Coronary artery bypass without extracorporeal circulation versus percutaneous transluminal coronary angioplasty: Comparison of costs

The influence of a low ejection fraction on long-term survival in systematic off-pump coronary artery bypass surgery

OBJECTIVE

Poor left-ventricular ejection fraction (EF) is a recognized operative and long-term risk factor in coronary artery bypass surgery. Over the past decade, off-pump coronary artery bypass surgery has emerged as a new strategy to address myocardial revascularization in poor left-ventricular EF patients, but few reports have documented long-term results. The aim of this study was to investigate long-term clinical results in off-pump coronary artery bypass patients with ≤ 35% left-ventricular EF.

METHODS

From September 1996 to May 2006, 1250 patients underwent off-pump coronary artery bypass revascularization, and were prospectively followed-up at the Montreal Heart Institute. Among them, 137 patients (pts) had a preoperative left-ventricular EF ≤ 35%. Follow-up was completed in 97% of patients.

RESULTS

Mean follow-up was 66 ± 34 months. Rate of grafts per pts was comparable in both groups. Overall 30-day mortality was 1.7% (1.5% EF >35% pts vs 2.9% in EF ≤ 35% pts; p = 0.19). Ten-year survival was lower in poor EF patients (44 ± 7% vs 76 ± 2%), and remained significant even after adjusting for risk factors (p = 0.04). Freedom from cardiac death for both groups was also significantly reduced in poor EF patients (p = 0.008). After adjustment, freedom from the combined end point of cardiac or sudden death, myocardial infarction, repeat coronary revascularization, unstable angina, and cardiac failure was comparable in both groups (p = 0.5).

CONCLUSIONS

Off-pump coronary artery bypass surgery can be performed adequately and safely in poor EF patients. However, overall and cardiac survival was decreased in this subset of patients with a comparable freedom from major cardiac adverse related events.

Off-pump bypass of the left anterior descending coronary artery: 23- to 34-year follow-up

OBJECTIVE

We sought to develop a baseline for long-term survival of patients after off-pump bypass of the left anterior descending coronary artery with the heart beating.

METHODS

We reviewed results for 241 consecutive patients with significant obstruction of the left anterior descending coronary artery who underwent surgery between November 1969 and the end of 1980. The off-pump operative technique involved elevating and stabilizing a segment of the distal left anterior descending coronary artery with 4 traction sutures. Starting in 1973, an internal thoracic artery became the graft of choice, so that a total of 171 patients received an internal thoracic artery bypass graft, and 70 patients received a saphenous vein graft.

RESULTS

The median survival of patients with internal thoracic artery grafts was 23.7 years versus 17.9 years for patients with venous grafts (P < .02). Early patency of arterial grafts was 95%, and late patency was 90%. There were 2 (0.8%) operative deaths. Seventy of the 74 patients still alive in 2003 were interviewed by telephone, and 40 (57%) did not require additional invasive treatment, which is consistent with our finding that more than 50% of our patients after bypass of the left anterior descending coronary remained stable without obstruction of the right or circumflex arteries. However, atherosclerosis progressed in 30 (43%) of the survivors, who underwent reinterventions.

CONCLUSIONS

Off-pump bypass of the left anterior descending coronary artery with an internal thoracic artery can be done on a beating heart safely and results in median survival of patients for more than 23 years.

A comparison of on-pump and off-pump coronary bypass surgery in low-risk patients

BACKGROUND

The performance of coronary bypass surgery without cardiopulmonary bypass ("off pump") may reduce perioperative morbidity and costs, but it is uncertain whether the outcome is similar to that involving the use of cardiopulmonary bypass ("on pump").

METHODS

In a multicenter, randomized trial, we randomly assigned 139 patients with predominantly single- or double-vessel coronary disease to on-pump surgery and 142 to off-pump surgery. Cardiac outcome and cost effectiveness were determined one year after surgery. The uncertainty surrounding the cost-effectiveness ratio (cost differences per quality-adjusted year of life gained) was addressed by bootstrapping.

