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Ann Thorac Surg 2002;73:798-802
© 2002 The Society of Thoracic Surgeons

Original article: cardiovascular

Conversion to off-pump coronary bypass without increased morbidity or change in practice

Ani C. Anyanwu, FRCSa, Sharif Al-Ruzzeh, FRCSa, Shane J. George, FRCAa, Rikin Patel, MRCSa, Sir Magdi H. Yacoub, FRSSa, Mohamed Amrani, MD, PhD*a

a Harefield Hospital, Uxbridge, United Kingdom

Accepted for publication October 15, 2001.

* Address reprint requests to Dr Amrani, Harefield Hospital, Uxbridge, Middlesex UB9 6JH, United Kingdom
e-mail: mr.amrani{at}rbh.nthames.nhs.uk


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. This article examines the feasibility of complete conversion from conventional coronary artery operation to routine off-pump coronary bypass operation.

Methods. Data on our first 285 off-pump procedures using the Octopus system (Medtronic Inc, Minneapolis, MN) represent our learning curve. This is a complete experience in coronary bypass surgery over 16 months.

Results. The cohort was nonselected. All patients had at least two-vessel disease. Eight hundred seven grafts were performed (mean, 2.8 per patient) of which 647 grafts (84%) were arterial (mean, 2.3 per patient). One hundred seventy nine patients (63%) underwent total arterial revascularization. Eight patients required cardiopulmonary bypass; all other operations were completed off-pump. Complications were: mortality, 3 patients (1.5%); renal failure, 24 patients (8%); stroke, 2 patients (< 1%); and atrial fibrillation, 60 patients (21%). The morbidity data and frequency of arterial grafting did not differ from that of 355 patients who underwent coronary bypass operations in a preceding 18-month period.

Conclusions. Complete shift from routine use of cardiopulmonary bypass to nonselective off-pump coronary bypass operation is possible with a low conversion rate and without an apparent increase in morbidity or change in technique. Whereas short-term safety and efficacy seem certain, studies of long-term outcome are necessary before the eventual role of off-pump coronary bypass in myocardial revascularization can be defined.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
It has been our view that minimally invasive coronary artery bypass graft (CABG) operations should allow revascularization of all coronary territories without compromising choice of conduit, number of bypass grafts, or other vital aspects of the procedure. Encouraged by the results of coworkers, we adopted the multivessel off-pump coronary artery bypass (OPCAB) technique in July 1999. This article describes the first 16 months of our OPCAB program and examines whether a complete shift from conventional CABG operations using cardiopulmonary bypass (CPB) to OPCAB operations are feasible without patient selection, without additional risk to patients, and without compromising the number or type of grafts performed (specifically a preference for arterial grafting).


   Material and methods
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 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
In the 18 months before July 1999 we performed 355 CABG procedures of which less than 3% were done without CPB; these were mainly single vessel minimally invasive direct coronary artery bypass (MIDCAB) procedures and occasional two-vessel bypass procedures, but did not involve the circumflex territory. After reviewing the literature on off-pump operations, visiting units and having discussions with coworkers at units practicing OPCAB operations, and after attending a training course, we completely shifted from our routine practice of using CPB for routine multivessel OPCAB operations in July 1999. Because we had some previous experience with beating heart operations involving the left anterior descending and right coronary arteries, our efforts were directed at developing the methods for off-pump circumflex revascularization. After the conversion date, our surgical strategy for all CABG procedures was to start the operation with a plan to perform OPCAB, yet maintain the same revascularization strategy that we would normally follow if the procedure were performed with CPB. There were no selection criteria; all patients accepted for CABGs were accepted for OPCAB operations. The only exception was with patients who required CPB for an additional procedure (such as the repair of a ventricular aneurysm). Informed consent was obtained from all patients. We reviewed all 285 patients who underwent CABG in the first 16 months of our OPCAB program. This represents an entire CABG experience by a single surgeon (M.A.) within the study period with the exception of single vessel MIDCAB procedures. Other surgeons within our institution predominantly used CPB with selective application of OPCAB. Referral practices were no different, and all surgeons operated on similar patients.

Operations were performed by median sternotomy initially using the Octopus 2 tissue stabilization system and then subsequently the Octopus 3 (Medtronic Inc, Minneapolis, MN). We prefer to perform the graft to the left anterior descending artery first and any circumflex grafts last. When a vessel was occluded and collateralized, we grafted the occluded vessel first. Deep pericardial verticalization sutures were used to aid circumflex exposure. Intracoronary shunts were selectively used in nonoccluded vessels. When intracoronary shunting was not used, the coronary artery was simply occluded distally and proximally using vascular bulldog clamps or occasionally plegetted 4-0 polypropylene snares. Shunts between the aorta and distal coronary artery or devices to improve right heart emptying were not used.

