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Ann Thorac Surg 2001;72:2013-2019
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Off-pump coronary artery bypass grafting for elderly patients

^a Department of Cardiovascular Surgery, Kobari General Hospital, Chiba, Japan
^b Department of Cardiovascular Surgery, Shin-Tokyo Hospital, Chiba, Japan

Accepted for publication July 20, 2001.

* Address reprint requests to Dr Hirose, Department of Cardiovascular Surgery, Kobari General Hospital, 29-1 Yokouchi, Noda City, Chiba, 278-8501, Japan
e-mail: genex{at}nifty.com

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. The use of off-pump coronary artery bypass grafting (CABG) has recently become widespread, and it has been proven to be less invasive and to facilitate early recovery. In this study, we investigated the efficacy of off-pump CABG for patients aged 75 years or more.

Methods. A retrospective chart review was carried out for patients who underwent isolated off-pump and on-pump CABG at Shin-Tokyo Hospital between January 1997 and December 2000. The patients’ demographic, operative data, and postoperative results were collected.

Results. The off-pump group consisted of 60 men and 44 women with a mean age of 78.8 years, and the on-pump group consisted of 54 men and 20 women with a mean age of 77.6 years. Distal anastomoses were significantly fewer in the off-pump group (2.4 in off-pump group versus 3.7 in on-pump group), but total arterial bypass was more frequently achieved in off-pump group (82.7% versus 25.7%). Intubation time (8.4 versus 18.4 hours), intensive care unit stay (2.2 versus 3.5 days), and postoperative stay (13.8 versus 20.0 days) were significantly shorter in the off-pump group than in the on-pump group (p < 0.05). The frequency of the occurrence of major complications was significantly lower in the off-pump group than the on-pump group, especially in regard to postoperative stroke and respiratory failure (p < 0.05). Multivariate analysis showed that off-pump CABG significantly reduced patient recovery period and the incidence of postoperative complications. Early follow-up results, cardiac event-free and survival rates, did not significantly differ between the two groups.

Conclusions. Off-pump CABG is safe for the elderly patient. Off-pump CABG successfully facilitates early recovery and reduces the incidence of postoperative complications among elderly patients.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
The elderly population has been increasing in Western countries as well as in Japan. Coronary artery bypass grafting (CABG) for the elderly patient carries significant operative risks, and we previously reported the results of CABG for elderly patients [1]. Recently, the use of off-pump CABG has become widespread and it has proven to be less invasive [2]. To minimize operative mortality and morbidity, off-pump CABG has been utilized for the past 3 years in our institution. In this study, we retrospectively analyzed the inhospital and early follow-up data of the patients who underwent off-pump CABG at Shin-Tokyo Hospital, focusing on patients aged 75 years or more, and compared the findings with the results of patients in the same age group who underwent conventional on-pump CABG.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Between January 1, 1997, and December 31, 2000, a total of 1,095 patients underwent isolated CABG at Shin-Tokyo Hospital. Among them, 178 patients (16.3%) were aged 75 or older. The patients were divided into two groups according to the use of cardiopulmonary bypass (CPB) during the CABG. The off-pump group consisted of 104 patients (60 men and 44 women, mean age of 78.8 years) and the on-pump group consisted of 74 patients (54 men and 20 women, mean age of 77.6 years). Their medical records were retrospectively reviewed, and the following information was collected; patient age, sex, results of preoperative angiography, cardiac profiles, preoperative risk factors, graft materials, surgical data, postoperative complications, and mortalities. Definitions of the preoperative risk factors and postoperative complications were made according to The Society of Thoracic Surgeons criteria. Major complications were defined as life-threatening complications such as low output syndrome, postoperative myocardial infarction, postoperative stroke, mediastinitis, reexploration for bleeding, pneumonia, respiratory failure requiring reintubation or ventilator support for more than 5 days, and hemodialysis. Patients who had undergone valvular surgery, left ventricular surgery, or surgery related to other vascular or major general surgery procedures were excluded from the study. Remote cardiac events included angina recurrence, percutaneous transluminal coronary angioplasty (PTCA), congestive heart failure requiring admission, arrhythmia requiring admission, and sudden death.

