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Ann Thorac Surg 2002;74:S1377-S1382
© 2002 The Society of Thoracic Surgeons

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Supplement: Cardiothoracic Techniques and Technologies

Off-pump coronary artery bypass with complete avoidance of aortic manipulation

^a Department of Thoracic and Cardiovascular Surgery, and Department of Anesthesiology, Clinical Research Institute, Seoul National University Hospital, Seoul, South Korea

* Address reprint requests to Dr Kim, Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, 28 Yeun-Kun Dong, Chong-Ro Ku, Seoul 110-744 South Korea.
e-mail: kimkb{at}snu.ac.kr

Presented at the Eighth Annual Cardiothoracic Techniques and Technologies Meeting 2002, Miami Beach, FL, Jan 23–26, 2002.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
BACKGROUND: Off-pump coronary artery bypass (OPCAB) with complete avoidance of aortic manipulation may further reduce perioperative morbidity in addition to the benefits achieved by avoiding cardiopulmonary bypass and cardioplegic arrest.

METHODS: We prospectively analyzed 222 consecutive patients with multivessel disease who underwent OPCAB without aortic manipulation (group I), and compared them with 123 consecutive patients who underwent OPCAB using additional free arterial or saphenous vein grafts that were anastomosed on the ascending aorta (group II) and 76 consecutive patients who underwent on-pump conventional coronary artery bypass grafting (group III).

RESULTS: No significant differences were noted in operative mortalities among the three groups (2/222, 3/123, and 2/76 in groups I, II, and III, respectively; p = NS). Fewer distal anastomoses were done in group I compared with groups II and III (3.2 ± 0.9, 3.5 ± 0.8, and 3.7 ± 0.9 in groups I, II, and III, respectively; p < 0.001). No differences were noted in the incidences of postoperative morbidities such as mediastinitis, pulmonary complication, and reoperation for bleeding. The incidences of stroke, atrial fibrillation, and acute renal failure were significantly lower in group I than in group III (p < 0.05), although there were no significant differences between groups II and III. The incidence of perioperative myocardial infarction was significantly lower in group I than in groups II and III (p < 0.05), although there was no significant difference between groups II and III.

CONCLUSIONS: Our results demonstrate that OPCAB with complete avoidance of aortic manipulation may further reduce the incidence of perioperative morbidities such as stroke, atrial fibrillation, acute renal failure, and perioperative myocardial infarction.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
The surgical results of coronary artery bypass grafting without cardiopulmonary bypass (off-pump coronary artery bypass [OPCAB]) have demonstrated several advantages by avoiding the potentially detrimental effects of cardiopulmonary bypass and eliminating intraoperative global myocardial ischemia [1–3]. However, if OPCAB is performed using additional saphenous vein grafts anastomosed on the ascending aorta, the ascending aorta has to be partially clamped and the aortic fat pad is removed. Aortic manipulation and use of a saphenous vein graft may increase the chance of cerebral embolization from ascending aortic atherosclerotic plaques [4], may cause an autonomic imbalance by removal of the aortic fat pad [5], and may retain the possibility of a low patency rate and the sequelae of saphenous vein graft occlusion [6]. Off-pump coronary artery bypass with total arterial grafting allows the surgeon to avoid manipulating the ascending aorta completely, and may further reduce the incidence of postoperative morbidities such as stroke, atrial fibrillation, and perioperative myocardial infarction.

The aims of this study were to compare the surgical results of OPCAB without aortic manipulation with those of OPCAB using additional free grafts on the ascending aorta and those of on-pump conventional coronary artery bypass grafting (CABG). We wanted to demonstrate the advantages of OPCAB with complete avoidance of aortic manipulation.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
A total of 345 consecutive patients who underwent OPCAB for multivessel coronary artery disease between January 1998 and December 2001, and another 76 consecutive patients who underwent conventional CABG for multivessel coronary artery disease in 1997 were studied in a prospective nonrandomized manner. A computer-based patient database system was used for this study. The 345 OPCAB patients were divided into two groups: 222 patients whose OPCAB included complete avoidance of aortic manipulation (group I) and 123 patients whose OPCAB included a single partial clamping of the ascending aorta for additional free grafts that were anastomosed to the ascending aorta (group II). Patients who required revascularization for single-vessel territory were excluded from the study. These 345 OPCAB patients comprised 74.2% (345/465) of all isolated CABG cases for multivessel disease performed during the same period. The operations were all performed by a single surgeon (K.-B.K.).