RESULTS

At one year, the rate of freedom from death, stroke, myocardial infarction, and coronary reintervention was 90.6 percent after on-pump surgery and 88.0 percent after off-pump surgery (absolute difference, 2.6 percent; 95 percent confidence interval, - 4.6 to 9.8). Graft patency in a randomized subgroup of patients was 93 percent after on-pump surgery and 91 percent after off-pump surgery (absolute difference, 2.0 percent; 95 percent confidence interval, - 6.5 to 10.4). On-pump surgery was associated with $1,839 in additional direct costs per patient ($14,908 vs. $13,069--a difference of 14.1 percent) and an increase in quality-adjusted years of life of 0.83 as compared with 0.82 (difference, 0.01 year; 95 percent confidence interval, - 0.03 to 0.04). Off-pump surgery was more cost effective than on-pump surgery in 95 percent of bootstrap estimates.

CONCLUSIONS

In low-risk patients, there was no difference in cardiac outcome at one year between those who underwent on-pump bypass surgery and those who underwent off-pump surgery. Off-pump surgery was more cost effective.

Grafts for Left Main Trunk Lesion Using “MIDCAB Doughnut” on Beating Heart

Successful beating heart multiple bypass grafting to the left anterior descending and circumflex artery for a left main trunk lesion was performed in 5 patients through a left thoracotomy using the “MIDCAB doughnut” for immobilization and hemostasis. After completion of left internal thoracic artery-to-left anterior descending artery grafting, a radial artery or saphenous vein graft was anastomosed safely to the obtuse marginal branch, without hemodynamic deterioration. Extending the left anterior small thoracotomy 3 or 4 cm laterally, the obtuse marginal branch could be approached easily without rotating the beating heart. The device achieved a still and stable operative field even for circumflex grafting. An inflow of the graft to the circumflex was placed at the left axillary artery to prevent blood flow shortage to the left coronary system. Mean perioperative blood flow was 29.5 ± 7.1 mL·min−1 in the internal thoracic artery grafts and 43 ± 8 mL·min−1 in the circumflex grafts. Postoperative angiography revealed patency of all grafts. The technique may extend the surgical indications for beating heart bypass surgery without cardiopulmonary bypass.

Minimally invasive coronary artery bypass surgery

Advances in videoscopic instrumentation and expanding experience with the performance of coronary artery bypass surgery without cardiopulmonary circulatory support is changing the surgical approach to many patients requiring coronary arterial revascularization. We describe the present status of minimally invasive coronary artery bypass surgery being used today.

Techniques of exposure and stabilization in off-pump coronary artery bypass graft

Recent advances in techniques of coronary artery exposure and myocardial stabilization in off-pump myocardial revascularization have provided cardiac surgeons with a wide variety of new devices and techniques. Until recently, the main obstacle to performing complete myocardial revascularization without using cardiopulmonary bypass (CPB) has been the technical difficulties of exposing and stabilizing coronary targets, especially those located on the lateral and inferior wall of the heart. The extraordinary cardiac tolerance to nonconstrictive anterior elevation and lateral displacement, however, has allowed the development of new strategies of coronary exposure. These advances, in combination with the development of new techniques of mechanical myocardial stabilization, have impacted on the feasibility and safety with which coronary anastomoses on the beating heart can be constructed. The aim of this article is to describe the technical aspects involved in off-pump coronary revascularization, focusing primarily on the most recent strategies of cardiac elevation and coronary exposure, the various techniques of myocardial stabilization, and some of the technical details of constructing distal anastomoses on the beating heart.

Quantitative angiographic assessment of coronary anastomoses performed without cardiopulmonary bypass

BACKGROUND

The quality of the anastomosis performed during coronary artery bypass grafting without cardiopulmonary bypass is a current concern, and myocardial wall restraining devices have been designed to optimize results. A quantitative angiographic analysis was performed to assess coronary anastomoses performed on beating hearts.

METHODS

We studied 34 patients who underwent coronary artery bypass grafting without cardiopulmonary bypass between February 1996 and April 1997. The left internal thoracic artery was anastomosed to the left anterior descending coronary artery in all patients. Coronary angiograms were performed 4 +/- 2 days after the operation. The diameter of the anastomoses was quantified by computer-assisted analysis of grafts and native coronary arteries at the toe and heel of the anastomosis.

