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Robert A. Guyton
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Ann Thorac Surg 2005;79:801-806
© 2005 The Society of Thoracic Surgeons

Original article: Cardiovascular

Emergency Coronary Artery Bypass Grafting Can Be Performed Safely Without Cardiopulmonary Bypass in Selected Patients

Faraz Kerendi, MD, John D. Puskas, MD, MS*, Joseph M. Craver, MD, William A. Cooper, MD, Ellis L. Jones, MD, Omar M. Lattouf, MD, PhD, J. David Vega, MD, Robert A. Guyton, MD

Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia

Accepted for publication August 4, 2004.

* Address reprint requests to Dr Puskas, 550 Peachtree St, 6th Floor, MOT, Atlanta, GA 30308 (E-mail: john_puskas{at}emoryhealthcare.org).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
BACKGROUND: Patients requiring emergency surgical revascularization are often not considered for off-pump coronary artery bypass grafting (OPCAB).

METHODS: From 1996 to 2003, 614 patients underwent emergency coronary artery bypass grafting (Society of Thoracic Surgeons definition) at an academic institution. Forty-four (7%) of these procedures were performed without cardiopulmonary bypass, while 570 were conventional coronary artery bypass procedures with cardiopulmonary bypass (CABG/CPB). Data were collected prospectively into a computerized database and reviewed retrospectively.

RESULTS: Though a greater proportion of CABG/CPB patients had critical left main stenosis (15.9% vs 38.3%, p = 0.005), other preoperative risk factors were similar between groups. Completeness of revascularization (No. distal anastomoses/No. diseased vessel systems) was significantly greater in the CABG/CPB group (1.51 ± 0.03 vs 1.25 ± 0.07, p = 0.003). There were no differences among individual complication rates (death, cardiac reoperation, postoperative myocardial infarction, permanent cerebral vascular accident, deep sternal wound infection, renal failure requiring hemodialysis, and respiratory failure requiring reintubation). However, the combined incidence of these endpoints was significantly lower in the OPCAB group (6.8% vs 21.1%, p = 0.038). OPCAB patients received fewer blood transfusions (65.9% vs 84.9%, p = 0.004) and had a significantly shorter intensive care unit stay (1.47 vs 3.20 days, p = 0.016). In-hospital mortality (0% vs 6.3%, p = 0.168) and mean postoperative length of stay (5.48 vs 7.03 days, p = 0.414) favored OPCAB, but did not reach statistical significance.

CONCLUSIONS: Off-pump coronary artery bypass can be performed safely and effectively and should be considered in selected patients with acceptable hemodynamics undergoing emergency coronary revascularization.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 

Drs Craver, Guyton, and Puskas disclose that they have financial relationships with Medtronic, Inc.

 

Over the past decade, off-pump coronary artery bypass grafting (OPCAB) has gained popularity and now accounts for approximately 22% of all coronary artery bypass grafting (CABG) procedures performed in the United States [1]. During the early stages of its development, OPCAB was limited to uncomplicated patients with few confounding risk factors. However, as surgeon proficiency with OPCAB has evolved [2], along with improvements in stabilization devices and anesthetic management, the applicability of OPCAB has expanded to include more complex patients with outcomes comparable to or superior than CABG with cardiopulmonary bypass (CABG/CPB) [3, 4]. In fact, many surgeons now prefer OPCAB for patients with multiple comorbidities, such as diabetes, renal failure, or impaired left ventricular function. Several retrospective studies have indicated that these high-risk patients may benefit most from avoiding cardiopulmonary bypass and its associated inflammatory response [5–9].

Nevertheless, application of OPCAB techniques to patients undergoing emergency surgical revascularization remains controversial. As defined by the Society of Thoracic Surgeons guidelines (Table 1), these patients have sustained a recent myocardial infarction within 24 hours or have ongoing myocardial ischemia resulting in hemodynamic instability, and are classically thought to benefit from the protection afforded by cardioplegic arrest, which reduces metabolic demand and resuscitates the ischemic myocardium [10–12]. However, avoiding the inflammatory reactions incited by cardiopulmonary bypass and global ischemia of cardioplegic arrest may be of equal or greater benefit to the already injured myocardium. The objective of this study is to examine the feasibility and efficacy of OPCAB in a subset of patients at our institution requiring emergency coronary revascularization and to compare postoperative outcomes to a similar group of patients who underwent emergency CABG/CPB during the same period.