We described the methods of conventional on-pump and off-pump CABG in our previous report [2]. Briefly, CPB for on-pump CABG was run at normothermia (36°C) and cardioplegia was given antegradely or retrogradely, or both, to achieve cardiac arrest. It was our hospital policy not to use general hypothermia or topical cooling for isolated CABG. Off-pump CABG was performed in two different ways: the first was minimally invasive direct coronary artery bypass (MIDCAB), which was approached through a left fourth or fifth intercostal small thoracotomy and allowed us to bypass the left anterior descending artery (LAD) with the left internal mammary artery (LIMA), with the heart beating; the other was off-pump CABG through midsternotomy (OPCAB), which was approached through midline sternotomy and allowed us to perform single or multivessel revascularization. In selected cases, an intracoronary shunt-tube was used to maintain distal perfusion during anastomosis. As mentioned in our previous report, we used different types of coronary stabilizer to perform OPCAB [2]. Before February 28, 1999, a compression device (Ring system; US Surgical, Norwalk, CT) was used for local coronary stabilization. The utility of this first generation of coronary stabilizing system was limited to the anterior surface of the heart and the procedure to the left circumflex artery (LCX) area was extremely restricted. After March 1, 1999, a second generation of stabilizer (suction device, Octopus-2; Medtronic, Minneapolis, MN) was used in our institute. The suction device, combined with the use of the retropericardial sutures, allowed us to perform bypass grafting on any surface of the heart while the heart was beating [3].

Postoperative angiography was performed in patients with normal renal function with the patient’s consent. In the off-pump group, angiography was systematically performed to verify the quality of anastomoses. In the on-pump group, angiography was performed if the quality of native coronary arteries was poor or if it was requested by the referring cardiologists.

Statistical analyses were performed using Student’s t tests for continuous variables or ² tests (Fisher’s exact tests if n < 5) for categorical variables. Results were expressed as the mean ± SD. Postoperative patient survival and event-free rates were calculated using the Kaplan-Meier method and compared using the Mantel-Cox log rank tests. A p value less than 0.05 was considered significant. Relative risk (RR) was calculated by logistic regression analysis and expressed with 95% confidence interval (CI). Since mean intubation period, intensive care unit (ICU) stay, and postoperative stay for young (age 75) patients in our previous study [1] were 12 hours, 3 days, and 18 days, respectively, a prolonged intubation period, ICU stay, and postoperative stay were defined as longer than 12 hours, 2 days, and 18 days, respectively. Significant variables by univariate comparisons were further analyzed by multivariate logistic regression analysis. All statistical analyses were performed using Statview version 5.0 (SAS Institute, Cary, NC).

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
The preoperative data for each group are shown in Table 1. Patients with three-vessel disease were more often treated by on-pump CABG, but the frequencies of emergent or redo surgery, coronary risk factors, and coexisting medical problems were equally distributed.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
The most important concern of cardiologists who refer patients with angina to surgery is surgical mortality and morbidity as well as long-term freedom from cardiac events. Elderly patients usually have numerous medical problems such as a history of stroke, renal dysfunction, chronic pulmonary disease, and advanced arteriosclerosis, all of which are known risk factors for CPB. Conventional on-pump CABG requires aortic cannulation, which may result in distal emboli or perioperative stroke [4]. Fluid volume in the CPB circuit might increase the risk of fluid overload and dilutional anemia [5]. Prolonged CPB time has also been reported to affect adversely postoperative outcomes in elderly patients [6–8]. Off-pump CABG does not require CPB, however, and is free of the risks related to CPB. Our surgical results showed a decreased frequency of postoperative stroke and respiratory failure when the use of CPB was avoided, as previously reported by Buffolo and coworkers [9]. At our institute we use normothermia for on-pump bypass, which may have potentially biased the comparison in favor of the off-pump group. During the 4 years of this study, there were no changes in anesthesia method or the extubation criteria. The multivariate analysis showed that off-pump CABG was one of the independent factors that contributed to reduce the recovery time and postoperative complication. In the off-pump group, intubation time was shortened to less than half, and ICU stay and postoperative length of stay was also shortened by two thirds, compared with the on-pump group.

The complication rates of off-pump CABG in our series were comparable with previous results of PTCA for the elderly. Owing to the presence of advanced arteriosclerosis, coronary calcification, and totally occluded vessels, which are frequently encountered in the elderly, the clinical success rates of PTCA for this patient group were between 80% and 93% and their procedural mortality rates were between 1.0% and 8.5% [10–13]. The reported 1-year event-free rate after PTCA was 81% to 89%, which was attributed to restenoses of the coronary artery [10, 13]. Our early follow-up results in patients after off-pump CABG showed 1-year event-free rates of 98.6% and excellent short-term graft patency rates, although these figures could not be compared directly.