RESULTS

Five of the patients who underwent coronary artery bypass without a stabilizer (n = 20) had stenoses of the internal thoracic artery grafted to the left anterior descending coronary artery of more than 50% at the level of the anastomosis proper, 3 had stenoses at the heel of the coronary anastomosis, and 5 had stenoses at the toe. One of the patients in whom a stabilizer was used (n = 14) had a stenosis of more than 50% at the anastomosis, and 1 had stenosis at the heel. Eight patients in whom the anastomoses were performed without stabilization (8/20, 40%) had stenoses of more than 50%, whereas there was only 1 stenosis of more than 50% of coronary luminal diameter among the patients in whom the operation was performed with a stabilizer (P =.02).

CONCLUSION

The quantitative angiographic evaluation suggests that left internal thoracic artery graft to left anterior descending coronary artery anastomoses have a lesser degree of intraluminal stenosis when performed with the use of a myocardial wall stabilizer.

Video-assisted minimally invasive coronary bypass surgery without cardiopulmonary bypass

BACKGROUND

There is a growing interest in cardiac surgery towards minimally invasive approach to coronary bypass operations without cardiopulmonary bypass.

PATIENTS AND METHODS

From March 1995 to March 1997, 41 patients underwent a single left internal mammary artery (LIMA) to the left anterior descending artery (LAD) coronary grafting without cardiopulmonary bypass through a small left anterior thoracotomy (MIDCABG). The mean age was 61.2+/-8.7 years (range 43-77 years), 28 patients. were male (68.2%) and the redo rate was 4.8% (2/41). In all patients the coronary artery disease involved the LAD, which was occluded in seven patients (17.1%). Thirty-eight patients (96.2%) selected for MIDCABG had a monovascular disease on LAD not suitable for percutaneous coronary angioplasty; two (4.8%) a bivascular disease, and one (2.4%) a trivascular disease. Skin incision was performed in the 4th anterior intercostal space from the left parasternal line for a 10.5 cm length on average. The LIMA harvesting was partially video-assisted by thoracoscopy.

RESULTS

The LAD temporary occlusion was achieved with two double 5/0 polypropilene round-LAD sutures. The mean LAD ischemic time was 22+/-8 min (range 4-35 min). No thoracotomy procedure was changed into a sternotomy approach. We had one (2.4%) perioperative AMI; two patients (4.8%) were reoperated for bleeding. All patients underwent a postoperative angiographic reinvestigation within 1 month after surgery. All anastomoses were perfectly patent but two (4.8%). One patient was reoperated via a sternotomy access recycling the LIMA graft, the other one underwent successful PTCA. All patients also underwent an early and mid-term (6 months after surgery) echo-Doppler study of the LIMA flow and patency. At follow-up, performed at a mean of 8.7 months (range 1-23) after discharge, all patients were alive; no one experienced recurrence of angina. All patients also performed a mid-term negative treadmill stress test.

CONCLUSIONS

MIDCABG is, in selected patients, reliable and safe, and offers encouraging early and mid-term clinical results.

Centrifugal pumps as left ventricular assist for coronary revascularization on a beating heart

During recent years, coronary bypass surgery has progressed toward minimizing invasiveness. One important feature of this approach is performing surgery on a beating heart. During the crucial phase of such surgery, the mechanical support of the heart with a left ventricular assist device (LVAD) is a possible option. During the period from October 1, 1994 until June 30, 1997, we employed a centrifugal pump system in 118 cases of coronary artery bypass graft (CABG) procedures with LVAD support (mechanically supported CABG [SUPPCAB]). A total of 179 distal anastomoses with an average of 1.5 +/- 0.5 coronary anastomoses per patient was performed. Three types of pumps were used: 23 BioPump, 87 Isoflow, and 8 Capiox systems. The median time on mechanical support was 44 min (range, 16-116 min). The mean flow rate during support time was 3.5 +/- 0.8 L/min, which results in a calculated flow of 1.7 +/- 0.6 L/min/m2 body surface area (BSA). The average flow was 3.2 +/- 0.8 L/min with the BioPump and 3.7 +/- 0.8 L/min with the Isoflow pump, respectively (p < 0.01). The mean arterial pressure during mechanical support was 75 +/- 12 mm Hg. In 2 patients, the pump system was kept running postoperatively in the ICU. Eight of the patients received operations under resuscitation or in cardiogenic shock. Nine (7.9%) of the patients did not survive the early postoperative phase. For coronary revascularization of the anterolateral and diaphragmatic parts of the heart, the SUPPCAB procedure is feasible with excellent mechanical support of the heart by centrifugal pumps. Especially in high risk cases, this procedure can be recommended.