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  		Table 1. The Society of Thoracic Surgeons Criteria for Emergency Status at the Time of Surgery
 

   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Patient Selection
This study was conducted under approval of the institutional review board of Emory University. Between January 1996 and March 2003, 614 patients underwent emergency coronary artery bypass grafting as defined by the Society of Thoracic Surgeons national database guidelines (STS National Database, Adult Cardiac Surgery Section, version 2.41, www.sts.org) by nine surgeons at two affiliated university hospitals. By definition, these patients either had ongoing ischemia or mechanical dysfunction with shock (Table 1). Patients who underwent salvage operation, defined as those undergoing cardiopulmonary resuscitation en route to the operating room or before anesthesia induction, and patients undergoing combined valve-coronary procedures were excluded from analysis, as these patients are not candidates for beating heart surgery. On the other hand, patients with acceptable hemodynamics after medical treatment or placement of intraaortic balloon pumps (IABP) were considered for OPCAB. Forty-four (7%) such emergency cases were performed without the use of cardiopulmonary bypass (OPCAB), while 570 were conventional coronary artery bypass procedures (CABG/CPB) with aortic cross-clamping and cardioplegic arrest (Table 2). Patients undergoing beating heart, on-pump surgery were not included as there were relatively few such cases performed at our institution during this time.


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  		Table 2. Number of Cases Performed by Each of 9 Surgeons
 
Surgical Techniques
All patients underwent operation through a standard median sternotomy. After harvesting the internal mammary artery under direct visualization, patients in the CABG with CPB group were fully anticoagulated with heparin (300 U/kg) followed by supplemental doses of 100 U/kg to maintain an activated clotting time greater than 400 seconds. The OPCAB patients received a "half-pump" dose of heparin (150 U/kg) followed by 3,000 U every 30 minutes until completion of the last anastomosis.

Patients in the CABG with CPB group were routinely cooled to 34°C. At surgeon discretion, anterograde and/or retrograde high-potassium blood cardioplegia was used. IABPs were employed to assist in separation from CPB when pharmacologic support was inadequate.

For OPCAB procedures, deep pericardial traction sutures were used for cardiac manipulation and exposure until 2001, after which the Starfish apical positioning device (Medtronic, Inc, Minneapolis, MN) was routinely used. For stabilization of distal target sites, compression devices were used in the early period (1996 through 2000); however, since 2000, suction stabilizers (Medtronic Octopus II and Octopus III) were predominantly used. In all OPCAB cases hemodynamic stability was maintained either with the use of appropriate inotropic and vasopressor agents, or the use of IABP as necessary. Intracoronary shunts were used when there was excessive back-bleeding from the target vessel or it was deemed that occlusion of the target vessel would be poorly tolerated. In all patients, distal anastomoses were constructed using continuous running 7-0 or 8-0 monofilament suture. Proximal anastomoses were created with 5-0 or 6-0 monofilament suture under a partial occlusion clamp.

Data Collection and Analysis
A complete set of perioperative data were collected for all patients, including preoperative risk factors and demographics, intraoperative variables, and postoperative outcomes and complications. These data were entered prospectively into a computerized database and reviewed retrospectively. A composite endpoint of morbidity and mortality (adapted from Shroyer and colleagues [13]) based on the STS operative mortality and morbidity risk models was compared between groups. This was defined as operative mortality, perioperative myocardial infarction, permanent stroke, renal failure requiring hemodialysis, respiratory failure requiring reintubation, deep sternal wound infection, and any cardiac-related reoperation (including reoperation for bleeding, cardiac tamponade, acute graft spasm or occlusion, or rubber dam closure requiring delayed chest closure).

