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Ann Thorac Surg 2003;76:660-661
© 2003 The Society of Thoracic Surgeons

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Correspondence

Non-cardioplegic coronary bypass is effective, teachable, and still widely used: letter 1

^a Lancaster General Hospital, 555 North Duke St, PO Box 3555, Lancaster, PA 17604-3555, USA

e-mail: lbonchek{at}prodigy.net

To the Editor:

Raco and coworkers, from Blackpool, England, reported excellent results in 800 patients who had isolated noncardioplegic CABG [1]. Recent understanding of ischemic preconditioning has dispelled most of the skepticism that once prevailed similar excellent results from many centers. However, in the invited commentary of Raco and coworker’s [1] article De Paulis reveals his persistent skepticism by emphasizing that the operations in Raco and coworker’s [1] study were all performed by a single experienced surgeon, and by asserting that "recommending this technique for large scale application or transferring these results to other cardiac centers is another matter. Intermittent cross-clamping is not preferred by trainees" [1].

To the contrary, intermittent cross-clamping is widely used in United Kingdom training programs, particularly in London; and in the United States, we and others use it routinely. We previously reported our initial experience [2], and we have now done CABG on more than 8,300 patients without cardioplegia. Results continue to be gratifying with unadjusted operative mortality rates in elective, urgent, and emergency patients of 0.9%, 1.5%, and 4.0%, respectively. The overall mortality of 1.7% is considerably lower than the 3.27% predicted by the Society of Thoracic Surgeons National Database model. Moreover, our experience represents the work of five surgeons, three of whom had never seen noncardioplegic coronary artery bypass grafting (CABG) during their training, but who adopted it enthusiastically in Lancaster because of its inherent advantages. At the Medical College of Wisconsin from 1975 to 1983, I found intermittent cross clamping to be optimally suited to a training program, because it allowed reperfusion at leisure between distal anastomoses, and because there was no ischemic burden while fine points of technique were discussed or demonstrated, or while the operative plan was revised (eg, to harvest more vein or another arterial conduit). Noncardioplegic CABG is demonstrably simple and safe, but it is also very rapid if the operation is planned efficiently. These attributes are also helpful in a training program.

Familiarity with noncardioplegic CABG, done with local control of the target vessel and without aortic cross-clamping, also eases the transition of off-pump CABG for trainees, and simplifies the management of severely diseased or porcelain aortas. A proximal anastomosis to a had aorta can be done on pump with moderate hypothermia (26°C to 30°C) and brief circulatory arrest (4 minutes); local control is then used for all distal anastomoses. With these techniques, our incidence of permanent stroke is 1.4% in a series that began long before the modern era of echocardiography. For the last 3 years our incidence of permanent stroke has been less than 1%.

Finally it is puzzling that Raco and coworkers [1] seem to describe using both aortic cross clamping and local control of the target coronary artery in all patients. In fact, whenever local control of the target vessels is obtained, it is generally unnecessary to clamp the aorta; conversely, when the aorta is cross-clamped, potentially injurious encircling sutures around the target coronary are rarely necessary. Also, we prefer small clamps on the coronary arteries, rather than sutures, to spread the occluding force over a wide area. We have described our entire technique in detail [3].

I commend the authors on their outstanding results.

References

1. Raco L., Mills E., Millner R.J. Isolated myocardial revascularization with intermittent aortic cross-clamping: experience with 800 cases. Ann Thorac Surg 2002;73:1436-1440.[Abstract/Free Full Text]
2. Bonchek L.I., Burlingame M.W., Vazales B.E., Lundy E.F., Gassmann C.J. Applicability of noncardioplegic coronary bypass to high-risk patients. J Thorac Cardiovasc Surg 1992;103:230-237.[Abstract]
3. Bonchek L.I. Technical considerations for coronary artery bypass without cardioplegia. J Card Surg 1992;7:333-341.[Medline]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Lawrence I. Bonchek Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bonchek, L. I. Search for Related Content PubMed PubMed Citation Articles by Bonchek, L. I. Related Collections Myocardial protection