[Video-assisted MICABG for the patient with right mammary carcinoma--a case report]

A 69-year-old female with advanced right mammary carcinoma presented to us with diffuse stenosis of the proxymal left anterior descending artery (LAD). Right mastectomy had been suspended. The LAD was treated with minimally invasive CABG (MICABG) assisted with a thoracoscopic procedure. The left internal thoracic artery (LITA) was taken down through thoracoscopy from the upper margin of the 1st rib to the lower margin of the 5th rib using only the Harmonic Scalpel (Ethicon Endo-Surgery). Coronary anastomosis to the LAD was completed without cardiopulmonary bypass through a small thoracotomy on the anterior 4th intercostal space. The operation time was 4 h 30 min and the blood loss was 120 ml. Post operative course was uneventful. Doppler study and angiography demonstrated patent LITA to the LAD. Right mastectomy was achieved 29 days after MICABG. MICABG can be a veneficial alternative method for the patient with malignant disease, allowing quick convalescence and early cancer operation. Thoracoscopy allows for sufficient LITA harvest up to the 1st rib or higher with the Harmonic Scalpel.

[Reoperative coronary artery bypass grafting without cardiopulmonary bypass]

Between October 1995 and February 1997, 2 men and 4 women aged 53 to 75 years (mean, 66.3) underwent reoperative coronary artery bypass grafting without cardiopulmonary bypass. Isolated reoperative circumflex or intermediate artery bypass was performed through a left thoracotomy (n = 2), reoperative bypass to the left anterior descending coronary artery was performed through a median sternotomy (n = 3), and bypass to the right coronary artery was performed through an upper median laparotomy (n = 1). Single coronary bypass grafting utilizing arterial grafts (left internal thoracic artery: 3, right gastroepiploic artery: 3) was performed in all cases. There were no operative deaths. All cases required neither cathecolamine nor intraaortic balloon pumping). Peri/post operative blood transfusion was necessary in only one case. Postoperative coronary angiography revealed that the 6 arterial grafts were patent. Reoperative coronary artery bypass grafting without cardiopulmonary bypass can be performed with low perioperative morbidity and mortality, easy postoperative management, satisfactory graft patency, and good symptomatic improvement.

Coronary artery bypass grafting without cardiopulmonary bypass through sternotomy and minimally invasive procedure

Coronary artery bypass grafting without cardiopulmonary bypass (CPB) is now an accepted technique of myocardial revascularization in a special subset of patients. This paper presents our total experience in 1761 cases operated on since September 1981 until April 1997 out of a total of 9164 patients revascularized with the conventional technique during this period of time. Among the 1761 patients, 53 (3%) were operated on by minimally invasive surgery. The overall applicability was 19.2% and the most common grafted arteries were left anterior descending artery (LAD), right coronary artery (RCA), and diagonal. Results indicate that the operation can be performed with an acceptable mortality (2.3%) and that all types of arterial conduits can be used. The incidence of major postoperative complications were significantly lower in this group of patients when compared with our patients receiving conventional myocardial revascularization. Most importantly there was decrease cost when the procedure was used because no extracorporeal circulation cardioplegia sets or other cannulas were used. We conclude based on in this fifteen years experience that the technique of myocardial revascularization in a beating heart is justified, safe and can offer to selected patients the best option of coronary insufficiency surgical treatment.

Port-access cardiac operations with cardioplegic arrest

BACKGROUND

A less invasive approach to cardiac surgery has been propelled by recent advances in video-assisted surgery. Previous obstacles to minimally invasive cardiac operations with cardioplegic arrest included limitations in operative exposure, inadequate perfusion technology, and inability to provide myocardial protection.

METHODS

Port-access technology allows endovascular aortic occlusion, cardioplegia delivery, and left ventricular decompression. The endoaortic clamp is a triple-lumen catheter with an inflatable balloon at its distal end. Antegrade cardioplegia is delivered through a central lumen, which also acts as an aortic root vent, a second lumen is used as an aortic root pressure monitor, and a third lumen is used for balloon inflation to provide aortic occlusion.