Our choice of conduits remained unchanged from our pre-OPCAB practice [1]. The left internal thoracic artery was the conduit of choice and was preferentially placed as a pedicle graft to the left anterior descending artery. The right internal thoracic artery preferentially was grafted to a circumflex artery as a pedicle through the transverse sinus. When the right internal thoracic artery was of insufficient length it was used as a free graft or connected as a pedicle to the left anterior descending artery (and the left internal thoracic artery was connected to the circumflex or used as a free graft to the circumflex). When use of a second internal thoracic artery was contraindicated (some insulin-dependent diabetics, previous radiotherapy, severe obstructive airway disease, or corticosteroid use), the radial artery was preferentially used for the circumflex graft. Otherwise the radial artery was placed on the right coronary system. No other arterial conduits were used. Sequential grafts or saphenous veins were used for additional grafts as required. The saphenous vein was also used if multiple arterial grafting was deemed to be of minimal marginal benefit (severe distal coronary artery disease, advanced age, and disease conditions limiting life-expectancy).

General anesthetic technique comprised low-intermediate dose opioid (usually fentanyl 8 to 15 µgkg-1) and a propofol infusion (3 mg/kg per hour). Some patients had thoracic epidural blockade using bupivicaine and fentanyl that was maintained for 24 to 72 hours postoperatively (depending on preference of the anesthesiologist). Standard intraoperative monitoring techniques were used. Additional monitoring was undertaken with transesophageal echocardiography. Pulmonary artery flotation catheters were not placed routinely. Heating mattresses and a warm airflow sheet on the lower half of the body were used to prevent excessive heat loss during the procedure. Anticoagulation was achieved using 150 units per kg of heparin. The activated clotting time was maintained at more than 250 seconds. Heparin was reversed with protamine at completion of the procedure. Cell-saving devices were not used routinely. Blood pressure was optimized during the procedure by means of repositioning the heart and selective use of vasoconstrictors. Other measures to improve cardiac output, such as elevation of feet and increasing the heart rate, were used as appropriate. Perfusionist standby was available for all patients. "Conversion" was defined strictly as the use of CPB at any stage during the treatment episode. For example, patients who arrested on induction of anesthesia, or who arrested on the intensive care unit and required CPB as part of resuscitative measure, would be classified as conversions. Patients who were converted at any stage during the operation (including prior to the onset of grafting) were also considered conversions. Criteria for intraoperative conversion to CPB were persistent hypotension (mean arterial blood pressure less than 50 mm Hg) ie, nonresponsive to pharmacological and surgical maneuvers and worsening arrhythmias related to ischemia.

Data were obtained from a prospective database held on all cardiac procedures done at our institution, with additional data obtained from a retrospective chart review. Comparisons were made with the pre-OPCAB practice of the same surgeon to ascertain if the practice changed with the adoption of off-pump CABG. Mortality was defined as in-hospital deaths and deaths within 30 days. Acute renal failure was defined as postoperative creatinine more than 2.0 mg per dL, regardless of need for dialysis; and stroke was defined as persistent or transient motor neurological deficit, regardless of cause.


   Results
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 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Patients
Demographic data and risk factor prevalence are shown in Table 1. Comparative data for patients in the immediate pre-OPCAB era are shown. In all patients there was a preoperative plan to graft at least two coronary vessels. A total of 807 grafts were performed in 285 patients (mean, 2.8 per patient) of which 647 grafts (80%) were arterial (mean, 2.3 per patient). One hundred seventy-nine patients (63%) underwent total arterial revascularization. In the pre-OPCAB cohort, 81 of 355 patients (23%) had total arterial revascularization; however the proportion of patients having total arterial revascularization was on the increase before we adopted OPCAB from less than 10% in early 1998 to 40% in mid 1999.


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  		Table 1. Patient Characteristics

 
Operative strategy
The left internal thoracic artery was used in 274 patients (96%), right internal thoracic artery in 119 patients (42%), a single radial artery in 199 patients (70%), bilateral radial arteries in 10 patients (3%), and saphenous vein in 106 patients (37%). Conduits used on the various coronary vessels are shown in Table 2. Thirty-eight sequential grafts were performed, so the number of anastomoses exceeds the number of conduits. All patients had at least one arterial graft. Eleven patients had a single bypass graft; these were not planned but resulted because other vessels were technically ungraftable. Of the 274 left internal thoracic artery grafts, 270 (99%) were used as pedicle grafts, whereas 113 of 119 (95%) of right internal thoracic artery grafts were pedicled. Forty-two (19%) radial grafts were constructed as Y-grafts off the left internal thoracic artery or off another radial graft, whereas the remaining grafts were attached to the aorta. All but five operations were first time cardiac procedures. The median operation time was 180 minutes (interquartile range, 140 to 215).