Data were analyzed using SigmaStat statistical software version 3.0 (SPSS, Inc, Chicago, IL). Discrete data are expressed as percentages and were compared using the Fisher exact test or {chi}2 test. Continuous variables are presented as mean ± standard error of the mean and were analyzed using the unpaired Student’s t test. Differences were considered significant if p was less than 0.05.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Preoperative Patient Characteristics
Table 3 summarizes the preoperative risk factors of both groups. A significantly greater proportion of CABG/CPB patients had left main coronary artery stenosis (15.9% vs 38.3%, p = 0.005). More patients undergoing CABG/CPB had Canadian Cardiovascular Classification angina scores of III or IV (54.6% vs 69.2%), but this difference did not reach statistical significance (p = 0.066). All other variables were similar between groups, including age, gender, associated comorbidities, mean ejection fraction, and preoperative use of IABP. Importantly, the incidence of acute evolving myocardial infarction (MI) and preoperative cardiogenic shock were similar between groups. A similar percentage of patients in each group were operated on following failed coronary angioplasty (25.6% vs 35.5%, p = 0.366). Preoperative medications, including anticoagulants, platelet inhibitors, and administration of intravenous nitrates were also similar between groups (Table 4).


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  		Table 3. Preoperative Demographics and Risk Factors
 

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  		Table 4. Preoperative Medications
 
Outcomes
The left internal mammary was used in 82.1% of OPCAB patients compared to 75.5% in the CABG/CPB group (p = 0.469). Completeness of revascularization (COR), as measured by the mean number of distal anastomoses divided by the mean number of diseased vessel systems (ie, left anterior descending artery system, circumflex system, or right coronary artery system), was greater in the CABG/CPB group (1.51 ± 0.03) than in the OPCAB group (1.25 ± 0.07, p = 0.003) when compared over the entire study period. However, from 2001 to 2003, when the latter half of OPCAB cases were performed, there was no difference in COR between the two groups (1.30 ± 0.08 for OPCAB vs 1.34 ± 0.07 for CABG/CPB, p = 0.759, Table 5).


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  		Table 5. Completeness of Revascularization
 
The combined incidence of major postoperative morbidity and mortality (defined as death, any cardiac reoperation, postoperative MI, permanent cerebrovascular accident, deep sternal wound infection, renal failure requiring hemodialysis, and respiratory failure requiring reintubation) was significantly higher in the CABG/CPB group (21.1%) as compared to the OPCAB group (6.8%, p = 0.038). The CABG/CPB group had a higher incidence of neurologic, cardiac, infectious, renal, and bleeding complications; however, when analyzed individually, these differences were not statistically significant (Table 6). There were no operative deaths (defined as death during the initial hospitalization or within 30 days of surgery) in the OPCAB group compared to 6.3% in the CABG/CPB group, but this difference was not statistically significant (p = 0.168).


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  		Table 6. Postoperative Morbidity and Mortality
 
In previous reports, OPCAB has been associated with a reduction in coagulopathy and transfusion requirements. In the current study, there was no difference in the rate of reoperation for bleeding between groups. However, significantly fewer OPCAB patients required transfusion of packed red blood cells as compared to the CABG/CPB group (61.5% OPCAB vs 84.8% CABG/CPB, p < 0.001, Fig 1). The rate of platelet transfusion also favored OPCAB (12.8% vs 28.4%), but this difference was not statistically significant (p = 0.061). There was no difference in the rate of transfusion of cryoprecipitate or fresh frozen plasma between groups.



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  		Fig 1. Percentage of patients requiring transfusion of blood products. {blacksquare} = off-pump coronary artery bypass grafting; {square} = coronary artery bypass grafting with cardiopulmonary bypass; * = p < 0.05. (CPT = cryoprecipitate; FFP = fresh frozen plasma; PLAT = platelets; RBC = packed red blood cells.)

 
Postoperative intensive care unit (ICU) length of stay (LOS) was significantly lower in the OPCAB group (1.47 ± 0.15 days for OPCAB vs 3.20 ± 0.30 days for CABG/CPB, p = 0.016). Total postoperative hospital LOS (5.31 ± 0.56 days for OPCAB vs 6.91 ± 0.31 days for CABG/CPB) also favored OPCAB, but was not statistically significant (p = 0.414). Readmission within 30 days of discharge was similar for both groups.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Traditionally, patients requiring emergent surgical revascularization have been thought to benefit from the cardioprotection afforded by vented cardiopulmonary bypass and resuscitative cardioplegia [10]. However, operative mortality remains high in these patients despite improvements in the composition and administration of cardioplegia [14–16]. Off-pump coronary artery bypass has been successfully applied in other high-risk groups [4–8]. It is unclear whether patients requiring emergency coronary bypass surgery would benefit more from cardioplegic resuscitation or avoidance of the inflammatory state and global ischemia associated with cardiopulmonary bypass.

