Off-pump coronary artery bypass. Mid-term results

Perioperative outcomes in minimally invasive direct coronary artery bypass versus off-pump coronary artery bypass with sternotomy

Introduction

Surgical treatment of isolated left anterior descending coronary artery disease can be performed with either minimally invasive direct coronary artery bypass via a left anterior thoracotomy (MIDCAB) or off-pump coronary artery bypass via a median sternotomy (OPCAB).

Aim

To compare the perioperative outcomes of patients undergoing MIDCAB or OPCAB surgery.

Material and methods

Patients who underwent either MIDCAB or OPCAB for isolated left anterior descending (LAD) coronary artery disease between October 2013 and December 2015 were retrospectively evaluated. Operations were carried out by the same surgical team. Preoperative, intraoperative and postoperative data of the patients were recorded for analyses.

Results

Twenty-three patients (7 females, 16 males) underwent MIDCAB surgery, and 24 patients (4 female, 20 males) underwent OPCAB surgery. The two groups were comparable regarding preoperative patient characteristics. Duration of mechanical ventilation (5.1 ±0.7 h vs. 6.6 ±0.9 h), intensive care unit stay (19.4 ±2.5 h vs. 45.8 ±5.4 h) and hospital stay (4.3 ±0.4 days vs. 5.6 ±0.8 days) were significantly shorter in the MIDCAB group (p < 0.01). Patients in the OPCAB group required significantly more blood transfusions (1.83 ±0.38 units vs. 0.17 ±0.38 units) and fresh frozen plasma use (2.33 ±0.96 units vs. 0.69 ±0.76 units) (p < 0.01). Conversion to sternotomy was not required in the MIDCAB group. There was no mortality, conversion to cardiopulmonary bypass or serious complication in either group.

Conclusions

We believe that the MIDCAB technique is more advantageous than the OPCAB technique in the treatment of patients with a critical LAD lesion.

Myocardial revascularization without extracorporeal circulation; Why hasn't it convinced yet?

Extracorporeal circulation has led to a great development in cardiovascular surgery during the last five decades. Its time-proven efficacy and safety have made on-pump coronary artery bypass grafting (CABG) the gold standard method of surgical revascularization. However, coronary revascularization on cardiopulmonary bypass and the accompanying aortic manipulation are related to plenty of deleterious complications. Therefore, off-pump CABG surgery was established to avoid complications. Nevertheless, despite the initial enthusiasm on this technique, only 20% of myocardial revascularization procedures worldwide are performed off-pump. Not only are off-pump cardiac procedures more technically difficult but also they do not provide better results in terms of graft patency, completeness of revascularization, repeat revascularization requirement, cost, and quality of life. Completeness of revascularization and anastomotic quality should not be compromised to avoid cardiopulmonary bypass.

Coronary artery bypass grafting in the octogenarians: should we intervene, or leave them be?

Objective

Coronary artery bypass grafting (CABG) is gradually increasing in the elderly population. We aimed to investigate the risk factors and the results of CABG along with the long term survival in patients at an age of 80 and older.

Methods

Between January 2002 and December 2011, a total of 101 consecutive patients at an age of 80 and older who underwent CABG in our hospital were included in the study. The patients were followed and the long-term survival was estimated.

Results

The mean age of the patients was 82.98 ± 2.27 years. Sixty-four (63.4%) were males and 37 (36.6%) were females. Emergency surgery, duration of cardiopulmonary bypass, the intensive care unit (ICU) stay, inotropic support, intra aortic balloon pulsation application, amount of erythrocyte transfusion and fresh frozen plasma transfusion and ventilation period were significantly higher in the patients who died in the hospital. The duration of cardiopulmonary bypass (CPB) was found to be an independent predictor of mortality (OR: 1.18, 95% CI 1.01−1.38, P = 0.034). The in-hospital mortality was 16.8%. Kaplan-Meier analyses revealed a survival ratio of 91.3% at one year, 82.9% at three years and 69.0% at five years.

Conclusions

Patients at the age of 80 and older can be candidates for the CABG procedure bearing in mind that they may have a longer ventilation period and intensive care unit stay. The morbidity and mortality of this age group is considered within an acceptable range. Approaches to minimize CPB, or the choice of off-pump surgery, may be a preventive method to lower the incidence of mortality. Hence, CABG may be performed in this age group with a satisfactory survival ratio.

Meta-analysis of randomized trials comparing off-pump with on-pump coronary artery bypass graft patency

BACKGROUND

Off-pump coronary artery bypass graft surgery (OPCAB) is increasingly becoming a widely used technique and challenges conventional on-pump coronary artery bypass grafting as the standard surgical therapy for coronary artery disease. Little information, however, is available concerning postoperative performance of bypass grafts done with this new technique. The aim of this study is to assess differences in graft patency between OPCAB and coronary artery bypass grafting by meta-analysis of data published in randomized trials.

