The Unclampable Ascending Aorta in Coronary Artery Bypass Patients : A Surgical Challenge of Increasing Frequency (original) (raw)
Related papers
International Journal of Cardiology, 2007
Objectives: Off-pump coronary artery bypass grafting (OPCAB) and complete arterial revascularization without proximal anastomosis to the aorta may decrease neurological events after open-heart surgery. Few reports exist regarding the combination of OPCAB and complete arterial revascularization exploring the theoretical advantage of avoiding manipulation of the aorta. We review our results in 110 patients who underwent multiple grafts off-pump complete arterial revascularization. Methods: 110 patients underwent multiple grafts OPCAB complete arterial revascularization, and were compared to 216 patients who underwent traditional multiple grafts on pump CABG. Preoperative renal failure was 12.7% (n = 14) as compared to 5.1%, (n = 11, p = 0.01) in the control group and 33.6% (n = 37) of the patients were 75 years or older as compared to 19.0% (n = 41, p = 0.003) in the control group. Results: The mean number of grafts per patient undergoing multiple OPCAB complete arterial revascularization was 2.3, as compared to 3.11 in the control group (p < 0.001). The mortality rate was 2.73% as compared to 1.85% (NS) in the control group. The incidence of CVA was 0% as compared to 2.31% (p = 0.17) in the control group. Conclusions: Complete arterial OPCAB revascularization without manipulation of the aorta in high-risk patients can be performed with short-term similar results to conventional CABG and very low neurological complications.
No-touch aorta off-pump coronary surgery: The effect on stroke
The Journal of Thoracic and Cardiovascular Surgery, 2005
Objective: Studies examining the neuroprotective effects of off-pump coronary artery bypass grafting have shown inconsistent results. Most studies, however, have not differentiated between clampless and clamp off-pump techniques. The aim of this study was to evaluate the effect of avoiding aortic manipulation on major neurologic outcomes after off-pump coronary artery bypass grafting. Methods: A total of 700 consecutive patients undergoing multiple-vessel off-pump coronary artery bypass grafting between 2000 and 2003 were included. The 429 patients undergoing aortic no-touch technique were compared with 271 patients in whom partial aortic clamps were applied. The aorta was screened by manual palpation, and epiaortic ultrasonography was used selectively. Results: The frequency of detected atherosclerotic aortic disease was higher in the no-touch group (17.4% vs 5.1%, P Ͻ .0001). No-touch revascularization was achieved with arterial conduits, arranged in T-graft or in situ configurations (50%). The respective graft/patient ratios were 2.5 Ϯ 0.6 and 2.6 Ϯ 0.6 in the side-clamp and no-touch groups (P ϭ .009); however, revascularization of the posterolateral myocardial territory was comparable (87% vs 90%, difference not significant). The incidence of stroke (0.2% vs 2.2%, P ϭ .01) was significantly lower in the no-touch group (1/429). Logistic regression identified partial aortic clamping as the only independent predictor of stroke (odds ratio 28.5, confidence interval 0.22-333, P ϭ .009), increasing this risk 28-fold. Peripheral vascular disease (P ϭ .068), diabetes (P ϭ .072), and history of stroke (P ϭ .074) trended toward stroke. Conclusions: Avoiding partial aortic clamping during off-pump coronary artery bypass grafting provides superior neurologic outcome. The results are reproducible and irrespective of the severity of aortic disease or the method of aortic screening. This technique is recommended whenever technically feasible.
Implementation of the aortic no-touch technique to reduce stroke after off-pump coronary surgery
The Journal of thoracic and cardiovascular surgery, 2018
Despite substantial scientific effort, the relationship between stroke after coronary artery bypass grafting and the use of the aortic no-touch off-pump technique (anOPCAB) remains incompletely understood. The present study aimed to define the effect of anOPCAB on the occurrence and time point of stroke. A total cohort of 15,042 consecutive patients underwent surgical myocardial revascularization at a single institution. After establishing anOPCAB as routine procedure, 4695 patients received surgery by 18 different surgeons using the anaortic approach. After the exclusion of all patients with cardiogenic shock and "side-clamp" off-pump coronary artery bypass grafting, 13,279 patients (4485 with anOPCAB) were included in the study. Perioperative strokes were classified as strokes occurring during the hospital stay, with early strokes observed immediately after emergence from anesthesia (vs delayed strokes). The anOPCAB technique reduced the postoperative stroke rate to 0.49...
The Annals of Thoracic Surgery, 2001
Previous reports have demonstrated that reoperative coronary revascularization, advanced age, female sex, and impaired left ventricular dysfunction are independent predictors of operative mortality after coronary artery bypass grafting (CABG). CABG without cardiopulmonary bypass (off-pump CABG) has been proposed as a potential therapeutic alternative in these high-risk patient groups. Despite the substantial learning curve associated with off-pump CABG, early outcomes of off-pump CABG in high-risk patients are better than those associated with the conventional on-pump CABG approach. These results suggest that off-pump CABG is a safe alternative to on-pump CABG in high-risk patients. Randomized prospective studies are needed to validate the results of these initial retrospective reports and to demonstrate the long-term benefits of this approach.
European Journal of Cardio-Thoracic Surgery, 2012
OBJECTIVES: The combination of aortic 'no-touch' off-pump surgery (OPCAB) and total arterial revascularization (TAR) can reduce peri-procedural morbidity and yields excellent long-term outcomes albeit at a reported risk of incomplete revascularization. The feasibility of OPCAB-TAR with specific regards to the complete revascularization (CR) in patients with multi-vessel disease was evaluated.
