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Ann Thorac Surg 2001;72:S1026-S1032
© 2001 The Society of Thoracic Surgeons

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Supplement: Cardiothoracic techniques and technologies

Further reduction in stroke after off-pump coronary artery bypass grafting: a 10-year experience

^a Escorts Heart Institute and Research Centre, New Delhi, India

Address reprint requests to Dr Mishra, Escorts Heart Institute and Research Centre, Okhla Rd, New Delhi 110025, India
e-mail: manishamishra{at}yahoo.com

Presented at the Seventh Annual Cardiothoracic Techniques and Technologies Meeting 2001, New Orleans, LA, Jan 24–27, 2001.

	Abstract

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Background. Perioperative stroke is a devastating complication after coronary artery bypass grafting (CABG). The reported incidence of neurologic complications after conventional CABG is 3% to 7%. With improved monitoring and surgical techniques, we have been able to achieve a drastic reduction in the stroke rate in our institution. This study evaluates the incidence of neurologic sequelae in patients who underwent off-pump CABG.

Methods. Over a 10-year period from January 1990 to September 2000, off-pump coronary artery bypass (OPCAB) operation was performed on 2,800 patients of the 18,037 patients undergoing CABG during that time frame at the Escorts Heart Institute and Research Centre. Initially, OPCAB was performed selectively in the high-risk group of patients (atheromatous aorta, renal impairment, chronic obstructive pulmonary disease, octogenarians, etc). Lately we performed multivessel OPCABs electively in about 60% to 65% of the patients undergoing CABG.

Results. Mean age of the patients was 58.0 ± 9.91 years (range 27 to 85 years) and mean number of grafts was 2.9 per patient. Neurologic complications (stroke/transient ischemic attack) occurred in 0.14% of patients. Overall hospital mortality in OPCAB patients was 2.14%, whereas mortality from neurologic complications was 0.07%. Predicted mortality (National Society of Thoracic Surgeons Cardiac Surgery Database Risk Model for CABG) for the entire patient group was 3.86% (p < 0.001).

Conclusions. Although current techniques of monitoring and surgical procedures have significantly reduced the risk of stroke from CABG, our data strongly support OPCAB as a technique to further reduce stroke after CABG, especially in the high-risk group of patients.

	Introduction

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Perioperative stroke is a devastating complication after cardiac surgical procedures. The current evolution in concepts for improving patient comfort and outcomes through minimally invasive operation, be it port access, minimally invasive direct coronary artery bypass grafting (MIDCABG), off-pump coronary artery bypass (OPCAB), or robotics, holds great promise. Recent advances in cardiopulmonary bypass (CPB) also represent examples of innovative thinking. Nevertheless, any medical device as maximally invasive as artificial breathing and circulation necessarily has some side effects. The complications of CPB have been well documented and include possible microembolization, hypoperfusion, and systemic inflammatory response syndrome. In a study, Murkin and Stump [1] showed that 33% of patients had neurocognitive deficits and 22% continued to show significant dysfunction at 2 months’ follow-up after coronary artery bypass grafting (CABG) with CPB. Recognizing that CPB is linked to side effects that include neurologic injury, researchers have suggested that avoidance of CPB is the solution. For many patients, fixing CPB, not nixing it, is a more rational approach to improve neurologic outcomes after cardiac operations [1].

A number of risk factors for the development of stroke in patients undergoing CABG have been identified [2, 3]. Extensive arteriosclerosis of aortic arch and associated carotid artery disease are associated with a high incidence of stroke [4–6]. Prophylactic carotid endarterectomy (CEA) in patients with high-grade or bilateral disease may reduce the incidence of perioperative stroke as suggested by Faggioli and associates [7], and by our group [8]. Katz and colleagues [9] highlighted the significance of aorta as a source of atheroemboli and as a risk factor for perioperative stroke, which was 25% among patients with mobile plaques of aortic arch. Although carotid artery stenosis is frequently associated with severe aortic arteriosclerosis, it has a positive predictive value of only between 16% and 57% [10].