METHODS

A literature search for the period beginning January 1990 until December 2004 supplemented with manual bibliographic review was performed for all peer-reviewed English-language publications. A systematic overview (meta-analysis) of randomized trials was conducted to assess differences between OPCAB and coronary artery bypass grafting in graft occlusion rates.

RESULTS

Literature search yielded five comparable randomized studies, for a total of 872 and 998 grafts performed during OPCAB and coronary artery bypass grafting procedures, respectively. Meta-analysis of these studies showed an increased risk of graft occlusion in the OPCAB group of patients, both when all the studies were analyzed together (odds ratio, 1.51; 95% confidence intervals, 1.15 to 1.99; p = 0.003), and when low-quality (odds ratio, 1.46; 95% confidence intervals, 1.05 to 2.03; p = 0.02) and high-quality (odds ratio, 1.65; 95% confidence intervals, 0.99 to 2.75; p = 0.05) studies were analyzed separately.

CONCLUSIONS

Cumulative analysis of the few prospective randomized studies currently available in the literature documents a reduction in postoperative patency of coronary artery bypass grafts performed during OPCAB procedures. The risk of reduced graft patency needs to be considered when choosing OPCAB as tailored strategy for selected patients.

Clinical outcome of cardiac surgery in octogenarians

The purpose of this study was to investigate the operative results and the clinical outcomes for octogenarians who underwent cardiac surgery. Twenty consecutive octogenarians who had cardiac operations at Samsung Medical Center from October 1994 through December 2004 were included in the study. The medical records were retrospectively reviewed and the follow-up results were obtained by the interview. The patients were 15 men and 5 women, and their mean age was 83.1 yr (range: 80-89 yr). The surgical priority was urgent for 5 patients and it was elective for 15 patients. Coronary artery bypass grafting (CABG) was performed in 14 patients, valve surgery was performed in 4 patients and CABG plus valve surgery was performed in 2 patients. There was one hospital death on day one after urgent CABG in an 80-yr-old man who had left main coronary artery occlusion. There were three deaths during the follow-up. Sudden death occurred in one patient at 2 months after valve surgery, and there were two non-cardiac deaths at 12 and 14 months, respectively, after CABG. Non-fatal postoperative complications occurred in 2 of 5 urgent patients and in 3 of 15 electives. The survival rate for the 19 hospital survivors at 24 months after surgery was 80% and the mean follow-up period was 22.5 months (range: 1-58 months). In conclusion, cardiac surgery could be performed within acceptable limits of the risk and its long-term results could be expected to be favorable for the octogenarians.

Early results of off-pump coronary artery bypass: retrospective consecutive comparative study

OBJECTIVE

The purpose of this study is to compare the operative results of off-pump coronary artery bypass (OPCAB) and on-pump (conventional) coronary artery bypass (CCAB), to clarify qualitative problems and whether OPCAB is less invasive or not.

METHODS

OPCAB was consecutively performed in 63 patients and CCAB in 63 patients between July 1998 and December 2003.

RESULTS

The mean number of bypass grafts was 2.43 +/- 0.82 in the OPCAB group and 2.70 +/- 0.71 in the CCAB group (p = 0.096). In-hospital mortality was 0% in the OPCAB group and 3.2% in the CCAB group. The incidence of perioperative myocardial infarction was 0% in the OPCAB group and 3.2% in the CCAB group. The incidence of postoperative major complications was significantly lower in the OPCAB group than in the CCAB group (OPCAB group=4 complications, CCAB group=13 complications). Cerebrovascular accidents occurred in 1.6% of patients in both groups. The incidence of sternal infection or mediastinitis was 0% in the OPCAB group and 3.2% in the CCAB group. The early patency rate of graft was 94.0% in the OPCAB group and 92.8% in the CCAB group, and was not significantly different (p = 0.822).

CONCLUSION

Operative mortality and major complications after surgery in OPCAB were lower than that in CCAB. The early patency rate in OPCAB was as good as that in CCAB. It is considered that OPCAB is less invasive and the quality of bypass in OPCAB is as good as that in CCAB.

Bypass to the Distal Right Coronary Artery Using In Situ Gastroepiploic Artery*

OBJECTIVE

We investigated the clinical outcomes after coronary artery bypass grafting (CABG) using the in situ gastroepiploic artery (GEA) exclusively bypassing to the distal right coronary artery (RCA).

METHODS

Between, 1991 and 2002, 1020 consecutive patients (788 male and 232 female with a mean age of 63.6 +/- 9.7) underwent CABG to the distal coronary artery using in situ GEA in the Shin-Tokyo Hospital Group. Their perioperative and follow-up data were retrospectively analyzed.

