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Ann Thorac Surg 1996;61:63-66
© 1996 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Coronary Artery Bypass Grafting Without Cardiopulmonary Bypass

Enio Buffolo, MD, José Carlos Silva de Andrade, MD, João Nelson Rodrigues Branco, MD, Carlos Alberto Teles, MD, Luciano Figueiredo Aguiar, MD, Walter José Gomes, MD

Escola Paulista de Medicina, Hospital São Paulo, Disciplina de Cirurgia Cardiovascular, São Paulo, SP, Brazil

Accepted for publication July 26, 1995.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background. Coronary artery bypass grafting without cardiopulmonary bypass is now an accepted technique of myocardial revascularization. We herein report our total experience with this procedure.

Methods. In a consecutive series of 8,751 patients operated on in our institution for coronary artery disease from 1981 to 1994, 1,274 patients received coronary artery bypass grafting without cardiopulmonary bypass.

Results. Results indicate that the operation can be performed with an acceptable mortality (2.5%), and that all types of arterial conduits can be used. Most commonly the left anterior descending and right coronary arteries were bypassed. The incidence of arrhythmias and of pulmonary and neurologic complications were significantly lower in this group of patients compared with patients receiving coronary artery bypass grafting with cardiopulmonary bypass. Most importantly, there was decreased cost when the procedure was used because no extracorporeal circulation, cardioplegia sets, or other cannulas were used.

Conclusions. We conclude that the continuing use of coronary artery bypass grafting without cardiopulmonary bypass is justified and that, with proper selection of patients, the procedure is safe and cost-effective.


   Introduction
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 Introduction
Material and Methods
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Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) was first performed by Kolessov in the former Soviet Union [1] and by Favaloro [2] and Garret and associates [3] in the United States. Trapp and Bisarya [4] in Canada and Ankeney in the United States [5] reported on the technique but later abandoned it as the use of CPB and cardioplegic arrest became routine. Our experience with CABG without CPB began in 1981 as new drugs used to slow heart rate and decrease oxygen consumption of the heart became available to us. Initial clinical results from our institution were reported [6, 7] documenting the advantages of the technique, as confirmed by others [8–13]. We herein present our total experience with 1,274 patients who underwent CABG without CPB.

For editorial comment, see page 10.


   Material and Methods
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 Abstract
 Introduction
 Material and Methods
Results
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From September 1981 to August 1994, 8,751 patients underwent cardiac operations at our institution. Among them, 7,477 patients received CABG with the use of CPB and 1,274 underwent CABG without the use of CPB.

The arterial blood pressure, electrocardiogram, central venous pressure, and urine output were monitored throughout the procedure. Anesthesia was induced and maintained using neuroleptic and analgesic agents. After median sternotomy, the left internal mammary artery (LIMA) was dissected simultaneously with harvesting of the long saphenous vein. Traction sutures were applied to the margins of the pericardium, displacing the heart superiorly. For exposure of the left anterior descending coronary artery (LAD), the heart was luxated slightly medially and ventrally with a moist sponge placed behind its laterodorsal aspect. Exposure of the distal right coronary artery in the atrioventricular groove was achieved by displacement of the right ventricle medially at its marginal border. The patient was heparinized using half the dose normally used for CPB (2 mg/kg). Immediately before occlusion of the coronary artery, verapamil (5 mg) was administered intravenously to reduce the systemic blood pressure and the heart rate. A 5-0 Prolene (Ethicon, Somerville, NJ) suture was applied around the coronary artery proximal and distal to the site selected for the arteriotomy. The suture was snared with a thin silicone tube, thereby allowing for a dry operative field. A longitudinal incision (6 mm) was made and an anastomosis with saphenous vein, LIMA, or other conduit was performed using a running 7-0 Prolene suture. The time of coronary occlusion varied between 11 and 19 minutes. The proximal anastomoses were performed after a tangential clamp was applied to the ascending aorta using a continuous suture of 6-0 Prolene. In cases of multiple grafts, the coronary artery with the most severe stenosis or occlusion was bypassed first. After all anastomoses were completed, heparin was neutralized with protamine sulfate.