RESULTS

Experimental and clinical studies have demonstrated the feasibility of port-access coronary artery bypass grafting and port-access mitral valve procedures. Endovascular cardiopulmonary bypass using the endoaortic clamp was effective in achieving cardiac arrest and myocardial protection to allow internal mammary artery to coronary artery anastomosis in a still and bloodless field. Intracardiac procedures, such as mitral valve replacement or repair, have been successfully performed clinically.

CONCLUSION

The port-access system effectively achieves cardiopulmonary bypass and cardioplegic arrest, thereby enabling the surgeon to perform cardiac procedures in a minimally invasive fashion. This system provides for endovascular aortic occlusion, cardioplegia delivery, and left ventricular decompression.

Safe and effective method of stabilization for coronary artery bypass grafting on the beating heart

BACKGROUND

There is an emerging interest in performing coronary artery bypass grafting on the beating heart. This study examines the efficacy and safety of two types of coronary artery stabilizers developed to perform coronary artery bypass grafting on the beating heart.

METHODS

Four dogs underwent left internal mammary artery to left anterior descending artery anastomosis using a retractor-fixed stabilizer. Measurements of hemodynamic indices and range of motion of the targeted arteriotomy were done before and after application of the stabilizers. Patency of the anastomosis was evaluated by angiography. To clinically validate the safety of this stabilizer, we collected data on 150 patients from centers that had access to the retractor-fixed stabilizer.

RESULTS

All animals survived the procedure with no ischemic changes or hemodynamic alterations. A significant reduction in range of motion (mm) of the left anterior descending coronary artery was achieved after application of the stabilizers. Angiographic studies showed good anastomotic patency. Histologic examination showed no myocardial injury. Patient data revealed successful completion of the anastomosis, with conversion to sternotomy or cardiopulmonary bypass in 1 patient each. Intraoperative and postoperative myocardial infarctions occurred in 1 patient each, with one in-hospital death.

CONCLUSIONS

Significant stabilization of targeted coronary arteries allowing the performance of safe and reliable anastomosis on a beating heart can be achieved using the stabilizer.

Video-assisted minimally invasive coronary operations without cardiopulmonary bypass: a multicenter study

OBJECTIVE

The need to avoid the risks associated with cardiopulmonary bypass has led to the interest in coronary operations without cardiopulmonary bypass.

PATIENTS AND METHODS

From April 1994 to September 1995, 44 patients (mean age 63.3 +/- 10.0 years, range 43 to 83 years) were selected for video-assisted coronary artery bypass grafting without cardiopulmonary bypass through a small anterior thoracotomy. Mean preoperative ejection fraction was 50.7% +/- 13.4% (range 20% to 65%). Four patients had left ventricular dysfunction (ejection fraction below 35%). Thirty patients had stable angina (26 with class 3 angina) and 14 had unstable angina. One had recurrent angina (redo). In all cases a small (3.5 to 11 cm) anterior thoracotomy (43 left and one right) was performed and the harvesting of the left internal thoracic artery was video-assisted by thoracoscopy.

RESULTS

The left internal thoracic artery was used in 43 cases to graft the left anterior descending coronary artery; the right thoracic mammary was used in one case to graft the right coronary artery; the radial artery was used in one case to perform a T-graft to the first diagonal and first marginal branches. We recorded one death (2.3%) and one case of postoperative low cardiac output syndrome (2.3%). Perioperative myocardial infarction occurred in two cases (4.5%). We did not record noncardiac complications (cerebrovascular complications, kidney failure, prolonged ventilatory support, or wound complications). Supraventricular and ventricular arrhythmias were never detected.

CONCLUSION

According to our experience, video-assisted coronary bypass through a small anterior thoracotomy is a new promising technique that can be considered an alternative in most cases to angioplasty and complementary to conventional coronary operations.

"Keyhole" coronary artery bypass surgery

OBJECTIVE

The objective of this study was to identify the utility of "keyhole" thoracotomy approaches to single vessel coronary artery bypass surgery.

SUMMARY BACKGROUND DATA

Although minimally invasive surgery is efficacious in a wide variety of surgical disciplines, it has been slow to emerge in cardiac surgery. Among 49 selected patients, the authors have used a left anterior keyhole thoracotomy (6 cm in length) combined with complete dissection of the eternal mammary artery (IMA) pedicle under thoracoscopic guidance or directly through the keyhole incision to accomplish IMA coronary artery bypass grafting (CABG) to the left anterior descending (LAD) coronary artery circulation or to the right coronary artery (RCA).