Preoperative patient evaluations included with clinical history, neurologic examination, and cardiac examination. The neurologic examination consisted of an interview and neurologic evaluation by a neurologist, carotid duplex ultrasonography, and transcranial Doppler or magnetic resonance angiography. The patients were reevaluated 1 week after their operation, or earlier if necessary, and followed by the same neurologist who performed the initial neurologic examination. Stroke was defined as a new and sudden onset of neurologic deficits lasting more than 24 hours with no apparent nonvascular causes. The patients were continuously monitored postoperatively by electrocardiogram during the patient’s stay in the intensive care unit and in the general ward until the chest tubes were removed. A standard 12-lead electrocardiogram was checked daily thereafter during the postoperative hospital stay. To evaluate the incidence of perioperative myocardial infarction, serial determination of serum creatine kinase isoenzymes, electrocardiograms, and a postoperative transthoracic echocardiogram were performed. Perioperative myocardial infarction was defined as positive results on at least two of three different tests: the peak serum creatine kinase isoenzyme level (> 200 IU/L), appearance of new Q waves on the electrocardiogram, or newly developed regional wall motion abnormalities on the postoperative echocardiogram. Postoperative acute renal failure was defined as a rise in serum creatinine of 1 mg/100 mL above base line. In patients with a previous change in serum creatinine levels, postoperative acute renal failure was considered as an increase of 50% or more from the preoperative level.

There were no differences in sex, age, ratio of unstable to stable angina, urgent or emergent operations, preoperative risk factors, and angiographic diagnosis among the three groups. The left ventricular ejection fraction measured by transthoracic echocardiography was higher in group I compared with group II (p < 0.05) (Table 1).

The most critical vessel, the left anterior descending (LAD) coronary artery in almost all the patients, was revascularized first to provide a backup to the less critical area. The distal anastomosis was constructed using a continuous technique with 8-0 polypropylene sutures. Bilateral ITAs were preferred for use as in situ grafts for myocardial revascularization under the assumption that multiple blood sources would be better than a single blood source to improve long-term outcome. Both ITAs were used when possible for revascularization of the left coronary territory. The right ITA was used to revascularize the LAD by crossing the midline, the ramus or high obtuse marginal branch through the transverse sinus, and sometimes the right coronary artery or posterior descending coronary artery as an in situ graft. If the right ITA was too short to reach the left coronary territory or if the left coronary territory could not be completely revascularized with bilateral in situ ITA grafts, a Y graft was constructed before starting the distal anastomosis. In most cases of Y graft construction, the right ITA was divided at its proximal section and was anastomosed to the side of the left ITA in a Y fashion using an 8-0 polypropylene continuous suture. Most of these end-to-side Y anastomoses were performed at the level of the pulmonary artery, and occasionally the right ITA was anastomosed to the distal left ITA unless it reached an optimal vessel such as the right coronary territory. If using the bilateral ITAs as in situ or Y grafts did not achieve complete revascularization, the right gastroepiploic artery as an in situ or composite graft, or radial artery as a composite graft was used for additional revascularization.

Until June 1999, protamine (0.5 mg) was administered for each 100 U of heparin given at the end of the procedure. Protamine was not given at the end of the procedure after July 1999 [6].

Group II (OPCAB with aortic manipulation)
In this group of patients, OPCAB was performed using unilateral or bilateral ITAs and additional free arterial or saphenous vein grafts that were anastomosed to the ascending aorta. A standard skeletonizing technique for harvesting the ITA was used after August 1999. The proximal anastomoses on the ascending aorta were constructed after the distal anastomoses, using a single partial clamping of the aorta and 7-0 polypropylene continuous sutures.