   Results
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Comment
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The age and sex distribution is shown in Figure 1Go. Note that a large proportion of patients were more than 60 years of age. Preoperative clinical conditions were as follows: chronic coronary insufficiency, 885 (69.5%); unsuccessful angioplasty, 116 (49 for acute ischemia and 67 chronic ischemia) (9.1%); reoperations, 86 (6.8%); after thrombolysis, 67 (5.3%); unstable angina (includes angina in hospital evolution of myocardial infarction, intermediate syndrome, angina crescendo), 66 (5.2%); and acute evolving myocardial infarction (operated on within 6 hours of pain onset), 54 (4.2%). Patients undergoing operation for failed percutaneous transluminal coronary angioplasty were either treated as an emergency (49/116 patients) or an elective case (67/116 patients). Patients presenting with acute myocardial infarction received thrombolysis (5.3% of the patients) and were operated on during the first week. In 54 patients (4.2%) the operation was performed while the patient had an evolving myocardial infarction, as determined by clinical status, electrocardiogram, and creatine kinase-MB level. Twenty patients (1.6%) received additional procedures during CABG without CPB: endarterectomy in 7, left ventricular aneurysm plication in 3, pacemaker implantation in 2, stellate ganglion resection in 1, Vineberg procedure (left interum mammary artery implantation) in 1, coronary artery fistula ligation in 1, bypass to brachiocephalic trunk in 1, correction of pericardial hernia in 1, thymectomy in 1, coronary artery aneurysm in 1, and pulmonary resection in 1.



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  		Fig 1. . Distribution of 1,274 patients according to age and sex.

 
Although there was a prevalence of bypass to the LAD, other arteries also received grafts: LAD, 365; right, 659; diagonal (high lateral), 69; posterior descending, 20; marginal, 17; marginal right, 14; and ramus intermedius, 10. Patients received an average of 1.7 grafts. Obtuse marginal branches in the posterior aspect of the left ventricle were bypassed using CPB. The number of grafts is shown in Figure 2Go. The types of graft were as follows: saphenous vein, 1,175 (55.1%); LIMA, 916 (42.9%); saphenous vein/sequential, 9; ``free'' LIMA, 8; right mammary ``in situ'', 6; bovine mammary artery, 3; artificial Y saphenous vein, 6; sequential mammary, 5; gastroepiploic artery, 5; and Gore-Tex graft (W. L. Gore & Assoc, Flagstaff, AZ), 1. The LIMA was the most commonly used conduit for the LAD.



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  		Fig 2. . Distribution and number of bypassed coronary arteries.

 
Postoperative complications are shown in Table 1Go, comparing CABG with and without CPB. Any arrhthymias perioperatively were recorded; there was significantly lower incidence in the group without CPB. Similarly, there were fewer pulmonary and neurologic complications in this group. There was no difference in the incidence of myocardial infarction, bleeding, and infarction in patients receiving CABG with or without CPB.


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  		Table 1. . Postoperative Complications
 
The in-hospital mortality was 2.5%. Nine patients in cardiogenic shock due to failed percutaneous transluminal coronary angioplasty died in heart failure. Four patients died suddenly, presumably due to cardiac causes. Three patients with neurologic sequelae died. Other causes of death were as follows: sternum infection/septicemia, 3; arrhythmias (1 Chagas' disease), 3; mesenteric thrombosis, 2; aortic dissection, 2; shock lung, 2; pulmonary embolism, 2; rupture of abdominal aortic aneurysm, 1; and hypopotassemia, 1. Univariate analysis demonstrates patients more than 70 years of age and with acute presentations to be at high risk of operative death (Table 2Go). The mean hospital stay for patients operated on without CPB was 5.2 days versus 9.6 days for those operated on with CPB. The need for blood transfusion in this whole group was 0.6 units/patient.


