recently presented our series of total arterial revascularization on the beating heart in the context of a low ejection fraction [10].

The concept of composite arterial grafting is not novel, however, the application of this technique to the beating heart is unique. Ever since the left ITA has been documented to be associated with increased survival, surgeons have devised and applied new methods of arterial revascularization [11]. Complete myocardial revascularization with a ITA-ITA T-graft [12, 13] and ITA-RA Y-graft [14] have already been reported. Additionally, coronary artery bypass grafting with an RGEA composite graft has also been described [15]. Recent data indicate that creation of a composite graft does not compromise blood flow in either limb of the graft but rather increases proximal flow rates, indicating, at least in the ITA, there is a flow reserve [16].

We are satisfied with our exposure for this procedure using either the median sternotomy or lateral thoracotomy approach, depending on the coronary anatomy. Our interest in the use of the MIDCAB incision has waned, as we have not been able to demonstrate any advantage over the other two approaches, and in fact, we have observed more wound-related problems [17].

Our observed incidence of permanent stroke (CVA) of 2% (5 of 290) was no different than the predicted value but nevertheless suprisingly high considering the absence of aortic manipulation/instrumentation. The wide spectrum of neurocognitive dysfunction, after conventional CABG [18], has been attributed to CPB and resultant air/debris emboli, however, we are now trying to determine whether the mechanism of CVA in our series is different. Presently, it is unclear whether these unfortunate patients developed a state of hypercoagulability, which, when superimposed on a substrate of cerebrovascular atherosclerosis, resulted in CVA. We have not yet begun empiric anticoagulation therapy with agents other than aspirin in our postoperative protocols until further scientific data are available.

It also should be noted that our mortality of 3.1% (9 of 290) was only slightly less than the expected using the STS database (3.82%). It may not be an accurate comparison because the STS data are based on a similar population of patients where CPB was instituted.

The incidence of atrial fibrillation was certainly higher than the STS expected value (27% vs 20.8%). This result is curious because the lack of instrumentation of the heart in the OPCAB patient should theoretically reduce the amount of cardiac trauma. These results therefore support the concept that postoperative atrial fibrillation is multifactorial and not solely related to trauma [19].

As our experience has evolved, we now find few if any contraindications to the OPCAB operation. We even have our own small series of successful reoperative procedures performed on the beating heart as previously demonstrated by others (not included in this series) [20]. Ongoing ischemia as manifested by electrocardiographic changes remains the only relative contraindication to complete arterial OPCAB surgery. In these rare cases, we are inclined to use both venous conduit and CPB.

Although the harvest and preparation of arterial grafts is labor intensive, we strongly believe that they represent the conduits of choice for patients in the new millennium. It is unclear whether our low 30-day readmission rate for angina, when compared with the STS database (1% vs 5.7%), is due to our choice of conduits or the beating heart approach. Hopefully, our long-term data, which we are presently collecting, will allow us to separate these issues. Finally, we support the concept that beating heart surgery is not a "passing trend" but rather in most circumstances the preferred method of coronary revascularization [18], and we now perform over 85% of our CABGs without CPB. Intramyocardial coronaries, ventricular dysfunction, atrial fibrillation, cardiomegaly, and repeat sternotomy, no longer, in our practice, contraindicate beating heart surgery.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Matata B.M., Sosnowski A.W., Galinances M. Off-pump bypass graft operation significantly reduces oxidative stress and inflammation. Ann Thorac Surg 2000;69:785-791.[Abstract/Free Full Text]
  2. Ascione R., Lloyd C.T., Underwood M.J., et al. On-pump versus off-pump coronary revascularization: evaluation of renal function. Ann Thorac Surg 1999;68:493-498.[Abstract/Free Full Text]
  3. Diegeler A., Hirsch R., Schneider F., et al. Neuromonitoring and neurocognitive outcome in off-pump versus conventional coronary bypass operation. Ann Thorac Surg 2000;69:1162-1166.[Abstract/Free Full Text]
  4. Koutlas T.C., Elberry J.R., Williams J.M., et al. Myocardial revascularization in the elderly using beating heart coronary artery bypass surgery. Ann Thorac Surg 2000;69:1042-1047.[Abstract/Free Full Text]
  5. Ullyot D.J. Look ma, no hands!. Ann Thorac Surg 1996;61:10-11.[Free Full Text]
  6. Ronan J.W., Perry L.A., Burner H.B., et al. Radial artery harvest: comparison of ultrasonic dissection with standard technique. Ann Thorac Surg 2000;69:113-114.[Abstract/Free Full Text]
  7. Parolari A., Rubini P., Alamanni F., et al. The radial artery: which place in coronary operation?. Ann Thorac Surg 2000;69:1288-1294.[Abstract/Free Full Text]
  8. Pym J., Brown P., Pearson M., et al. Right gastroepiploic-to-coronary artery bypass: the first decade of use. Circulation 1995;92(Suppl II):45-49.[Abstract/Free Full Text]
  9. Quigley R.L., Dienhart K.J., Pelkowski D.J., et al. Coronary artery bypass with "snake" grafts: fifteen-year follow-up. J Card Surg 1998;13:18-23.[Medline]
  10. Quigley R.L., Weiss S.J., Highbloom R.Y., et al. A low ejection fraction does not preclude total arterial revascularization on the beating heart. J Card Failure 2000;6(Suppl 2):41.
  11. Loop F.D., Lytle B.W., Cosgrove D.M., et al. Influence of the internal mammary artery graft on 10 year survival and other cardiac events. N Engl J Med 1986;314:1-6.[Medline]
  12. El-Nakadi B., Choghari C., Joris M. Complete myocardial revascularization with bilateral internal thoracic artery T graft. Ann Thorac Surg 2000;69:498-500.[Abstract/Free Full Text]
  13. Tector A.J., Amundsen S., Schmahl T.M., et al. Total revascularization with T grafts. Ann Thorac Surg 1994;57:33-39.[Abstract/Free Full Text]
  14. Barner H.B. Arterial grafting: techniques and conduits. Ann Thorac Surg 1998;66:S2-S5.[Abstract/Free Full Text]
  15. Sato T., Isomura T., Suma H. Coronary artery bypass grafting with gastroepiploic artery composite graft. Ann Thorac Surg 2000;69:65-69.[Abstract/Free Full Text]
  16. Delatore J.R., Theman T.E., Garzia F.M. Intraoperative flow rate measurements of T-grafts: calculating a flow reserve. Heart Surg Forum 1991;2:235-238.
  17. Quigley R.L., Davies C.T., Rupp M.D., et al. A modified thoracotomy for minimally invasive coronary artery bypass grafting. J Card Surg 1997;12:63-66.[Medline]
  18. Newman M.F., Kirchner J.L., Phillips-Bute B., et al. Longitudinal assessment of neurocognitive function after coronary artery bypass surgery. N Engl J Med 2001;344:395-402.[Medline]
  19. Katariya K., DeMarchena E., Bolooki H. Oral Amiodorone reduces incidence of postoperative atrial fibrillation. Ann Thorac Surg 1999;68:1599-1604.[Abstract/Free Full Text]
  20. Stamou S.C., Pfister A.J., Dangas G., et al. Beating heart versus conventional single-vessel re-operative coronary artery bypass. Ann Thorac Surg 2000;69:1383-1387.[Abstract/Free Full Text]



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