The Journal of Thoracic and Cardiovascular Surgery, 2003
Use of epiaortic scanning in coronary surgery is still a matter of debate. It is unclear whether the findings obtained by epiaortic scanning lead to effective changes in surgical technique that may reduce stroke rates. Methods: Epiaortic scanning was performed in 352 patients undergoing primary coronary artery bypass grafting before opening the pericardium using a 7.5-MHz ultrasonic probe. In the presence of moderate atherosclerosis (maximum aortic wall thickness of 3 to 5 mm), primarily single aortic crossclamping was carried out. In cases of severe sclerosis (maximum aortic wall thickness Ͼ 5 mm), aortic no-touch techniques on the beating heart were used. Results: The degree of ascending aortic atherosclerosis was normal or mild in 151 patients (42.9%), moderate in 167 patients (47.5%), and severe in 34 patients (9.6%). The operative technique was modified in 31.1% of patients with moderate aortic sclerosis and in 91.2% of patients with severe aortic sclerosis. Perioperative mortality was 0.0% for mild disease, 3.0% for moderate disease, and 8.8% for severe disease (P ϭ .005). Corresponding stroke rates reached 2.0%, 2.4%, and 2.9% (P ϭ .935). Logistic regression adjusting for EuroSCORE showed that ascending aortic atherosclerosis was an independent predictor of perioperative mortality (P ϭ .013, odds ratio 1.67, confidence interval 1.11-2.50). The influence of aortic disease on the stroke prevalence was probably due to chance (P ϭ .935), demonstrating a potentially positive effect of operative modifications concerning stroke caused by aortic manipulation. Conclusions: We conclude that intraoperative screening of coronary artery bypass grafting patients by epiaortic scanning can reveal useful information about the operative risk and with an aortic no-touch concept, perioperative stroke rates in high-risk patients may be lower than predicted. A therosclerosis of the ascending aorta has emerged as one of the most important risk factors for postoperative complications in cardiac surgery, particularly in on-pump coronary artery bypass grafting (CABG) when the diseased aorta is manipulated by cannulation and clamping. These maneuvers can be associated with intraoperative atheromatous embolization into the cerebral circulation, resulting in persistent cognitive deficit or postoperative
The Annals of Thoracic Surgery, 2004
Background. Cerebral embolization of atherosclerotic plaque debris caused by aortic manipulation during conventional coronary artery bypass grafting (CABG) is a major mechanism of postoperative cerebrovascular accidents (CVA). Off-pump CABG (OPCABG) reduces stroke rates by minimizing aortic manipulation. Consequently, the effect of different levels of aortic manipulation on neurologic outcomes after CABG surgery was examined.
A no-touch technique for calcified ascending aorta during coronary artery surgery
Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital, 1998
Despite improvements in cardiovascular surgery techniques over the years, the incidence of neurologic complications has not declined, and stroke remains a possible (and devastating) sequela to coronary artery surgery. In this report, we describe a moderate hypothermic fibrillatory arrest technique that avoids cross-clamping or otherwise touching the aorta; use of the internal thoracic arteries and the right gastroepiploic artery provides optimum revascularization and minimizes the risk of cerebrovascular accident. Over a 1-year period, we used the technique in 21 patients who had heavy calcifications of the ascending aorta. No hemodynamic problems, lower-limb ischemia, or neurologic complications were seen. Only 1 patient underwent reoperation (for bleeding), and another--whose revascularization was incomplete--had a high postoperative level of myocardial creatine kinase MB isoenzyme and a new Q wave, but no hemodynamic deterioration. This technique seems reasonable, because it appe...
Brazilian Journal of Cardiovascular Surgery
Objective: To evaluate the sequential changes of hemodynamic and metabolic parameters in patients who underwent aorta notouch off-pump coronary artery bypass surgery (OPCAB). Methods: Prospective study involving twenty-seven consecutive patients who underwent aorta no-touch OPCAB. The FloTrac/PreSep/Vigileo™ system (Edwards Lifesciences) was used to continuously record heart rate (HR), mean arterial blood pressure (MABP), central venous pressure (CVP), continuous cardiac index (FCI), stroke volume (SV), stroke volume variation (SVV), and central venous oxygen saturation (ScvO 2). The parameters were assessed 5 min before, during and 5 min after each anastomosis (left anterior descending [LAD], posterior descending [PD], obtuse marginal [OM] and diagonal [Dg]). Postoperative lactate was also evaluated. Results: There was no significant change in HR and MABP for all anastomoses, except for MABP during PD grafting (-10.1±2.7 mmHg, P=0.03). There was a significant decrease in ScvO 2 only during PD and OM anastomoses (-9.4±0.4, P=0.03;-4.4±0.4, P=0.02; respectively). CVP drop after PD manipulation was strongly associated with a higher lactate during the first hours after surgery (r=-0.82; P=0.001). These hemodynamic changes were transient and entirely recovered after the heart was returned to its anatomical position. No significant differences were observed in FCI, SVV, or the systemic vascular resistance index (SVRI) during all anastomoses, except for a drop in SVRI during PD grafting (-8.03±2.3, P=0.007). SV tended to decrease during the procedure in all territories, but with statistically significant drop only in PD and OM grafting (-10.4±1.2, P=0.02;-13.6±5.1, P=0.007; respectively). Conclusion: Heart displacement for performing aorta notouch OPCAB is well tolerated, with transient and endurable hemodynamic variations.