METHODS

Keyhole CABG was accomplished in 46 of 49 patients in which this approach was attempted. All patients had significant (> 70%) obstruction of a dominant coronary artery that had failed or that was inappropriate for endovascular catheter treatment (percutaneous transluminal coronary angioplasty or stenting). Forty-four of the 49 patients had proximal LAD and 5 had proximal RCA stenoses. The mean age of the patients (35 men and 14 women) was 61 years, and their median New York Heart Association anginal class was III. The mean left ventricular ejection fraction was 42%. Femoral cardiopulmonary bypass support was used in 9 (19%) of 46 patients successfully managed with the keyhole procedure. Short-acting beta-blockade was used in the majority of patients (38 of 46) to reduce heart rate and the vigor of cardiac contraction.

RESULTS

As 49 patients have survived operation, which averaged 248 minutes in duration. Median, postoperative endotracheal intubation time for keyhole patients was 6 hours with 25 of 46 patients being extubated before leaving the operating room. The median hospital stay was 4.3 days. Conversion to sternotomy was required in three patients to accomplish bypass because of inadequate internal mammary conduits or acute cardiovascular decompensation during an attempted off-bypass keyhole procedure Postoperative complications were limited to respiratory difficulty in three patients and the development of a deep wound infection in one patient. Nine (19%) of 46 patients received postoperative transfusion. There have been no intraoperative or postoperative infarctions, and angina has been controlled in all but one patient who subsequently had an IMA-RCA anastomotic stenosis managed successfully with percutaneous transluminal coronary angioplasty.

CONCLUSIONS

These early results with keyhole CABG are encouraging. As experience broadens, keyhole CABG may become a reasonable alternative to repeated endovascular interventions or sternotomy approaches to recalcitrant single-vessel coronary arterial disease involving the proximal LAD or RCA.

Coronary artery bypass grafting without cardiopulmonary bypass

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.

Video assisted coronary bypass surgery

An alternative way to revascularize coronary vessels is described, using arterial conduits without extracorporeal circulation. The heart is exposed via a small thoracotomy over the fifth left intercostal space. A thoracoscope is introduced into the thorax, to assist in the harvesting of the left internal mammary artery (LIMA). In selected patients with two or three vessel disease, the same procedure can be achieved on the right side, harvesting the right internal mammary artery to revascularize the right coronary artery. The gastroepiploic artery can be easily reached and used to revascularize the posterior descending artery, through a mini-subxiphoid median laparotomy. This technique was used to revascularize 30 patients from April 1994 to June 1995. All received a LIMA graft to the left anterior descending artery, and two had a free radial artery graft from the LIMA, sequentially bypassing the diagonal and obtuse marginal branches. There was neither perioperative mortality nor morbidity myocardial infarction. Fifteen patients were restudied angiographically before discharge. Average hospital stay was 43 +/- 11 hours.

Reoperative coronary artery bypass grafting without cardiopulmonary bypass

Between June 1979 and January 1992, 46 men and 13 women aged 35 to 81 years (mean, 58 years) underwent reoperative coronary artery bypass grafting without cardiopulmonary bypass. Isolated reoperative circumflex bypass was performed through a left thoracotomy, and reoperative bypass to the right coronary artery and left anterior descending coronary systems was through a median sternotomy. Complete revascularization was the goal in all patients. Saphenous vein grafts were placed to the right coronary artery (n = 21), circumflex artery (n = 11), and left anterior descending artery (n = 24), and 14 internal thoracic artery to left anterior descending artery bypass grafts were performed. The overall mortality rate was 3.4% (2 deaths). Postoperative morbidity included myocardial infarction in 1 patient and pleuropulmonary complications in 6. No patient was reexplored for hemorrhage, and 19 patients required no blood products. Twenty patients underwent repeat coronary angiography, and 18 of 20 grafts placed without cardiopulmonary bypass were patent. At a mean follow-up interval of 42.2 months 35 of 50 evaluable patients were in functional class I or II. In selected patients, reoperative coronary artery bypass grafting can be performed without cardiopulmonary bypass with a low perioperative morbidity and mortality rate, satisfactory graft patency rates, and good long-term symptomatic improvement.