A single LAD lesion is the best candidate for MIDCAB. Single-vessel disease can be treated by PTCA; however, considering the relatively high restenosis rate [10, 13] once PTCA has failed, the restenosis lesion should be revascularized surgically. Palliative MIDCAB has been also performed especially in elderly patients [14]. Protecting the LAD by the LIMA will reduce the risk of PTCA to other coronary lesions. There were no incidences of MIDCAB failure, conversion to median sternotomy, or CPB assist during our study. Among 24 patients undergoing MIDCAB, 15 patients (62.5%) underwent postoperative angiography, with only one incidence of anastomosis stenosis observed. In the MIDCAB group, the mean intubation time was 5.3 ± 1.3 hours, ICU stay was 1.4 ± 0.7 days, and postoperative stay was 10.1 ± 3.9 days. There was only one procedure-related complication, wound dehiscence, in the MIDCAB group. Postoperative recovery period in the MIDCAB group was less than half that of the on-pump group. However, the limitations of MIDCAB are also evident; through the small operative field provided by the MIDCAB incision only single-vessel revascularization can be performed. Thus patients requiring multivessel revascularization should undergo OPCAB or conventional on-pump CABG.

Compared with MIDCAB, OPCAB (off-pump CABG through median sternotomy) offers a wider operative field, which may provide possible options for aortocoronary bypass in addition to in-situ bypass and the possibility of multivessel revascularization. The relative contraindications to off-pump CABG, in our institute, are intramyocardial coronary artery or severely calcified coronary artery [15]. We considered that denudation of the deeply buried coronary artery while the heart is beating is not safe and carries a risk of free wall perforation. Bypass to the LCX area is no longer a contraindication to off-pump CABG under the current stabilizing system: 44 (64.7%) of 68 patients underwent LCX bypass using a suction device, whereas 3 (25%) of 12 patients underwent LCX bypass using a compression device. The first generation of compression stabilizer decreased venous return while it was being applied to the posterior wall of the heart and the hemodynamics became unstable; thus patients requiring bypass to the LCX were previously referred for on-pump bypass. Using the suction device, however, an off-pump operation can be safely performed for these patients. The complete revascularization rate also improved from 50% with the compression device to 79% with the suction device. On-pump bypass now is primarily chosen only if intracardiac manipulation such as valvular repair or left ventricular surgery is required.

The number of distal anastomoses in the off-pump group was significantly fewer than in the on-pump group, which could be one of the disadvantage of off-pump CABG even using the new coronary stabilizing system. Patients who underwent incomplete revascularization had severe preoperative complications and their activity of daily life was limited owing to noncardiac reasons such as osteoartheritis, prior cerebral vascular accident, or dementia. The purpose of surgery for these elderly patients with limited activity is control of angina with minimum operative risks. In these cases, we chose off-pump CABG to avoid the risk of cardiopulmonary bypass. The cardiopulmonary bypass may enhance inflammatory responses and bleeding tendency, and manipulation of the aorta during cannulation for cardiopulmonary bypass and clamping of the aorta may lead to embolic phenomena, resulting in serious neurologic and other organ injury. These cases should be carefully selected and the level of procedural complication should be as low as possible. Before the era of off-pump CABG, these high-risk patients were not referred to surgery because of the risk of cardiopulmonary bypass itself but now they can be treated safely by off-pump CABG. The key issue for the high-risk patient is minimizing the invasiveness of surgery. Full revascularization would be ideal, but for these particular patients, limited revascularization to the culprit lesions and the LAD is usually sufficient for relief of angina and to prevent cardiac death. Therefore we consider that incomplete revascularization as a palliative operation may be an acceptable procedure of choice for this high-risk patient group.

In our practice, arterial conduits were used as much as possible, expecting superior long-term graft patency compared with venous conduits [16]. The selection of the graft was as follows: the LIMA or RIMA should be used for bypass of the LAD. The LCX was bypassed with the LIMA or the radial artery. The right coronary artery was bypassed with the gastroepiploic artery. If further bypass was required, the saphenous vein was harvested. Fewer grafts were performed in the off-pump CABG group than in the on-pump CABG group; however, the use of the arterial conduits in the off-pump CABG group was significantly more frequent than in the on-pump CABG group.

The early results of off-pump CABG were favorable. Multivariate analysis showed that off-pump CABG reduced the chance of transfusion and major complications, especially respiratory failure and stroke, and shortened postoperative recovery in elderly patients. Supported by the initial good results using off-pump CABG, the percentage of patients 75 years and older undergoing off-pump CABG gradually increased: 15% in 1997, 33% in 1998, 84% in 1999, and 93% in 2000. Moreover, off-pump CABG has recently become the standard method of choice for performing isolated CABG.

During the limited follow-up period in our study, the outpatient results, cardiac event-free and survival rates, were not significantly different between on-pump and off-pump groups. The reported disadvantages of off-pump CABG—fewer distal anastomoses and frequent incomplete revascularization, resulting in increase of cardiac events—were not evident during our short follow-up period. Further follow-up is necessary to determine the long-term outcomes.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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