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  		Table 2. Conduits Used for the Various Coronary Vessels

 
Postoperative course
The median duration of postoperative ventilation was 5 hours (interquartile range, 3 to 9). Twenty-nine patients (10%) were extubated on the operating table and returned to intensive care breathing spontaneously. There were 3 deaths; 2 patients had adult respiratory distress syndrome develop as part of a multiorgan failure, and 1 patient died after mediastinitis. Postmortem results did not show any anastomotic failure in these patients; in 1 patient a vein graft to an obtuse marginal artery was thrombosed. Postoperative events are shown in Table 3 with data from the pre-OPCAB group shown for comparison. The median duration of hospitalization was 7 days (interquartile range, 6 to 8). Fourteen patients were discharged on postoperative day 4.


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  		Table 3. Complications

 
Conversions
Cardiopulmonary bypass was used in 8 patients (3%). These were patients number 1, 63, 74, 121, 125, 154, 160, and 190 in the sequence of the 285 operations. All these patients survived to discharge from hospital, although morbidity was high (Table 4). All patients remain alive and free of angina at last follow-up (range, 9 to 24 postoperative months). None of these patients have undergone coronary reintervention.


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  		Table 4. Conversions to Cardiopulmonary Bypass

 

   Comment
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 Abstract
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 Material and methods
 Results
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References
 
This relatively small population of patients representing our learning curve with the OPCAB technique show that complete conversion from conventional CABG operations using CPB to the routine application of OPCAB operations can be achieved without changing the revascularization practice. There were no clear detrimental effects to patients as morbidity rates were not higher than those we experienced in the pre-OPCAB era. We did not compromise our preferred operative strategy of arterial revascularization. We were able to maintain our preference for left-sided arterial grafting with 98% of the left anterior descending artery and 78% of circumflex grafts performed with arterial grafts. Of patients less than 70 years old (our target group for arterial grafting), 80% had total arterial revascularization. Therefore our early experience suggests that with appropriate training, the learning curve for OPCAB can be undertaken without major risk or change in practice.

To be a true alternative to conventional CABG operations OPCAB operations should permit the same range of revascularization techniques as is possible using CPB and should be applicable to the majority of patients requiring CABG operations. A desire to avoid CPB should not result in compromise on the optimal revascularization procedure. Several approaches to minimally invasive CABG operations have emerged, including compromise on the number of grafts performed [2, 3], MIDCAB approaches applicable only to single vessel territories, hybrid procedures combining angioplasty with MIDCAB [4], target vessel revascularization, and videoscopic techniques. Although these techniques are useful additions to the surgeon’s repertoire for treating coronary artery disease, they are not true minimally invasive alternatives to conventional CABG operations because they cannot be applied to the majority of patients requiring CABG operations without compromising the extent or quality of revascularization. These concerns previously limited our interest in minimally invasive CABG operations. However with the advent of improved methods of heart stabilization, such as suction devices [5], off-pump revascularization of all coronary territories can be reproducibly performed. We did not define any criteria to exclude patients from OPCAB operations and have successfully maintained our practice of arterial revascularization despite routine use of OPCAB operations, thus fulfilling our objective of a true alternative to conventional CABG operations.

Several pioneering coworkers have reported the use of OPCAB techniques for arterial grafting. For example, in Jansen and coworker’s series [6], 94% of 141 grafts were arterial; whereas Pym [7] used total arterial revascularization in 98% of 125 patients. However these studies differ from our series in which patients were selected from a larger group with the off-pump series representing less than 50% of their CABG practice. Most reports in the literature on off-pump CABG procedures suggest some form of patient selection and concern, either single-vessel MIDCAB or OPCAB operations utilizing saphenous veins for the majority of grafts. For example, Cartier’s [8] series of 275 patients reported a mean of 2.9 grafts per patient that included an average of 1.82 vein grafts per patient. Some groups have specifically defined criteria for selecting patients for OPCAB operations [9]. Our belief has been that for an OPCAB operation to be a practical and widely applied technique, patient selection should be minimal. The absence of patient selection in our series is reflected in the average number of grafts per patient, mean age, and proportion of patients with impaired ventricular function, which mirrors that reported in the United Kingdom cardiac surgery registry [10]. This figure was also similar to that reported by Cartier [8] who also used the OPCAB procedure systematically for the majority (97%) of procedures. Patient selection or altered practice is evident in several published series as reflected by the lower number of anastomoses performed per patient (less than 2 per patient in some series). There is a concern that a bid to pursue OPCAB operations increases the rate of incomplete revascularization [11]. Recent evidence suggests that incomplete revascularization predisposes lower long-term survival and higher rates of reintervention [12]; if an OPCAB operation is applied it remains vital that complete revascularization is not compromised.