Group III (on-pump conventional CABG)
Conventional CABG was performed with single stage venous cannula drainage, moderate systemic hypothermia, and antegrade or retrograde cold blood cardioplegia solution. With the intention of attempting to decrease neurologic complications, the left ventricle was routinely vented during cardiopulmonary bypass and proximal anastomosis of free grafts was performed during a single cross-clamp period. The semiskeletonized left ITA and additional saphenous vein grafts were used in most of the patients. The patients underwent heparinization with an initial dose of 3 mg/kg of heparin that was periodically supplemented with additional doses to maintain an activated clotting time of more than 480 seconds. At the end of the procedure, 1 mg of protamine per each 100 U of heparin was given.

Statistical analysis
Statistical analysis was performed with the Statistical Analysis System software package (version 6.12; SAS Institute, Cary, NC). The significance of differences among the three groups was assessed by analysis of variance or "relative to an identified distribution" (RIDIT) test. Comparison between two groups was performed by the unpaired Student’s t test, ² test, or Fisher’s exact test. All results were expressed as mean ± standard deviation, and a value of p less than 0.05 was considered statistically significant.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
No differences were noted among the three groups in the arterial grafts used, such as left ITA or radial artery. The right ITA and right gastroepiploic artery were used more frequently in group I (p < 0.001). Bilateral ITAs were used more frequently in group I than in groups II and III (95.5%, 22.0%, and 11.8%, respectively; p < 0.001). The saphenous vein graft was used less frequently in group I than in groups II and III (p < 0.001). In group I, the saphenous vein graft was used to construct a Y graft that was anastomosed to the side of the ITA in 2 patients (Table 2). Fewer distal anastomoses were done in group I than in groups II and III (3.2 ± 0.9, 3.5 ± 0.8, and 3.7 ± 0.9, respectively; p < 0.001).

In group I, the incidence of postoperative stoke, atrial fibrillation, and acute renal failure was significantly lower than in group III (p < 0.05), and the incidence in group II patients was not different from that in group III patients. The incidence of perioperative myocardial infarction was significantly lower in group I than in groups II and III (p < 0.05). No significant differences were noted in the incidence of postoperative morbidities such as mediastinitis, respiratory complication, and reoperation for bleeding among the three groups (p = NS) (Table 4).

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

Despite advances in cardiopulmonary bypass and myocardial protection, postoperative adverse events after CABG are mostly related to the use of cardiopulmonary bypass, global cardiac arrest, and hypothermia. With resurgent interest in OPCAB, the surgical results of OPCAB have demonstrated several advantages by avoiding the potentially detrimental effects of cardiopulmonary bypass and eliminating intraoperative global myocardial ischemia [1–3].

Stroke, one of the most serious postoperative complications, is associated with significantly increased morbidity and use of medical resources. Roach and associates [8] documented a 6.1% incidence of serious adverse neurologic events in a survey of 2,108 patients undergoing CABG at 24 US institutions. Three percent of these patients experienced perioperative stroke, while a further 3.1% experienced deterioration of intellectual function, or seizures. In the context of cardiac surgery, it is apparent that cerebral embolization or ischemic hypoperfusion are most likely the etiologic mechanisms in the genesis of adverse neurologic events. Resurgence in the use of OPCAB has demonstrated a significantly decreased incidence of serious neurologic complications by avoiding cardiopulmonary bypass and cardioplegic arrest [9–11]. The embolic signals monitored by intraoperative transcranial Doppler ultrasonography have demonstrated that most emboli detected during CABG were associated with the release of the aortic cross-clamp and partial occlusion clamp [4]. Although the embolic signals and neurohumoral marker protein S-100 have been demonstrated to be significantly decreased in patients who underwent OPCAB in comparison with those who underwent conventional CABG [12], OPCAB using free grafts anastomosed to the ascending aorta with a partial clamping still retains the possibility of perioperative stroke. Although the present study did not demonstrate a significantly decreased incidence of stroke in the patients who underwent OPCAB without aortic manipulation when compared with the patients who underwent OPCAB with free grafts anastomosed to the ascending aorta (0/161 versus 1/122, p = NS), the difference was significant in comparison with those who underwent conventional CABG (0/161 versus 2/76, p < 0.05).