RESULTS

The in-hospital morbidity rate was 15.1% and the mortality rate was 0.6%. Postoperative myocardial infarction associated with GEA graft failure occurred in two cases. Among the survivors, follow-up was completed in all patients with a mean period of 4.7 +/- 2.4 years. Actuarial 3- and 5-year angina or intervention-free rates were 93.6% and 89.9%, respectively. Actuarial 3- and 5-year survival rates were 95.8% and 91.6%, respectively. Postoperative angiography was performed on 482 patients within 1 year, 115 patients with 3 years, and in 87 patients more than 4 year after surgery. The GEA patency rates at 1, 3, and 5-year were 95.7%, 90.2%, and 85.7%, respectively. These patency rates were compared with other graft materials (the saphenous vein n = 291, radial artery n = 186, and right internal thoracic artery n = 23) used for bypass to the distal RCA, and we found no significant differences (p = 0.29).

CONCLUSION

The perioperative and clinical remote results of GEA grafting were satisfactory. The angiographic patency rates of GEA to the distal RCA was not inferior to the saphenous vein graft in this study.

Priming Reduced Extracorporeal Circulation Setup (PRECiSe) with the DeltaStream diagonal pump

Different systems for beating heart procedures and low priming systems limited to coronary artery bypass grafting (CABG) have been introduced. We describe Priming Reduced Extracorporeal Circulation Setup (PRECiSe), a new low priming system which sup-plies all the features of cardiopulmonary bypass (CPB). PRECiSe incorporates the DeltaStream diagonal pump, which pumps blood from the right atrium to the aorta via a membrane oxygenator and a filter; the system is placed beneath the patient's head resulting in extremely short tubing. A reservoir allows the use of suckers and vents. Autologous blood priming furthers reduces hemodilution. In a safety study the system was used for extracorporeal circulation in 11 patients undergoing CABG without adverse effects. By use of PRECiSe mean priming was reduced to 268.5 ml resulting in minimal hemo-dilution and transfusion requirements.

Our experiences for off-pump coronary artery bypass grafting to the circumflex system

BACKGROUND

Complete revascularization has been difficult in off-pump coronary artery bypass grafting (OPCAB). Hemodynamic deterioration often prevents access to the circumflex territory. This study presents instrumentation for accessing the circumflex territory, and our clinical experience.

METHODS

From August 1999 through December 2002, 140 patients underwent OPCAB via sternotomy in our institution. The 114 requiring reconstruction of the circumflex artery are the subjects of this study. There were no exclusion criteria. A series of techniques and instruments were developed to provide access to the circumflex area while hemodynamic stability was preserved, including the left pericardial traction technique, compression of the right pericardium, a right sternal retractor, and a type of shunt tube.

RESULTS

Patients received an average of 3.2 grafts (range, 2 to 6). Complete revascularization was achieved in 95% of the cases. Complications included respiratory insufficiency (0.8%), renal dysfunction (7%), and sternal wound infection (0.8%). Blood transfusions were required in 10 patients (8%). No patient suffered perioperative myocardial infarction or stroke. No operation was converted to cardiopulmonary bypass. There was no operative death. Predischarge angiography demonstrated a 99% patency rate.

CONCLUSIONS

With our techniques and instruments, off-pump coronary revascularizaion of the circumflex area may be performed safely to achieve complete revascularization. Early clinical results are excellent, but long-term longitudinal follow-up is required to assess the future effectiveness of OPCAB procedure with our techniques.

Left thoracotomy approach in reoperative off-pump coronary revascularization: bypass grafting from the left axillary artery or descending thoracic aorta

OBJECTIVE

Reoperative coronary bypass grafting is at high risk. Particularly in redo cases where the patent graft is running near the midline of the sternum, the graft may be exposed to injury by a median sternotomy and subsequent dissection. Whereas, off-pump bypass grafting from the left axillary artery or descending thoracic artery by a left thoracotomy approach is safe for preventing graft damage.

METHODS

From March 1998 to February 2002, we performed off-pump coronary artery bypass grafting by a left thoracotomy approach in 9 patients. The left axillary artery was used as the inflow vessel in 4 cases, and the descending thoracic aorta in 5.

RESULTS

The radial artery was anastomosed proximally to the axillary artery in 4 cases and the descending thoracic aorta in one case. The saphenous vein graft was anastomosed proximally to the descending thoracic aorta in 4 cases. Transdiaphragmatic minimally invasive bypass grafting for the right coronary artery was simultaneously performed in 3 cases. Postoperative cardiac events were ventricular arrhythmia in 6 cases and supraventricular arrhythmia in 3 cases. There was no damage to the patent grafts. Postoperative coronary angiography performed in 8 cases revealed all the grafts to be patent without stenosis. Cardiac symptoms were not found after the operation in any of the cases.