Even with strict definitions, our conversion rate was low (3%). We used a strict definition because it is the frequency of use of CPB in routine CABG operation practice that will determine the extent to which OPCAB operations can replace conventional CABG operations as the standard technique (assuming future studies do confirm OPCAB procedures are safe and have equivalent graft patency). If conversion rates of 1% or less can be achieved, then perfusionist standby may not be required for all patients, or alternatively, it may be possible to have a single perfusionist covering two or more concurrent procedures. Indeed, even at a conversion rate of 3%, the probability that 2 patients would need CPB simultaneously is 1 in 1,000; this would have large cost-saving implications, and it would also open up the possibility of selected CABG procedures being conducted in community hospitals with minimal perfusionist support. However we did note a high incidence of complications in the patients who required CPB. Although it is possible that these may have occurred even if the procedures were planned as on-pump (six of the eight conversions involved scenarios that also occur in patients having conventional CABG operations), we would caution against routine application of OPCAB operations if the intraoperative conversion rate is high because invariably there would have been undue insult to the heart and possibly other major organs, which may predispose to later morbidity and mortality.

We do not attempt to demonstrate superiority (or equivalence) of the OPCAB technique over conventional CABG operations, because to do so requires a controlled study, preferably randomized. Our study is limited by lack of medium-term follow-up and angiographic data. As part of our quality control, we performed early angiograms in 6 of the first 15 OPCAB patients and did not find any anastomotic failures. Further angiograms were not feasible in this cohort. Available evidence does however suggest that off-pump coronary artery operations generally yield early patency rates of 90% or more [13]. Longer follow-up is needed to determine if OPCAB operations have graft patency and recurrent cardiac event-free rates similar to those seen with conventional CABG operations. Any short-term benefits of avoiding CPB will only be relevant if OPCAB operations have similar long-term success compared with conventional CABG operations. Although there are suggestions of several short-term procedural benefits of OPCAB operations, such as early extubation, shorter intensive care, reduced blood use, and shorter hospital stay [14–17], these benefits are not inherent in the OPCAB technique and can also be achieved with conventional CABG operations using modern management protocols. A reduction in short-term complications and a reduction in cost [18] will be the main arguments for adopting the OPCAB technique. Future studies will define the eventual role of OPCAB operations in coronary artery revascularization.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Anyanwu A.C., Saeed I., Bustami M., Ilsley C., Yacoub M.H., Amrani M. Does routine use of the radial artery increase complexity or morbidity of coronary bypass surgery?. Ann Thorac Surg 2001;71:555-559.[Abstract/Free Full Text]
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  4. Riess F.C., Schofer J., Kremer P., et al. Beating heart operations including hybrid revascularization: initial experiences. Ann Thorac Surg 1998;66:1076-1081.[Abstract/Free Full Text]
  5. Jansen E.W., Grundeman P.F., Mansvelt B.H., Heijmen R.H., Borst C. Experimental off-pump grafting of a circumflex branch via sternotomy using a suction device. Ann Thorac Surg 1997;63:S93-S96.
  6. Jansen E.W., Borst C., Lahpor J.R., et al. Coronary artery bypass grafting without cardiopulmonary bypass using the octopus method: results in the first one hundred patients. J Thorac Cardiovasc Surg 1998;116:60-67.[Abstract/Free Full Text]
  7. Pym J. Off-pump arterial grafting: 125 cases using the Medtronic-Utrecht Octopus. Eur J Cardiothorac Surg 1999;16(Suppl 1):S88-S94.[Medline]
  8. Cartier R. Systematic off-pump coronary artery revascularization: experience of 275 cases. Ann Thorac Surg 1999;68:1494-1497.[Abstract/Free Full Text]
  9. Diegeler A., Matin M., Falk V., et al. Indication and patient selection in minimally invasive and off-pump coronary artery bypass grafting. Eur J Cardiothorac Surg 1999;16(Suppl 1):S79-S82.[Medline]
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