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Ann Thorac Surg 2006;81:85-89
© 2006 The Society of Thoracic Surgeons

Original article: Cardiovascular

Off-Pump Myocardial Revascularization: Critical Analysis of 23 Years' Experience in 3,866 Patients

Enio Buffolo, MD * , João Nelson R. Branco, MD, Luis Roberto Gerola, MD, Luciano F. Aguiar, MD, Carlos Alberto Teles, MD, José Honório Palma, MD, Roberto Catani, MD

Department of Cardiovascular Surgery, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil

Accepted for publication July 12, 2005.

* Address correspondence to Dr Buffolo, Rua Borges Laboa, 1080 Conj 701, CEP. 04038-002, São Paulo SP, Brazil (Email: enio.buffolo{at}terra.com.br).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
BACKGROUND: Surgical myocardial revascularization without cardiopulmonary bypass (CPB) is not new, with the first consecutive series of patients appearing in the early eighties. There has been increased interest in this alternative approach, especially in patients with comorbidities. There is controversy regarding advantages, risks, and usefulness of this method of myocardial revascularization. We herein report a consecutive series of 3,866 patients, from the first case in September 1981 to the last in November 2004, analyzing applicability, mortality, morbidity, and surgical technique.

METHODS: From September 1981 to November 2004, 3,866 consecutive patients were revascularized without CPB. This figure represents an overall applicability of 30.8% considering a total of 12,553 revascularization procedures performed during this time. There were 2,822 males (73%) with ages from 12 to 93 years (median, 62 ± 14). Mean grafts per patient was 1.9, and the internal mammary artery was used in 87.3% of cases. The main indications for surgery were chronic coronary insufficiency (89% of cases) and failure of angioplasty or stenting.

RESULTS: Hospital mortality was 1.9%, with low incidence of cerebrovascular accident (5 cases in the entire series). Morbidity, considering major postoperative complications, occurred in 12.5% of the patients. The applicability of the off-pump technique was 18% of cases in the beginning of our experience, increasing to 49% in the last 5 years with the use of stabilizers and maneuvers to expose posterior coronary branches.

CONCLUSIONS: Off-pump coronary surgery is an alternative method of myocardial revascularization that should be considered for every patient. The preference of this technique over conventional revascularization should be based on the surgeon's own experience, on the patient's preoperative condition and on the coronary anatomy. Off-pump myocardial revascularization represents an important development in coronary artery surgery. Over the years it has evolved into a valid form of surgery with the same safety as the conventional operation and with more advantages in high risk patients.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Coronary artery bypass surgery without CPB is not new, and its history goes hand in hand with that of cardiac surgery itself. Pioneers were Goetz and colleagues [1] and Kolessov [2] who performed the procedure in isolated cases. The first clinical series of consecutive patients was by Trapp and Bisarya [3] and Ankeney [4]. With the development of direct coronary surgery, under the leadership of Favaloro [5] and Green and coworkers [6], with procedures being performed in an arrested heart with the use of extracorporeal circulation, off-pump coronary surgery was abandoned. In 1981, after a brief period of experimentation, we began to perform myocardial revascularization without CPB in patients with lesions of the right coronary artery, the left anterior descending artery, and the diagonal branches with encouraging results [7–11]. At the same time, independently, Benetti [12] initiated a similar program.

It was the idea of mininvasive direct coronary artery bypass graft (MIDCABG), introduced in the mid 1990s by Benneti [12, 13], that called attention to the possibility and advantages of not using CPB [14, 15]. An extraordinary step in the development of off-pump coronary surgery was the Lima stitch [16], which allowed grafting of posterior branches of the coronary arteries. The introduction of stabilizers in the mid 1990s further facilitated the procedure. Even during this early phase, some publications already showed advantages of off-pump coronary surgery in small series of patients [17, 18, 19].

The purpose of this paper is to present an overview of a consecutive series of 3,866 patients operated upon since September 1981, discussing applicability, technical aspects, mortality, and morbidity. This represents the oldest and large consecutive series of off-pump procedures from a single institution.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
From September 1981 to November 2004, 12,553 myocardial revascularizations were performed at our institution. Of this total number, 3,866 procedures (30.8%) were performed without CPB (off-pump group). Ages varied from 12 to 93 years (mean, 62 ± 14), and 2,822 patients were male (73%). Chronic coronary insufficiency was the most common indication for surgery. Other preoperative conditions are shown in Table 1. In the beginning of our experience, we used this procedure in patients with lesions in the left anterior descending, diagonal, and right coronary artery. With special maneuvers and with the introduction of stabilizers in the mid 1990s, it became possible to expand the indications for off-pump coronary surgery.