CONCLUSIONS

These procedures can prevent the injury to patent grafts caused by a median sternotomy, and will be one of the useful strategies for reoperative off-pump coronary artery bypass grafting.

Clinical and six-month angiographic evaluation of coronary arterial graft interrupted anastomoses by use of a self-closing clip device: a multicenter prospective clinical trial

OBJECTIVES

To evaluate the safety and effectiveness of a self-closing surgical clip with an interrupted technique in left internal thoracic artery to left anterior descending artery bypass grafting.

METHODS

Eighty-two patients were enrolled and treated (February 2000 through August 2001) in a prospective, nonrandomized, multicenter trial. Left internal thoracic artery to left anterior descending artery anastomoses were performed in 60 off-pump coronary artery bypasses (73%), 12 conventional coronary artery bypass grafting (15%), and 10 minimally invasive direct coronary artery bypass (12%) procedures. Angiograms (64 to 383 days, mean 200 days) were obtained on 63 patients (77%). Qualitative and quantitative angiographic assessment was performed by an independent core laboratory.

RESULTS

The self-closing surgical clip was used for 82 left internal thoracic artery to left anterior descending artery interrupted anastomoses without the requirement for knot tying or primary suture management. Minimum left internal thoracic artery to left anterior descending artery anastomosis time was 3 minutes. There was one perioperative and one late death (both not heart related) and one reexploration for bleeding unrelated to the anastomotic site. FitzGibbon grades were as follows: A (n = 60, 95.2%), B (n = 3, 4.8%) including one kinked left internal thoracic artery, and O (n = 0, 0%). Quantitative analysis (n = 57) showed mean lumen diameters of left internal thoracic artery proximal to the anastomosis of 2.1 mm, at anastomosis of 2.0 mm, and in the left anterior descending artery distal to the anastomosis of 1.9 mm. The average ratio of the anastomosis to the left anterior descending artery diameter was 1.14 (0.45 to 1.93). Anastomotic stenosis as a percentage of average left internal thoracic artery to left anterior descending artery diameter was -2.3%, comparing favorably with results (23% to 24%) reported from the Patency, Outcomes, Economics, Minimally invasive direct coronary artery (POEM) bypass study.

CONCLUSIONS

The interrupted technique, facilitated by a self-closing anastomotic clip, yields favorable 6-month angiographic results when compared with other published studies.

Off-pump multivessel revascularization: efficacy of suction type of coronary stabilizer

OBJECTIVE

Off-pump coronary artery bypass grafting (CABG) has come into widespread use with the availability adequate coronary stabilization devices. We studied the efficacy of second-generation coronary stabilization devices (suction device) comparing to the first-generation device (compression device).

METHODS

We prospectively analyzed consecutive patients who underwent isolated off-pump CABG via a midline sternotomy at Shin-Tokyo Hospital Group between July 1, 1996, and August 31, 2000, comparing perioperative, and follow-up data in the group using a suction device (group S) to that in the group using a compression device (group C).

RESULTS

Preoperative risk factors were identical between the two groups, with the exception of a higher incidence of three vessel disease in group S. Complete revascularization increased from 47.3% in group C to 88.1% in group S, and the number of distal anastomoses from 2.1 +/- 0.6 in group C to 2.9 +/- 0.9 in group S. Revascularization of the circumflex artery was achieved in 21.7% of group S patients, which was significantly higher than that in group C (2.2%). Postoperative recovery, mortality, and morbidity did not differ significantly between groups. Calculated event-free rates at 2 years was 88.7% in group C and 92.0% in group S (p = NS).

CONCLUSIONS

Anastomosis to the posterior wall of the heart using the suction device is safe. An increased number of distal anastomoses may reduce the occurrence of cardiac events related to incomplete revascularization.

Coronary artery bypass grafting for patients with poor left ventricular function

Patients undergoing isolated first-time elective coronary bypass surgery were classified according to their preoperative ejection fraction: group 1 comprised 131 patients with poor left ventricular function (ejection fraction < 40%); group 2 was 1,496 control patients. The mean number of distal anastomoses was not significantly different in the 2 groups, however, clamp time, pump time, and operative time were longer in group 1. Patient recovery was significantly slower in group 1. Morbidity (14.5% in group 1 versus 7.4% in group 2, p < 0.005) and mortality (2.3% versus 0.1%, p < 0.0001) were higher in group 1. During late follow-up, the 5-year survival rate (70.1% versus 90.5%) and 5-year event-free rate (65.6% versus 81.9%) were significantly inferior in group 1 compared to group 2. The results of bypass surgery in cases of decreased left ventricular function were poor, and such patients need to be carefully followed up.