Postoperative atrial fibrillation, the most common complication after cardiac surgery, may cause a significant increase in the incidence and severity of cardiac surgical morbidity. In a series of 3,983 patients, Creswell and colleagues [13] found that postoperative atrial fibrillation was associated with an increased incidence of postoperative stroke, increased length of hospitalization in the intensive care unit and postoperative nursing ward, increased incidence of postoperative ventricular arrhythmias, and an increased need for placement of a permanent pacemaker. Among the numerous perioperative factors, cardiopulmonary bypass, atrial cannulation technique, myocardial ischemia, and myocardial preservation technique have been suggested as operative factors that increase the incidence of postoperative atrial fibrillation [14–16]. With the development and growing acceptance of technologies that facilitate less invasive approaches by avoiding cardiopulmonary bypass, atrial cannulation, and cardioplegic arrest for CABG, a reduction in the incidence of atrial fibrillation has been observed [14, 16, 17]. However, several conflicting studies showing no difference in the incidence of postoperative atrial fibrillation also have been published [18–20].

Complete avoidance of aortic manipulation by using total arterial revascularization preserves the aortic fat pad containing neurogenic tissue [5], and thereby may avoid an autonomic imbalance and further decrease the incidence of atrial fibrillation. The present study demonstrated that OPCAB with complete avoidance of aortic manipulation significantly reduced the incidence of postoperative atrial fibrillation compared with conventional CABG (11.4% versus 21.1%, p = 0.048), although OPCAB with a partial clamping of ascending aorta for additional free grafts did not reduce the incidence of atrial fibrillation.

Better myocardial preservation and a lower degree of renal injury with avoidance of cardiopulmonary bypass also have been reported [21, 22]. These studies demonstrated significantly reduced postoperative release of myocardial enzymes and reduced increase of serum creatinine concentration in patients undergoing OPCAB. However, the incidence of perioperative myocardial infarction and acute renal failure after OPCAB has been inconsistent. Some authors have reported decreased incidence of perioperative myocardial infarction and acute renal failure after OPCAB [11, 23], although others failed to show differences in the incidence of those morbidities [20, 24]. The present study demonstrated significantly reduced incidence of perioperative myocardial infarction and acute renal failure in the patients who underwent OPCAB without aortic manipulation, compared with those who underwent conventional CABG. The incidence of perioperative myocardial infarction was also different between the patients who underwent OPCAB without aortic manipulation and OPCAB with aortic manipulation. In the group of patients who underwent OPCAB with aortic manipulation, the saphenous vein was most commonly used as a free graft. The significantly higher incidence of perioperative myocardial infarction in the group of OPCAB patients in which the saphenous vein was commonly used for grafts might have resulted from a significantly lower patency rate of saphenous vein grafts after OPCAB seen in the early postoperative coronary angiographies at this institution [6].

This study was not performed in a randomized manner, because randomized controlled trials in this type of study are sometimes unrealistic and impractical. Although the study involved relatively small numbers and was not randomized, the trial was performed prospectively using a computer-based database system and demonstrated the advantages of OPCAB with complete avoidance of aortic manipulation.

In conclusion, OPCAB with complete avoidance of aortic manipulation may further reduce the incidence of perioperative morbidities such as stroke, atrial fibrillation, acute renal failure, and perioperative myocardial infarction.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
We appreciate the efforts of Dawn Schuessler in preparing this report.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments 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): Ki-Bong Kim Chang Hyun Kang Cheong Lim Jin Hee Kim Yong Lak Kim Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kim, K.-B. Articles by Kim, Y. L. Search for Related Content PubMed PubMed Citation Articles by Kim, K.-B. Articles by Kim, Y. L. Related Collections Coronary disease