The availability of intraoperative transesophageal echocardiography to image the thoracic aorta and preoperative carotid artery Duplex scanning provide the opportunity to determine the prevalence of these two conditions in patients undergoing CABG, and to formulate individualized surgical strategies based on these findings with the goal of reducing the incidence of neurologic injury in this high-risk patient population. In the present study we retrospectively evaluated the neurologic sequelae in patients undergoing OPCAB over a period of 10 years.

	Material and methods

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Patients
Between January 1990 and September 2000, 18,037 patients underwent CABG, of which 2,800 patients had off-pump procedures at the Escorts Heart Institute and Research Centre. Initially, OPCAB was performed selectively in the high-risk group of patients (atheromatous aorta renal impairment, chronic obstructive pulmonary disease, octogenarians, etc). Lately, we have been performing multivessel OPCAB electively in about 60% to 65% of the patients undergoing CABG. Carotid Doppler was performed in all patients scheduled for CABG. Transesophageal echocardiography was carried out according to our previously described protocol [8]. In patients in whom the ascending aorta felt hard on gentle palpation, epiaortic scanning using a sterile handheld echoprobe was performed.

The risk factors for a specific patient were entered into the logistic risk model of National Society of Thoracic Surgeons (STS) Cardiac Surgery Database Risk Model for CABG [11] and the mathematical calculations were carried out to yield the predicted probability of operative mortality for that patient.

Surgical strategy
The various off-pump CABG techniques we used can be subdivided into three major categories: minimally invasive techniques; OPCAB through a midsternotomy; and transmyocardial laser revascularization (TMLR) along with OPCAB.

Minimally invasive direct coronary artery bypass grafting
This is a technique in which, through small incisions and without full sternotomy, conduits are harvested and anastomosed to the target vessel without CPB. Thus, sternotomy and CPB both are avoided. We have performed MIDCABG through several approaches, for example, anterior thoracotomy, left lateral thoracotomy, ministernotomy, and suxiphoid approach.

Off-pump coronary artery bypass grafting
Multivessel CABG is performed through midsternotomy without CPB. If the ascending aorta is normal then the proximal anastomosis is constructed on the ascending aorta. In the case of atheromatous aortas, proximal anastomosis is avoided. The internal mammary artery, gastroepiploic artery, radial artery, or reversed saphenous vein grafts are used in the form of T grafts and sequential anastomoses. The area on the left anterior descending coronary artery (LAD) is stabilized for distal anastomosis with either CTS (Cardiothoracic Systems Inc) Octopus II tissue stabilizer or Genzyme stabilizer (Genzyme Surgical Products). An oxygen blower is used for providing a bloodless field. The blowing is done at low oxygen flow rates of 3 to 4 L to avoid barotrauma to the coronary endothelium or internal mammary artery intima. Normal saline is sprayed over the coronary endothelium and internal mammary artery to avoid drying. The mammary to coronary anastomosis is performed with running 7-0 or 8-0 polypropylene suture.

The obtuse marginal arteries are also bypassed in similar fashion except that deep pericardial sutures are used to rotate the heart and an extensive right pleurotomy along with the deep vertical right pericardiotomy is done to facilitate cardiac herniation into the right pleural cavity. Stabilization is always obtained by the Octopus II tissue stabilizer.

Similarly, the right coronary anastomosis is also performed. The RCA anastomosis is associated with more frequent and marked hemodynamic and electro cardiographic changes, so an intracoronary shunt is usually used to maintain the distal perfusion during the anastomosis.

Another technique was OPCAB with right heart support (Enabler). Multivessel CABG requires displacement of the heart, and performing this procedure on the beating heart causes severe hemodynamic instability. The Enabler pump (HemoDynamics Systems Ltd, Israel) is a catheter pump designed to expel blood from the right atrium to the pulmonary artery in a pulsatile flow pattern. The heart is displaced to expose LAD, while the left circumflex artery and right coronary artery are stabilized using the Octopus II Stabilizer. The anastomoses are performed in the usual manner using 7-0 or 8-0 polypropylene sutures.