Five year clinical follow up of patients who have had off pump coronary artery bypass grafting

BACKGROUND

Off pump coronary artery bypass (OPCAB) has become a common technique for conducting coronary artery surgery. There has been some concern that the anastomoses might not be conducted as effectively on the beating heart, which could lead to poor long-term results. The aim of the present study was to follow up all patients who had undergone OPCAB at our institution to determine clinical outcomes up to 5 years postoperatively.

METHODS

All living patients who had undergone OPCAB up until December 2000 were telephoned. For those who could be contacted, a detailed questionnaire was completed and the data were analysed.

RESULTS

The technique of OPCAB was carried out on 312 patients. Thirteen of these patients died, five perioperatively. Actuarial survival at 5 years was 94.6% and freedom from cardiac related events was 92.1%. There were only two patients with angina worse than class I. Patients showed a high rate of compliance with risk factor management. Forty per cent of patients claimed to have had psychological problems related to the surgery.

CONCLUSIONS

Mid-term results of OPCAB are very satisfactory, but randomised trials are needed to see whether they are different from the results of conventional coronary artery bypass grafting.

Current results of off-pump coronary artery bypass surgery

Whether to use or not use cardiopulmonary bypass-cardioplegic arrest to perform coronary artery bypass surgery is the main controversy presently facing our surgical specialty. The reported clinical outcomes are mainly retrospective and highly debatable for conclusiveness regarding the benefits of off-pump surgery. As more centers and larger patient cohorts are analyzed and reported, particularly over the last 2 years, off-pump surgery appears to provide significantly improved outcomes with decreased bleeding and transfusion requirements, less myocardial enzyme release, less ventilatory time, and decreased hospital stay and costs. Reported off-pump benefits for the major outcomes of operative mortality and stroke are encouraging, but less conclusive. From experienced centers, early off-pump angiographic graft patency has been comparable to previously published conventional results. High-risk, elderly patients may benefit the greatest from off-pump surgery. Although in relative technical infancy, off-pump coronary artery bypass grafting has demonstrated enough benefit outcomes that it is no longer an experimental procedure, but a valid surgical revascularization method requiring further investigation and continued usage.

Urgent off-pump coronary artery bypass grafting

OBJECTIVES

The use of off-pump coronary artery bypass grafting (CABG) has become widespread, since it has proven less invasive and to promote early recovery. In this study, we investigated the efficacy of off-pump CABG in patients in the evolving phase of acute myocardial infarction.

METHODS

Retrospective chart review was carried out for patients undergoing urgent isolated off-pump and on-pump CABG at Shin-Tokyo Hospital Group between January 1991 and June 2001. The patients' demographic, operative data, and postoperative results were collected.

RESULTS

The off-pump group consisted of 19 males and 11 females with a mean age of 72.0 years and the on-pump group of 91 males and 38 females with a mean age of 64.3 years. Preoperative use of intraaortic balloon pumping and preoperative shock was more frequently observed in the on-pump group. The mean number of distal anastomoses was 3.1 +/- 0.9 in the off-pump group and 3.2 +/- 1.1 in the on-pump group (p = NS). Intubation time (18.5 vs 32.9 hours), ICU stay (3.4 vs 4.9 days), and postoperative stay (13.5 vs 24.3 days) were significantly shorter in the off-pump group than in the on-pump group (P < 0.05). The frequency of the major complications was significantly lower in the off-pump group (9/30, 30%) than the on-pump group (65/129, 50.4%), especially for postoperative low output syndrome (p < 0.05). Multivariate analysis demonstrated a significant reduction in the recovery period by use of off-pump CABG. Early follow-up results were similar between the two groups, in terms of late cardiac events and survival.

CONCLUSION

Urgent off-pump CABG is safe and provides early recovery, provided that the patient's intraoperative hemodynamics are taken into account.

Combined coronary artery bypass grafting on the beating heart and abdominal aortic aneurysm repair

Abdominal aortic aneurysm (AAA) is commonly associated with coronary artery disease (CAD). Eleven patients underwent the combined operation of coronary artery bypass grafting (CABG) on the beating heart and AAA repair: 10 underwent off pump CABG and 1 patient required centrifugal pump and pulmonary assist with closed circuit because of unstable hemodynamics. All cases were discharged without severe complications and with patent coronary bypass grafts.

Off-pump coronary artery bypass grafting for patients with three-vessel disease

BACKGROUND

Off-pump coronary artery bypass grafting (CABG) has been performed since 1996 in our institute, and its application has recently been expanded to patients with three-vessel disease. A study was performed to clarify the benefit of off-pump CABG for patients with three-vessel disease.

METHODS

Between June 1, 1991 and September 30, 2001, a total of 1089 patients with three-vessel disease (832 men and 257 women; mean age, 64.0 +/- 9.1 years) underwent on-pump CABG. After 1997, a total of 310 patients with three-vessel disease (223 men and 87 women; mean age, 68.8 +/- 8.6 years) underwent off-pump CABG. Data of the historical cohort of on-pump CABG and the concurrent cohort of off-pump CABG were analyzed retrospectively.

RESULTS

The 2 groups were age and gender matched. Significant comorbidities were more often observed in the off-pump group than in the on-pump group. The mean number of bypass grafts in the off-pump versus on-pump CABG was 3.3 vs 3.7, P <.0001. The mean intubation period, intensive care unit stay, and postoperative hospital stay were 7.9 vs 11.7 hours, 2.2 vs 3.0 days, and 14.5 vs 17.5 days, respectively (P <.0001). In-hospital mortality rate (0.6% vs 1.2%, respectively) and morbidity rates (10.3% vs 12.9%, respectively) were not significantly different. After surgery, calculated event-free rates at 2 years were 93.3% vs 91.9%, respectively; P = not significant.

CONCLUSIONS

In patients with multivessel disease, off-pump CABG provided early recovery, and its complication rates and early follow-up results were equivalent to on-pump CABG.

Triple arterial coronary revascularization using the radial artery and bilateral internal mammary arteries versus the gastroepiploic artery and bilateral internal mammary arteries

Arterial grafts are frequently used in modern coronary artery bypass grafting (CABG) and the benefit of the 2 internal mammary arteries (IMA) has already been established. However, the choice of the third arterial conduit, in addition to the IMA, is controversial. We have retrospectively analized perioperative and the follow-up results of patients who underwent CABG with triple arterial bypass using either the radial artery (RA) or the gastroepiploic artery (GEA) in conjunction with the bilateral IMA (BIMA). Between December 1995 and June 2001, 1,516 consecutive isolated CABG operations were performed at Shin-Tokyo Hospital. Among them the RA and BIMA were used in 96 patients (78 males, 18 females; mean age, 63.2+/-6.7 years, group R), and the GEA and BIMA in 123 patients (101 males, 22 females; mean age, 61.0+/-11.6 years, group G). Their perioperative and follow-up data were studied. The preoperative risk factors were similar between the 2 groups, except that there were significantly fewer patients with renal dysfunction in group R. The surgical results did not differ between the 2 groups; however, the GEA was more commonly used for revascularization of the right coronary artery, while the RA was used for the diagonal, circumflex or right coronary arteries. Surgical mortality and morbidity rates were not significantly different. During the follow-up period of 2.3+/-1.6 years, the event-free rates as well as the survival rates were not significantly different. CABG with either the RA or the GEA in conjunction with the BIMA can be performed safely. The surgical results as well as the follow-up results were acceptable and no significant differences between the 2 groups were observed.

Skeletonized radial artery grafting: improved angiographic results

BACKGROUND

The radial artery has been used for coronary artery bypass grafting (CABG) but its early angiographic results were relatively inferior to that of the internal mammary artery, most likely due to spasm of the graft. To avoid vasospasm we harvested the radial artery using a skeletonized technique and spasm was completely reversed before use. The graft patency of the skeletonized radial artery was compared with the radial artery graft harvested as a pedicle.

METHODS

A total of 112 patients underwent isolated CABG using a pedicled radial artery between September 1, 1999, and August 31, 2000 (group P), and a total of 131 patients with a skeletonized radial artery between September 1, 2000, and August 31, 2001 (group S). An ultrasonic scalpel (Harmonic Scalpel; Ethicon EndoSurgery, Cincinnati, OH) was used for skeletonization and removing satellite veins and surrounding tissue. CABG was performed by the standard technique. Perioperative results were prospectively collected and compared between the two groups. Early angiographic results performed within 3 months were also compared.

RESULTS

There were two hospital deaths in group S. Major complications were observed in 11 (8.4%) in group S and 3 (2.7%) in group P (p = not significant [NS]). None were related to the radial artery graft. Angiography was obtained in 96 patients of group S and 76 patients in group P and revealed that the stenosis free graft patency rate of group S (138 of 143, 96.5%) was superior to that of group P (73 of 86, 84.9%) with p < 0.005.

CONCLUSIONS

Skeletonization of the radial artery with the ultrasonic scalpel is safe and contributes to reducing the incidence of early graft stenosis.

On-pump versus off-pump coronary artery bypass using quadruple arterial grafts

The optimal combination of arterial grafts for quadruple coronary artery bypass is the bilateral internal mammary artery, the radial artery, and the gastroepiploic artery. Patients who underwent quadruple bypass in our hospital group between December 1995 and March 2001 were retrospectively analyzed to determine whether off-pump surgery (n = 27) provides better outcomes than conventional on-pump surgery (n = 51). Preoperative risk factors as well as the mean number of distal anastomoses (4.5 in the off-pump versus 4.8 in the on-pump patients) were not significantly different between the 2 groups. Postoperative recovery was significantly faster in the off-pump group than in the on-pump group (intubation time, 6.4 versus 16 hours; stay in intensive care unit, 2 versus 3 days; and postoperative hospital stay, 12.3 versus 15.8 days). Early stenosis-free graft patency rates did not differ significantly (90.3% versus 89.3%). No late cardiac events were observed in the off-pump group, while 4 occurred in the on-pump group. Quadruple arterial bypass without cardiopulmonary bypass is safe, and it allows faster recovery. The follow-up results of off-pump patients so far have been satisfactory.

Coronary artery bypass grafting using the gastroepiploic artery in 1,000 patients

BACKGROUND

The gastroepiploic artery (GEA) has been used as a graft in 1,000 patients in our institution, and the clinical outcome and the angiographic long-term results were reviewed.

METHODS

Between June 1, 1991, and June 30, 2001, 1,000 consecutive isolated coronary artery bypass grafting procedures using the GEA were performed in the Shin-Tokyo Hospital Group. The perioperative data were retrospectively analyzed, and the late angiographic results, cardiac related events, and survival were examined. The end points of the follow-up study were death or the occurrence of a cardiac-related event.

RESULTS

The GEA was used in 767 men and 233 women (mean age, 63.8 +/- 9.4 years). The GEA was used as an in situ graft in 99.6% of patients and was anastomosed to the right coronary artery in 87.8% and the circumflex artery in 10.0%. In addition, the left internal mammary artery was used in 96.9% of patients, the right internal mammary artery in 28.5%, the radial artery in 41.7%, the inferior epigastric artery in 1.4%, and the saphenous vein in 40.1%. The hospital morbidity and mortality rates were 10.8% and 0.8%, respectively. No abdominal complications were observed. Postoperative myocardial infarction associated with GEA graft failure occurred in 2 patients. During the late follow-up of 4.0 +/- 2.3 years, cardiac-related events were observed in 155 patients. The actuarial 3- and 5-year event-free rates were 91.2% and 84.2%, respectively. There were 86 late deaths, 36 of which were cardiac related deaths. The actuarial 3- and 5-year survival rates were 96.6% and 92.6%, respectively. Angiography was performed on 437 patients within 1 year after operation and in 221 patients more than 1 year postoperatively (mean interval, 3.1 +/- 1.8 years). The actuarial 1-, 3-, and 5-year GEA graft patency rates were 98.7%, 91.1%, and 84.4%, respectively, and the actuarial 1-, 3-, and 5-year LIMA graft patency rates were 99.6%, 98.8%, and 97.0%, respectively (p < 0.0005).

CONCLUSIONS

The GEA was used for coronary artery bypass grafting with good perioperative results. However, the angiographic patency rate of the GEA was inferior to that of the internal mammary arteries. The late occurrence of angina attributed to GEA graft failure should be carefully monitored.

Off-pump coronary artery bypass grafting: new developments but a better outcome?

Off-pump coronary artery surgery is now performed safely and effectively without cardiopulmonary bypass. This review includes indications, approaches, anaesthetic and haemodynamic management, and compares the occurrence of postoperative complications and multiorgan dysfunction with conventional cardiac surgery.

Off-pump coronary artery bypass grafting for elderly patients

BACKGROUND

The use of off-pump coronary artery bypass grafting (CABG) has recently become widespread, and it has been proven to be less invasive and to facilitate early recovery. In this study, we investigated the efficacy of off-pump CABG for patients aged 75 years or more.

METHODS

A retrospective chart review was carried out for patients who underwent isolated off-pump and on-pump CABG at Shin-Tokyo Hospital between January 1997 and December 2000. The patients' demographic, operative data, and postoperative results were collected.

RESULTS

The off-pump group consisted of 60 men and 44 women with a mean age of 78.8 years, and the on-pump group consisted of 54 men and 20 women with a mean age of 77.6 years. Distal anastomoses were significantly fewer in the off-pump group (2.4 in off-pump group versus 3.7 in on-pump group), but total arterial bypass was more frequently achieved in off-pump group (82.7% versus 25.7%). Intubation time (8.4 versus 18.4 hours), intensive care unit stay (2.2 versus 3.5 days), and postoperative stay (13.8 versus 20.0 days) were significantly shorter in the off-pump group than in the on-pump group (p < 0.05). The frequency of the occurrence of major complications was significantly lower in the off-pump group than the on-pump group, especially in regard to postoperative stroke and respiratory failure (p < 0.05). Multivariate analysis showed that off-pump CABG significantly reduced patient recovery period and the incidence of postoperative complications. Early follow-up results, cardiac event-free and survival rates, did not significantly differ between the two groups.