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  		Table 2. . Univariate Analysis of Risk Factors for Operative Death
 
In a separate and prospective study, we assessed the patency rate of the LIMA anastomosed to the LAD in 60 patients (30 patients receiving CABG with CPB, and 30 patients receiving CABG without CPB), performed by the same surgeon and catheterized before discharge from the hospital (Table 3Go). There was no significant difference between the two groups, demonstrating the same patency rate with either techniques. Analyzing the last 5,838 patients undergoing myocardial revascularization procedures, we found that 20.3% were candidates to undergo operation without CPB. The technique is particularly suitable for patients with lesions in the LAD or right coronary artery, unsuccessful angioplasty, and reoperations.


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  		Table 3. . Patency Rates of Left Internal Mammary Artery Anastomosed to Left Anterior Descending Artery Before Hospital Discharge
 
The advantages and disadvantages of the technique are as follows:

Undoubtedly the procedure is technically more demanding and there is a learning curve. However, we have experienced lower morbidity/mortality, less use of blood, and decreased costs due to savings of operating room equipment, such as oxygenators, cardioplegic sets, and cannulas.


   Comment
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Coronary artery bypass grafting without CPB is gaining popularity as an alternative technique of myocardial revascularization. Although the method was described many years ago, it was abandoned with the advent of CPB and cardioplegic arrest. We became interested in this technique in 1981, and have carefully selected patients thought to be suitable for the procedure, namely, those with diseases other than the posterior branch of the circumflex artery. Patients with left main disease were excluded, as well as those with combined valvular and coronary diseases. Ventricular function was not used as an exclusion criteria, nor were associated systemic diseases. The technique is particularly used in high-risk patients such as those with renal failure, respiratory problems, advanced age, cerebrovascular accidents, and other systemic diseases.

Our on-going experience indicates that, with proper selection of patients, CABG without CPB is safe and effective. Arterial conduits, such as the LIMA, can be easily used, and most coronary arteries can be bypassed. The mortality rate was low (2.5%), and the incidences of serious complications such as arrhythmias, pulmonary sequelae, and neurologic sequelae were significantly lower than in patients undergoing CABG with CPB. The patency rate was similar to that in patients undergoing conventional CABG.

Further, at our institution, there was a cost saving of approximately US$3,000 per case due to decreased use of operating room equipment such as oxygenators, cardioplegic sets, cannulas, and others. There was also decreased stay in the intensive care unit and in the hospital. The management of these patients in terms of fluid, electrolyte, and respiratory care is simpler. In our institution, cardiologists currently favor CABG without CPB for single LAD lesions.

Undoubtedly the technique is more demanding, and there is a learning curve with this method of CABG. The surgeon, however, has the option of placing the patient on CPB should any problem occur.

In summary, in this large experience with CABG without CPB, the indications for operation with this method has been identified; the method can be used in approximately 25% of patients undergoing coronary revascularization. Arterial conduits can be used, and the patency rate is similar to that of conventional techniques. The mortality rate is acceptably low, and complication rates were lower compared with conventional techniques. In selected cases, the procedure is cost-effective due to lower use of hospital resources in the operating room, intensive care unit, and ward. The continuing use of this technique of coronary artery surgery is therefore justified.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 
Address reprint requests to Dr Buffolo, Rua Napoleao de Barros, 715, 3• Andar, São Paulo, SP, CEP 04024-002 Brazil.