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  		Table 1. Preoperative Clinical Characteristics
 
Surgical Technique
Before surgery, angiograms were reviewed and the number of grafts was planned. Although a perfusionist was always present in the operating room, the CPB circuit was not set up. After central venous access arterial pressure control, electrocardiography, and urine output, a 12 to 14 cm skin incision was performed, followed by full median sternotomy.

The left internal mammary artery was harvested, trying to avoid opening the left pleura. Other conduits such as saphenous vein, radial artery, epigastric, gastroepiploic, and right mammary arteries were harvested according to preoperative assessment.

Eighty-two patients were operated on through left anterior minimal thoracotomy, and 1 patient had robotic assistance.

Heparin (2 mg/kg) was administrated a few minutes before occlusion of the coronary artery. The target artery was occluded with a soft piece of silicone tube in a segment where there was no plaque. Concerned about the possibility of causing lesion in the snared coronary artery, a distal tourniquet was not used. In a previous experimental study, it was clear that snaring a segment with a plaque could fracture the coronary wall and cause future stenosis [20].

In the beginning of our experience, a bolus of verapamil (5 mg) was injected into the right atrium in an attempt at reducing the arterial pressure, heart rate, and oxygen consumption. This was a kind of "pharmacological stabilizer" that helped us very much in the absence of stabilizers at that time.

The right coronary artery represented a challenge. When its stenosis was not severe and coronary blood flow was interrupted, we observed bradycardia, ventricular dilatation, electrocardiographic changes, hypotension, and heart block, in that order. In this situation, we placed a shunt between the ascending aorta and the distal coronary artery utilizing a small silicone tube or a temporary intraluminal coronary shunt [21]. We always performed coronary anastomoses in arteries that were totally occluded first, and for each coronary artery, there was a specific exposure maneuver.

For the left anterior descending artery (LAD), the heart was elevated and brought medially by a sponge placed dorsolaterally. Some pericardial stitches also aided in exposure of the LAD. For the right coronary artery (RCA), we used the Trendelenburg position, leftward rotation, and traction of the marginal border of the right ventricle.

The left marginal coronary arteries were exposed by stitches applied deep to the pericardium, between the inferior vena cava and the left inferior left pulmonary vein. Traction on these stitches brought the heart out in a true ectopia cordis. Exposure of the target marginal branches was completed with stabilizers. In situations of hemodynamic instability during this exposure, we opened the right pleura widely to avoid right atrial compression and obstruction of venous return. All distal anastomoses were performed with 7-0 polypropylene running sutures. Proximal anastomoses were performed to the ascending aorta with lateral clamping, and continuous 6-0 polypropylene sutures. At the end of the procedure, protamine was administered and the chest was closed with one or two chest drains. In the last year, almost all patients were transported to the intensive care unit extubated for an average 24-hour stay.

Statistical Analysis
Data are presented as mean ± SD. The {chi}2 test or Fisher's exact test was used to compare categorical variables. Multivariate analyses were done through multiple logistic regression to identify the independent factor of mortality, and p values of less than 0.05 were considered significant.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
The number of grafts varied from 1 to 5, mean of 1.9 grafts per patient, and the distribution can be observed in Table 2.


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  		Table 2. Number of Grafts and Number of Patients
 
Coronary arteries grafted were LAD 3,366 (87.1%); distal RCA 2,109 (54.5%); diagonal 917 (23.7%); posterior descending or posterior ventricular 434 (11.2%); marginal branches 687 (17.7%). In all, 7,513 coronary arteries were grafted. Regarding the type of grafts, the majority of patients received a combination of left internal mammary artery and saphenous veins. The distribution of these grafts can be observed in Table 3. Associated procedures were performed in 51 patients (1.3%): carotid endarterectomy in 14 patients; exclusion of a ventricular scar by plicature in 11 patients; pacemaker implant in 9 patients; transmyocardial laser in 2 patients; Vineberg implantation in 1 patient; and other noncardiovascular surgeries (lung resection, thymectomy, and so forth).


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  		Table 3. Types of Grafts
 
Access and Applicability
Full sternotomy with limited skin incision was employed in 3,783 cases (97.8%). The so-called MIDCABG through a small left anterior thoracotomy was used in 83 patients, in 1 of these patients with robotic assistance. At the beginning of our experience, we considered for off-pump surgery only patients with lesions in the LAD, RCA, and diagonal to avoid hemodynamic instability during exposure of posterior branches. At that time, we did not have stabilizers, and maneuvers were not available to allow exposure of the marginal coronary arteries. That is the reason for the low applicability rates during that time. We had an applicability rate of 18% in the first 2 years (1981 and 1982), and increased it to a stable plateau of 49% in the last 5 years (Table 4).


