The Unclampable Ascending Aorta in Coronary Artery Bypass Patients : A Surgical Challenge of Increasing Frequency (original) (raw)
Aortic no-touch technique makes the difference in off-pump coronary artery bypass grafting
The Journal of Thoracic and Cardiovascular Surgery, 2011
Objectives: Both off-pump surgery (OPCAB) and aortic no-touch technique reduce stroke after coronary artery bypass grafting (CABG). We evaluate the impact of partial aortic clamping (PC) versus a no-touch technique using either the HEARTSTRING system (HS) or total arterial revascularization (TAR) on the incidence of stroke. Methods: From 2004 to 2009, 4314 patients underwent myocardial revascularization. Patients either underwent OPCAB (n ¼ 2203) or conventional on-pump CABG (n ¼ 2111). The OPCAB cohort was divided into 2 subgroups: patients requiring proximal anastomosis applying PC (n ¼ 567) or a ''no-touch'' technique with the HS (n ¼ 1365). Patients who received TAR (n ¼ 271) served as a control group (gold-standard). Data collection was performed prospectively using a propensity score (PS)-adjusted regression analysis. End points were stroke, mortality, major adverse cardiac and cerebrovascular events (MACCE), and a noncardiac composite end point including respiratory failure, renal failure, and bleeding. Results: The mortality rate (1.6% vs 2.4%; propensity-adjusted odds ratio [PAOR] ¼ 0.51; CI 95%, 0.26-0.99; P ¼ .047), MACCE (7.9% vs 17.1%; PAOR ¼ 0.67; CI 95%, 0.52-0.84; P ¼ .001) including myocardial infarction (1.1% vs 2.2%; PAOR ¼ 0.50; CI 95%, 0.26-0.98; P ¼ .044) and stroke (1.1% vs 2.4%; PAOR ¼ 0.35; CI 95%, 0.17-0.72; P ¼ .005) as well as the noncardiac composite (PAOR ¼ 0.46; CI 95%, 0.35-0.91; P<.001) were significantly lower for OPCAB when compared with on-pump CABG. In comparison with PC, OPCAB patients undergoing the HS approach had significantly lower frequencies of stroke (0.7% vs 2.3%; PAOR ¼ 0.39; CI 95%, 0.16-0.90; P ¼ .04) and MACCE (6.7% vs 10.8%; PAOR ¼ 0.55; CI 95%, 0.38-0.79; P ¼ .001), and these results were similar to those of the control group, who underwent no-touch TAR (stroke rate, 0.8%; MACCE, 7.9%). Conclusions: Our results confirm that OPCAB is superior with regard to risk-adjusted outcomes. There is no difference in the stroke rate when comparing on-pump CABG versus applying partial aortic crossclamping in OPCAB. Whenever a proximal anastomosis is needed, a no-touch technique should be applied, that is, using the HS device. (J Thorac Cardiovasc Surg 2011;142:1499-506) Earn CME credits at From the Clinic for Cardiovascular Surgery a and the Biostatistics Unit,
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. METHODS: From 2003 to 2010, 712 patients underwent TAR including 526 patients who had OPCAB-TAR and 186 patients who received on-pump TAR [(ONCAB grafting (ONCABG)-TAR)]. Of these, 52% (n = 272; OPCAB) vs. 83% (n = 155; ONCABG) had triple-vessel disease (TVD). To balance patient characteristics, a non-parsimonious, propensity score (PS) model was applied. Endpoints evaluated were mortality, stroke, major adverse cardiac and cerebrovascular events (MACCE). To evaluate CR, an 'Index of CR' (ICOR) was calculated, defined as the number of distal anastomoses divided by the number of the diseased coronary vessels. CR was assumed when the following requirements were fulfilled: the number of distal anastomoses was equal to or higher than that of diseased vessels (ICOR ≥ 1), and all affected coronary territories (left anterior descending, circumflex artery and/or right coronary artery) were grafted. RESULTS: Mortality was comparable between groups, whereas OPCAB patients suffered from significantly decreased rates of MACCE [3.0 vs. 7.0%; propensity-adjusted odd ratio (PAOR) = 0.24; confidence interval (CI) 95% 0.08-0.66; P = 0.006] including