   References
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 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Kolessov VL. Mammary artery-coronary artery anastomosis as method of treatment for angina pectoris. J Thorac Cardiovasc Surg 1967;54:535–44.[Medline]
  2. Favaloro RG. Saphenous vein autograft replacement of severe segmental coronary artery occlusion. Ann Thorac Surg 1968;5:334–9.[Medline]
  3. Garrett HE, Dennid EW, DeBakey ME. Aorto-coronary bypass with saphenous vein graft. Seven-year follow up. JAMA 1973;223:792–4.[Medline]
  4. Trapp WG, Bisarya R. Placement of coronary artery bypass graft without pump-oxygenator. Ann Thorac Surg 1975; 19:1–9.[Medline]
  5. Ankeney JL. To use or not use the pump oxygenator in coronary bypass operations. Ann Thorac Surg 1975;19:108–9.[Medline]
  6. Buffolo E, Andrade JCS, Succi JE, et al. Direct myocardial revascularization without cardiopulmonary bypass. Thorac Cardiovasc Surg 1985;33:26–9.[Medline]
  7. Buffolo E, Andrade JCS, Branco JNR, et al. Myocardial revascularization without extra-corporeal circulation. Eur J Cardiothorac Surg 1990;4:504–8.[Abstract]
  8. Benetti FJ. Direct coronary surgery with saphenous vein bypass without either cardiopulmonary bypass or cardiac arrest. J Cardiovasc Surg 1985;26:217–22.[Medline]
  9. Benetti FJ. Coronary artery bypass without extracorporeal circulation versus percutaneous transluminal coronary angioplasty: comparison of cost [Letter]. J Thorac Cardiovasc Surg 1991;102:802–3.
  10. Archer R, Ott DA, Parracvicini R, et al. Coronary artery revascularization without cardiopulmonary bypass. Tex Heart Inst J 1984;11:52–7.
  11. Fanning WJ, Kakos GS, Willians TE Jr. Reoperative coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1993;55:486–9.[Abstract]
  12. Laborde F, Abdelmequid I, Piwnica A. Aortocoronary bypass without extracorporeal circulation: why and when? Eur J Cardiothorac Surg 1989;3:152–5.[Abstract]
  13. Pfister AJ, Zaki MS, Garcia JM, et al. Coronary artery bypass without cardiopulmonary bypass. Ann Thorac Surg 1992;54:1085–92.[Abstract]

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M. Gaudino, F. Andreotti, R. Zamparelli, A. Di Castelnuovo, G. Nasso, F. Burzotta, L. Iacoviello, M. B. Donati, R. Schiavello, A. Maseri, et al.
The -174G/C Interleukin-6 Polymorphism Influences Postoperative Interleukin-6 Levels and Postoperative Atrial Fibrillation. Is Atrial Fibrillation an Inflammatory Complication?
Circulation, September 9, 2003; 108(90101): II-195 - 199.
[Abstract] [Full Text] [PDF]

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 SEMIN CARDIOTHORAC VASC ANESTHHome page
A. J. Chong, C. R. Hampton, and E. D. Verrier
Microvascular Inflammatory Response in Cardiac Surgery
Seminars in Cardiothoracic and Vascular Anesthesia, September 1, 2003; 7(3): 333 - 354.
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 J. Thorac. Cardiovasc. Surg.Home page
P.P. Lunkenheimer, K. Redmann, J.C. Florek, H.H. Scheld, A. Hoffmeier, C.W. Cryer, R.V. Batista, J.J. Stanton, J.D. F. Filho, and R.H. Anderson
Surgical reduction of ventricular radius by aspirated plication of the myocardial wall: an experimental study
J. Thorac. Cardiovasc. Surg., August 1, 2003; 126(2): 592 - 596.
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 Eur. J. Cardiothorac. Surg.Home page
S. Karthik, G. Musleh, A. D. Grayson, D. J.M. Keenan, R. Hasan, D. M. Pullan, W. C. Dihmis, and B. M. Fabri
Effect of avoiding cardiopulmonary bypass in non-elective coronary artery bypass surgery: a propensity score analysis
Eur. J. Cardiothorac. Surg., July 1, 2003; 24(1): 66 - 71.
[Abstract] [Full Text] [PDF]

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 Eur. J. Cardiothorac. Surg.Home page
D. J. Goldstein, R. B. Beauford, B. Luk, R. Karanam, T. Prendergast, F. Sardari, P. Burns, and C. Saunders
Multivessel off-pump revascularization in patients with severe left ventricular dysfunction
Eur. J. Cardiothorac. Surg., July 1, 2003; 24(1): 72 - 80.
[Abstract] [Full Text] [PDF]