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  		Table 4. Applicability of Off-Pump Techniques in the Last 5 Years
 
Hospital Mortality and Morbidity
The total hospital mortality rate was 1.9% (75 of 3,866), and the primary causes are shown in Table 5. There was low incidence of stroke (5 of 3,866). During the years, we performed comparative prospective studies using subgroups of this entire population. Postoperative complications in a prospective, not randomized, study of 709 patients with similar preoperative risk factors were analyzed. There were fewer postoperative complications regarding significant arrhythmias (12.6% on pump and 5.5% off pump), pulmonary complications (9.7% on and 3.2% off pump), and neurologic dysfunction (3.8% on and 1.1% off pump). Table 6 shows independent risk factors for hospital death among these 709 patients. Note that CPB is an independent risk factor for death. Blood transfusion was used in 90.5% of patients in the on-pump group and 54.3% in the off-pump group (p < 0.05).


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  		Table 5. Primary Causes of Death in the Entire Series
 

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  		Table 6. Independent Risk Factors for Hospital Mortality
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Our experience in off-pump coronary artery surgery began in September 1981. At that time, only three coronary territories were selected for this surgery: left anterior descending, and distal right and diagonal branches. Angioplasty was not at the time an accepted method of treatment of coronary obstructions, and the benefits of left internal mammary artery grafting were not well recognized. For many years, the use of direct coronary surgery without CPB was not accepted by the vast majority of cardiovascular surgeons owing to the difficulties in performing coronary anastomoses on a beating heart. Nevertheless, it was possible, with increasing experience, to show that, for a subgroup of patients, results regarding patency rates were similar between on and off pump with this less invasive surgical procedure.

With the introduction of stabilizers [22–24] and special maneuvers to expose marginal branches, the applicability for off-pump coronary artery surgery increased, reaching 49% in the last 5 years. We do not have, like others, high applicability rates because we do not believe we can perform the same high-quality anastomoses with safety in all patients and graft all coronary arteries under adverse conditions.

The main limitations to the use of off-pump techniques are these: enlarged hearts in hypertensive patients, reoperation with pericarditis, where it is difficult to find marginal branches, intramyocardial arteries, and the necessity to restore shape in the presence of myocardial scars (remodeling procedures). In the presence of on-going ischemia and instability, we prefer to perform the anastomoses in a beating heart under CPB support. Using these criteria, our rates of off-pump to on-pump conversion are low owing to preoperative selection, based on angiograms and clinical features. It seems to us that conversion from off pump to on pump due to instability increases surgical mortality and morbidity.

In a previous report with a select group of good candidates for myocardial revascularization, with criteria such as preserved ventricular function and young age, we did not observe differences regarding surgical risks and morbidity [25]. There is, however, real advantage regarding morbidity and mortality when it comes to groups of patients with significant comorbidities—and that means, "the worse the patient, the better the outcome" [26–39].

We tend to avoid on-pump revascularization especially in patients who are older, with calcified aortas, severe comorbidities, poor ventricular function, emphysema, renal insufficiency, previous cerebrovascular accidents, and other adverse clinical conditions.

In patients with low ejection fraction, off-pump revascularization is controversial [31, 32, 40–42]. Cardiopulmonary bypass and cardiac arrest under cardioplegia is a form of myocardial aggression. If grafting of the coronaries with selective blood flow interruption is possible, that would be best for the patient, achieving better myocardium recovery and less damage. Nevertheless, if we foresee that any maneuver used to expose the marginal branches could cause hemodynamic instability, our preference is to place the patient on CPB and perform the coronary anastomoses on an empty beating heart. In some situations, with important risk factors such as dialysis, chronic pulmonary disease, severe peripheral vascular disease, old age, and calcified aorta, off- pump revascularization is indicated and almost mandatory.

The controversial topics regarding the benefits and advantages of myocardial revascularization are under discussion in the literature, and prospective and randomized studies are required. They are mainly graft patency, the quality of the anastomoses, and lower number of grafts used [43, 44]. Off-pump procedure is another technique that every cardiovascular surgeon should learn and perform, offering an alternative to treat patients with certain conditions and background. On-pump and off-pump myocardial revascularization are not competitive methods. It is possible to offer a third concept: on-pump revascularization on a beating heart without cardiac arrest and cardioplegia. Cardiovascular surgeons should select the procedure for the individual patient based on their own experience, on the patient's preoperative condition, coronary angiogram, risks, and on the necessity of complete myocardial revascularization.

In summary, off-pump coronary surgery represents an important development in myocardial revascularization technology; it has consolidated as an alternative technique, with the same safety and superior outcome in a selected group of patients compared with standard coronary revascularization on CPB.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

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