a clear trend towards reduced stroke and myocardial infarction. In the subgroup with TVD, OPCAB patients presented with significantly reduced rates for MACCE (1.8 vs. 5.8%; PAOR = 0.07; CI 95% 0.01-0.65; P = 0.02), including a significantly lower rate for stroke. For all-comers, the number of diseased vessels was lower after OPCAB (2.36 ± 0.73 vs. 2.87 ± 0.39; P < 0.001) and consequently, these patients received an overall lower number of distal anastomoses (2.42 ± 1.15 vs. 3.06 ± 0.98; P < 0.001). Although the ICOR was slightly lower (1.04 ± 0.37 vs. 1.07 ± 0.37; P = 0.02), CR was achieved more frequently in OPCAB patients (82.1 vs. 73.1%; P = 0.01). In the subgroup with TVD, the number of distal anastomoses (2.99 ± 1.14 vs. 3.10 ± 0.98; P = 0.19) and the ICOR (1.00 ± 0.38 vs. 1.03 ± 0.33; P = 0.19) was comparable between groups. The frequency of CR was slightly higher (75 vs. 67.7%; P = 0.11), and the proportion of complete in situ grafting was significantly higher after OPCAB (37.1 vs. 23.9%; P = 0.005). CONCLUSIONS: Aortic 'no-touch' OPCAB-TAR leads to a significant reduction of MACCE. It does not compromise CR in patients with TVD and thus can be safely applied to these patients.
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.
Off-Pump Coronary Artery Bypass Surgery
2000
C oronary revascularisation plays an important role in the management of patients with ischaemic heart disease. Its principle builds on restoring antegrade flow thereby relieving angina. As a result, the need for medication is reduced which, in turn, may improve quality of life and socioeconomic independency. Also the prognosis is beneficially affected. This is not only true for patients with severe coronary atherosclerosis such as patients with left main or three vessel disease, but also for patients with less advanced disease. w1-3 c WHY OFF-PUMP BYPASS SURGERY?
Off-Pump Total Arterial Revascularization:. Our Experience
Journal of Cardiac Surgery, 2004
Background and Aim: Off-pump coronary artery bypass grafting with both the internal thoracic arteries, such as the Tector technique, can reduce the morbidity associated with extracorporeal circulation and aortic cross-clamp. The aim of the present study is to describe our experience and the results obtained. Methods: From April 1998 to December 2003, the off-pump Tector technique was performed on 743 patients, of whom 621 were male (83.5%), with a mean age of 65.3 ± 9.5 years (23-90). Preoperative risk factors were diabetes mellitus in 29.5% and peripheral vasculopathy in 14.7% of the patients. Angiography showed left main disease in 25.6% and triple-vessel disease in 50.3% of the patients, with a mean ejection fraction of 60% ± 13% (23-88). Both the internal thoracic arteries were harvested using the skeletonization technique and were anastomosed as "Y" or "T" grafts. Intraoperative graft patency was checked using a Doppler flowmeter. Results: A total of 2028 distal anastomoses were performed, the average being 2.7 (1 to 5) per patient. At least three distal anastomoses were undertaken in 62% of the patients. Postoperative complications included atrial fibrillation in 40 patients (5.4%), myocardial infarction in 24 (3.2%), mediastinitis and reoperation for bleeding in 7 (0.9%) and stroke in 3 (0.4%). Twenty-four patients (3.2%) died in the first month postoperatively. Conclusions: The off-pump Tector technique appears to be safe, showing a low surgical morbidity
The Annals of Thoracic Surgery, 2002
Methods. From January 1988 to December 2000, 4,875 patients had coronary operations; 33 who survived less than 24 hours and 19 who had aortic cannulation without cross-clamping were excluded. According to the degree of aortic manipulation, patients were divided into two groups: group A, aortic cannulation, cross-clamping, with (A1, n ