Incidence of perioperative stroke in clampless aortic anastomosis during off-pump coronary artery bypass grafting

Outcomes of 881 Consecutive Coronary Artery Bypass Graft Patients Using Heartstring Device

BACKGROUNDS

 One of the strategies to prevent stroke after coronary artery bypass grafting (CABG) may be the use of a device for proximal anastomosis without partial clamp of the ascending aorta.

METHODS

 We retrospectively investigated early and late outcomes in consecutive 881 patients undergoing isolated CABG using Heartstring for proximal anastomosis from January 2008 to December 2022, to reveal the validity to use it. All patients underwent preoperative imaging workups to evaluate neurovascular atherosclerosis.

RESULTS

 The mean age of the patients was 68.9 years, 20% were female and 13% had previous history of stroke. CABG was on-pump beating heart (52.2%) or off-pump (47.8%) with a mean number of distal anastomoses of 3.38 ± 0.93, using 1.62 ± 0.53 Heartstring devices under different aortic manipulations. In-hospital mortality was 2.0% and perioperative stroke rate was 0.9%, none of them died during hospital stay. During the follow-up period of 70 ± 47 months, the overall actuarial survival rates were 86 and 66%, and major adverse cardiac and cerebrovascular events (MACCEs)-free rates were 86 and 70% at 5 and 10 years, respectively. On multivariable analysis, risk factors for late death included male, previous history of stroke, postoperative sternomediastinitis, late new-onset stroke, and MACCEs, but did not include the perioperative stroke.

CONCLUSION

 Low stroke rate, as low as 0.9%, after CABG using Heartstring for proximal anastomosis, although under a variety of aortic manipulations, may contribute to the improved long-term prognosis.

Device Use for Proximal Anastomosis on Ascending Aorta in Off-Pump Coronary Artery Bypass Grafting

BACKGROUND

We recently reported early postoperative results comparing the use of an anastomosis-assist device with a side-biting clamp for ascending aorta during coronary artery bypass grafting (CABG). Transient neurological complications occurred less often with the device. Here, we evaluated the perioperative safety of the device compared with the aorta no-touch technique (no-touch).

METHODS

We evaluated patients listed in the Japan Adult Cardiovascular Surgery Database who received isolated off-pump CABG with either the device or the no-touch approach from 2014 to 2016. We performed a one-to-one matched analysis based on a propensity score modeled from patient demographics, comorbidities, cardiac conditions, and procedural characteristics. We compared early outcomes in both groups using Pearson's chi-square or Wilcoxon rank sum test as appropriate; P less than .05 was statistically significant.

RESULTS

Among 9546 device and 6890 no-touch patients, we found 5012 patient matches for each group. The device operation time was significantly longer (293 versus 281 minutes; P < .001) and homologous transfusion was significantly greater (56.9% versus 51.0%; P < .001) than with no-touch. Thirty-day operative mortality (1.5% versus 1.7%; P = .34), morbidity and mortality (6.8% versus 7.5%; P = .17), and stroke (0.9% versus 1.1%; P = .36) were similar in both groups. New-onset atrial fibrillation (11.9% versus 10.3%; P = .01) occurred significantly more often with the device. Newly initiated dialysis (1.4% versus 1.9%; P = .051) was more frequent with no-touch whereas reoperation for graft occlusion was more frequent with the device (1.0% versus 0.6%; P = .06) but was not significant for either outcome.

CONCLUSIONS

The clinical safety of use of the device in CABG was comparable to no-touch for mortality and morbidity. Hemostasis may be a key issue for accomplishing higher-level quality control when devices are used in proximal anastomosis of CABG.