CONCLUSIONS

Off-pump CABG is safe for the elderly patient. Off-pump CABG successfully facilitates early recovery and reduces the incidence of postoperative complications among elderly patients.

Double-vessel revascularization using a composite graft approached from small left thoracotomy

Minimally invasive direct coronary artery bypass usually includes single vessel revascularization via a small skin incision. In most cases, the left internal mammary artery has been used for bypassing to the left anterior descending artery, and only single vessel revascularization used to be performed due to the limited operating field. We present 2 cases of successful double-vessel revascularization approached from a left small thoracotomy, using a composite graft of the internal mammary artery and the inferior epigastric artery, anastomosing to the left anterior descending artery and diagonal artery.

Coronary artery bypass grafting for patients with non-dialysis-dependent renal dysfunction (serum creatinine > or =2.0 mg/dl)

INTRODUCTION

Patients with renal dysfunction carry a risk of coronary atherosclerosis. The purpose of this study was to evaluate the outcome after coronary artery bypass grafting (CABG) in patients with decreased renal function (serum creatinine > or =2.0 mg/dl).

METHODS

We retrospectively analyzed consecutive patients who had undergone isolated CABG at Shin-Tokyo Hospital between May 1, 1991 and April 31, 2000. Preoperative, perioperative, and follow-up data of the non-dialysis-dependent patients with preoperative serum creatinine equal to or more than 2.0mg/dl (group R, n=59) were collected, and compared with those of the control patients (serum creatinine < 2.0, group C, n=1666). Group R was further divided into the off-pump and on-pump CABG group and their perioperative results were compared.

RESULTS

Group R included 51 males and eight females with a mean age of 66.4. The mean number of anastomoses was not significantly different between groups; however, clump time and pump time were longer in group R. Postoperative recovery was longer in group R than in group C, which is associated with a more frequent occurrence of major complications (28.8% in group R and 10.7% in group C, P<0.0001) and mortalities (6.8% in group R and 0.5% in group C, P<0.0005). The patients who underwent off-pump CABG experienced relatively faster recovery than those who underwent on-pump CABG, despite decreased renal function. At the mean follow-up of 2.4 years, the actuarial 3-year survival rate of groups R and C were 75.3 and 96.9%, respectively (P<0.0001), excluding hospital mortality. The actuarial 3-year cardiac event-free rate was 76.7% in group R and 87.3% in group C (P<0.05).

CONCLUSIONS

Patients with decreased renal function carry significant operative risks and require prolonged hospital care. Even after adequate surgical revascularization was completed, the long-term cardiac event-free and survival rates in the patients with renal dysfunction were inferior to the patients with normal renal function.

Coronary artery bypass grafting using the radial artery: midterm results in a Japanese institute

BACKGROUND

To avoid remote cardiac events associated with graft occlusions, arterial conduits are being increasingly utilized in coronary artery bypass grafting (CABG). The development of antispasmic agents has enabled the use of the radial artery as a graft conduit in CABG.

METHODS

Between December 1995 and December 1998, 920 consecutive isolated CABG operations were performed at Shin-Tokyo Hospital. The radial artery was used for graft conduits in 475 of these patients, and their data were analyzed in this study. The patients were followed to determine midterm graft patency, cardiac events, and survival. All data are given as mean +/- standard deviation. The end points were patient death or occurrence of cardiac events.

RESULTS

The radial artery was used in 475 patients (366 males and 109 females, with a mean age of 64.5+/-8.5 years). The left internal mammary artery was used in 94.9% of patients, the right internal mammary artery in 17.5%, the gastroepiploic artery in 50.9%, the inferior epigastric artery in 0.2%, and the saphenous vein in 39.2%. The in-hospital morbidity and mortality rates of the studied group were 12.8% and 0.6%, respectively. A major complication related to radial artery harvesting, compartment syndrome of the arm due to postoperative bleeding, was observed in 1 patient. No postoperative myocardial infarction attributable to radial artery bypass was observed. During the late follow-up period of 3.5+/-0.9 years, cardiac events were observed in 63 patients, giving actuarial 2- and 3-year event-free rates of 92.8% and 89.6%, respectively. A total of 24 late deaths were noted, including seven cardiac deaths, giving actuarial 2- and 3-year survival rates of 98.1% and 97.2%, respectively. Postoperative angiography was performed in selected patients. The cumulative graft patency rate of the radial artery was 93.0% during the mean angiographical follow-up period of 1.5+/-1.1 years.

CONCLUSIONS

No adverse effects were noted after CABG using a radial artery graft in this short- and midterm follow-up period.