Transmyocardial laser revascularization along with off-pump coronary artery bypass
Patients may have one or two graftable coronary arteries along with diffuse disease in the other coronary branches that precludes total myocardial revascularization by CABG. In these situations we combined OPCAB with TMLR through a minimally invasive approach or through a standard median sternotomy. Our indications for TMLR combined with OPCAB have been described earlier [12].

	Results

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The preoperative demographic profile of the study group is presented in Table 1. The mean age of the patients was 58.0 ± 9.91 years (range 27 to 85 years). There were 2,383 men (85.10%) and 417 women (14.9%). In the series of 2,800 patients, 54.28% had unstable angina, 42.78% were hypertensive, and 54.5% were diabetic. In the high-risk group of patients, 30.57% had chronic obstructive pulmonary disease and 13.9% had renal dysfunction. The prevalence of peripheral vascular disease and cerebrovascular disease was 2.32% and 2.4%, respectively.

Table 2 elaborates the angiographic profile of the patients. A left ventricular ejection fraction of less than 0.30 was noted in 15.28% of the patients. The prevalence of left main coronary artery disease was 6.71%. A total of 26.4% of the patients had significant disease in one coronary artery system (single-vessel disease), 31.28% had significant disease in two coronary artery systems (double-vessel disease), and 42.32% had triple-vessel disease.

Initially we performed OPCABs in high-risk patients but lately we are electively performing it in 60% to 65% of the patients undergoing CABG (Fig 1). The spectrum of techniques of minimally invasive operation performed in our study group is presented in Table 4, and the indications are given in Table 5.

View larger version (18K): [in this window] [in a new window]   Fig 1. Comparative growth of off-pump coronary artery bypass grafting over 10 years (1990 until September 2000). n = 18,037. (CCABG = conventional coronary artery bypass grafting; OPCAB = off-pump coronary artery bypass.)

Off-pump coronary artery bypass through median sternotomy was performed in 1,559 patients. Multivessel OPCAB was performed in 1,433, whereas 22 patients underwent OPCAB with right heart bypass (Enabler). Off-pump coronary artery bypass was combined with TMLR in 104 patients.

Table 6 shows the postoperative course and complications. The mean hospital stay was 6.8 ± 1.3 days, whereas the average intensive care unit stay was 41 ± 11.4 hours. Blood transfusion was required in 19.28% of the patients. Reexploration rate was 1.10%. Renal dysfunction developed in 5.28% of the patients. Perioperative myocardial infarction occurred in 1.07% of the patients. Ventricular arrhythmia requiring antiarrhythmic drug therapy was noted in 1.10%. Prolonged ventilation was needed in 1.07% of the patients, of whom 0.64% underwent tracheostomy.

Table 8 shows the various causes of mortality in this group of 2,800 patients. Cardiac causes were responsible for 19 deaths. Renal failure was the cause of death in 9 patients. Seven patients died of respiratory failure. Multiorgan failure was responsible for 23 deaths. Thus the overall hospital mortality was 2.14%, although predicted mortality was 3.86% by National STS Cardiac Surgery Database Risk Model for CABG (p < 0.001) [11].

	Comment

Top Abstract Introduction Material and methods Results Comment References

Progress in the development of therapeutic and preventive strategies with respect to cerebral injury during CABG depends on an increased understanding of the mechanisms involved. This is a continuous thought process. At present, the best strategy is optimizing cerebral perfusion and minimizing in macroembolic and microembolic damage.

In a recent collective review of more than 35,000 patients, the stroke rate ranged from 0.9% to 3.9% after isolated CABG, with a mean stroke rate of 2%. The mortality from stroke in this review was 13% to 25% [13]. The overall stroke rate in our present series was 0.14% with OPCABs, even less than our previous series [8, 14], which had stroke rates of 0.76% and 0.96%, respectively. In another report, neurologic complications occurred in 1 of 82 OPCABs (1.22%) and 11 of 129 CABGs (8.53%) on pump [15].

We have developed elaborate screening techniques to detect preoperatively and intraoperatively some of the known lesions and factors that may cause perioperative stroke [8, 16], although we do not use transcranial Doppler. For example, the incidence of aortic arteriosclerosis increases with age [17]. The distribution of aortic arteriosclerosis has an important bearing on the safety of CABG. Autopsy study of 1,486 patients by Sternby [18] showed severe atherosclerotic disease more commonly located in the aortic arch and descending thoracic aorta. Ulcerations are seen four to five times more frequently in the descending aorta and aortic arch.