In prospective, randomized comparisons with OPCAB, CABG/CPB has been associated with a significantly higher elevation in the serum levels of proinflammatory cytokines such as interleukins 8 and 10 [17–19], tumor necrosis factor-alpha, [19] as well as neutrophil elastase [18], a marker of neutrophil activation. In addition, serum levels of troponin and creatine kinase MB fraction are significantly higher following CABG/CPB compared to OPCAB, suggesting that CPB and cardioplegic arrest may further damage the already jeopardized myocardium, [3, 20, 21] though the long-term clinical sequelae of increased serum enzyme levels remain unknown.

Citing the extension of ischemic injury that is generated by aortic cross-clamping, some have advocated on-pump, beating heart surgery [21]. This technique allows for perfusion of vital organs in hemodynamically unstable patients without incurring the global myocardial ischemia inherent in aortic cross-clamping. However, this method does not avoid the detrimental inflammatory effects of CPB and the potential myocardial damage that may occur as a result. In fact, in a recent prospective, randomized analysis, Wan and colleagues [19] compared OPCAB with on-pump beating heart surgery, demonstrating a significant elevation of interleukins 6, 8, and 10, and tumor necrosis factor-alpha in the on-pump beating heart group. This suggests that CPB alone, without aortic cross-clamping and cardioplegic arrest, can trigger an inflammatory response.

Little data currently exist in the literature to support the use of OPCAB in emergency situations [14, 22–24]. Locker and colleagues [14] published a series of 40 patients who underwent OPCAB within 48 hours after acute MI. Although the OPCAB group in their study had a lower hospital mortality rate, the incidence of recurrent angina, reinterventions, and late mortality were all higher in the OPCAB group. These late complications were attributed to incomplete revascularization of the lateral wall, a frequent criticism of OPCAB. However, recent studies suggest that as surgeon experience matures, complete revascularization can be achieved even in patients with multivessel disease [3, 4, 25]. Indeed, during the early period in the present study, completeness of revascularization was significantly less in the OPCAB group. However, during the latter half of the study, as surgeons gained more experience with OPCAB, complete revascularization comparable to CABG/CPB was achieved. This important point perhaps suggests that complex cases (such as emergency cases) should not be attempted with OPCAB until the surgeon has reached a plateau on the learning curve [25]. Although it is difficult to make generalizations as to where this plateau may be, one potential recommendation is that a surgeon should attempt complex cases only after performing 200 elective OPCAB procedures.

In the current study, we present a series of patients at our institution that underwent emergency OPCAB with favorable results. By definition, these patients had ongoing ischemia or were operated on within 24 hours of acute myocardial infarction. Baseline characteristics, indications for emergency revascularization, and postoperative outcomes were comparable to a similar group that underwent CABG with CPB during the same time period. Although the study was not powered to detect statistical differences in the incidence of infrequent individual endpoints, the combined morbidity and mortality rate was significantly lower in the OPCAB group. In addition, as other comparative studies have shown, [3, 20] the OPCAB patients in this series had a significantly lower rate of blood transfusion and shorter ICU stay.

The present study shares several limitations common to retrospective reviews. Most important among these is patient selection bias. Although other preoperative risk factors were similar between groups, more CABG/CPB patients had critical left main stenosis, potentially indicating that these patients had more severe disease and were at greater risk preoperatively. The reason for which there was a greater incidence of left main coronary artery (LM) stenosis among CABG/CPB patients is not entirely clear. We explored the possibility that OPCAB was considered in emergency situations only recently after our surgeons had gained adequate experience with OPCAB; however, we did not find this justification to be true, as the majority of OPCAB cases with LM disease occurred in the first 4 years of this study. It is more likely that most surgeons in this study chose not to perform OPCAB for patients with LM stenosis given the potential difficulties associated with LM occlusion during creation of the distal anastomosis. Along those lines, it is significant that nearly half of the OPCAB cases in this series were performed by one surgeon and the majority by four surgeons. This may additionally bias our results given that we did not compare outcomes of individual surgeons.