Iaco and associates [19] published a comparison of 472 OPCAB patients with 290 conventional CABG patients. They reported that mortality rates and incidence of cerebrovascular accidents were similar in both the groups. Similarly, Kshettry and colleagues [20] presented a series of 744 patients undergoing elective CABG with at least three distal anastomoses. Of these patients, 609 underwent conventional CABG, whereas 135 underwent OPCAB. Both groups had a 2% incidence of permanent stroke, which is much higher than the stroke rate in the present study.

Most of the above-mentioned studies demonstrate that the expected improvement in neurologic outcomes has not been realized. In part this may reflect the hemodynamic changes and decreases in cerebral perfusion that are seen during OPCAB, as greater degrees of myocardial dislocation become necessary for more extensive myocardial revascularization [21]. Maneuvers such as steep Trendelenburg position to perform anastomosis on the posterior wall have been shown to increase jugular venous pressure, potentially compromising cerebral blood flow [1]. This may also be because beating heart procedures have not yet addressed one of the primary causes of neurologic injury after cardiac operation. Today most beating heart operations are done as OPCAB. Yet the literature has repeatedly demonstrated that clamp application and removal is the greatest generator of embolic activity during the operation and that the release of emboli is closely linked to subsequent adverse neurologic outcomes. In a series of studies by Barbut and associates [22], more than 58% of the emboli generated during cardiac operations occurred during clamp manipulation of the ascending aorta. This was not the case in our study because great precision and care was taken during the handling of the ascending aorta.

The embolic potential of severe atherosclerotic disease has been documented in clinical and autopsy studies [15, 17]. In our series of 2,800 patients, 4 patients had neurologic injury. Coronary artery bypass grafting in patients with aortic atheromatous disease is a great surgical challenge. Various technical and strategic modifications have taken place in the last few years with the hope of a permanent solution in the new millennium. Strategies that have been used range from the minimally invasive to the maximally invasive to the various combination modalities. The procedure can be planned and individualized for each patient depending on the coronary anatomy, the location and extent of aortic arteriosclerosis, and associated systemic disorders. At present, all patients with proximal arch atheromas and grade III distal arch atheroma undergo OPCAB. Off-pump coronary artery bypass is a promising technique to tackle this problem. It offers the major advantage that, in addition to not applying the aortic cross-clamp, the damaging effects of CPB to the brain are avoided [23].

The operative mortality in our series was 2.14%, which is acceptable considering most of the patients were in the high-risk category. Predicted mortality as per National STS Cardiac Surgery Database Risk Model for CABG for the entire patient group was 3.86%. This difference between the actual and predicted mortality assumed statistical significance (p < 0.001). A large proportion of our patients were elderly and operative mortality is known to increase with age [17]. Subramanian and coworkers [24] reported an operative mortality of 3.8% in their study of MIDCABG. Cartier and colleagues [25] reported an operative mortality of 1.3% for OPCAB in 300 patients. A significant number of deaths (43.3%) in our series was related to patients having severe cardiac dysfunction (left ventricular ejection fraction < 0.25); 12 patients had a history of malignant ventricular arrhythmia who continued to have the same despite antiarrhythmic agents, intraaortic balloon pump, and adequate myocardial revascularization. Five patients died who had recent myocardial infarction (less than 7 days’ duration). Of these, 3 had massive anteroseptal infarction and 2 had inferior infarct.

To summarize, although over the years we have been able to reduce the incidence of stroke substantially in patients undergoing CABG on CPB by use of better screening techniques and individualized surgical approaches, our present study strongly supports OPCAB as a technique that can further reduce stroke after CABG, especially in high-risk patients.

	References

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This Article Abstract Full Text (PDF) 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): Naresh Trehan Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Trehan, N. Articles by Kasliwal, R. R. Search for Related Content PubMed PubMed Citation Articles by Trehan, N. Articles by Kasliwal, R. R. Related Collections Minimally invasive surgery