A further limitation is that the available data fields we examined did not include some important patient characteristics that may have been different between groups. Moreover, as a result of the small population size in the OPCAB group and the uneven number of patients in the two groups, the present study is not sufficiently powered to detect differences in important endpoints, such as death, MI, and stroke, which occur infrequently.

Nonetheless, given the lack of randomized trials in this patient population, this study is important in that it is one of the largest reported series of emergency coronary bypass cases performed without cardiopulmonary bypass. In this group of selected patients undergoing emergency surgical revascularization, OPCAB was feasible and accomplished safely. We hypothesize that OPCAB benefits patients by avoiding myocardial injury due to inflammation and ischemia associated with cardiopulmonary bypass and cardioplegic arrest. In conclusion, emergency OPCAB can be performed safely and effectively and should be considered in selected patients (ie, patients who have acceptable hemodynamics following pharmacologic and/or IABP support) undergoing emergency coronary revascularization.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Society of Thoracic Surgeons Adult Cardiac Surgery Database, www.sts.org..
  2. Puskas JD, Vinten-Johansen J, Muraki S, Guyton RA. Myocardial protection for off-pump coronary artery bypass surgery Thorac Cardiovasc Surg 2001;13:82-88.
  3. Puskas JD, Williams WH, Duke PG, et al. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting J Thorac Cardiovasc Surg 2003;125:797-808.[Abstract/Free Full Text]
  4. Puskas JD, Williams WH, Mahoney EM, et al. Off-pump vs conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes JAMA 2004;291:1841-1849.[Abstract/Free Full Text]
  5. Dewey TM, Magee MJ, Edgerton JR, et al. Off-pump bypass grafting is safe in patients with left main coronary disease Ann Thorac Surg 2001;72:788-792.[Abstract/Free Full Text]
  6. Magee MJ, Dewey TM, Acuff T, et al. Influence of diabetes on mortality and morbidity: off-pump coronary artery bypass grafting versus coronary artery bypass grafting with cardiopulmonary bypass Ann Thorac Surg 2001;72:776-781.[Abstract/Free Full Text]
  7. Chamberlain MH, Ascione R, Reeves BC, Angelini GD. Evaluation of the effectiveness of off-pump coronary artery bypass grafting in high-risk patients: an observational study Ann Thorac Surg 2002;73:1866-1873.[Abstract/Free Full Text]
  8. Al-Ruzzeh S, Nakamura K, Athanasiou T, et al. Does off-pump coronary artery bypass (OPCAB) surgery improve the outcome in high-risk patients? A comparative study of 1398 high-risk patients Eur J Cardiothorac Surg 2003;23:50-55.[Abstract/Free Full Text]
  9. Puskas JD, Sharoni E, Petersen R, et al. Angiographic graft patency and clinical outcomes among diabetic patients after off-pump versus conventional coronary artery bypass grafting: results of a prospective randomized trial Heart Surgery Forum 2003;6:S27.
  10. Vinten-Johansen J, Thourani VH. Myocardial protection: an overview J Extra Corpor Technol 2000;32:38-48.[Medline]
  11. Brown III WM, Horsley WS, Gott JP, Bufkin BL, Guyton RA. Myocardial protection for coronary artery bypass in patients with acute myocardial infarction: resuscitation of ischemic myocardium Semin Thorac Cardiovasc Surg 1995;7:191-197.[Medline]
  12. Beyersdorf F. Protection of evolving myocardial infarction and failed PTCA Ann Thorac Surg 1995;60:833-838.[Abstract/Free Full Text]
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  14. Locker C, Shapira I, Paz Y, et al. Emergency myocardial revascularization for acute myocardial infarction: survival benefits of avoiding cardiopulmonary bypass Eur J Cardiothorac Surg 2000;17:234-238.[Abstract/Free Full Text]
  15. Craver JM, Justicz AG, Weintraub WS, et al. Coronary artery bypass grafting in patients after failure of intracoronary stenting Ann Thorac Surg 1995;60:60-66.[Abstract/Free Full Text]
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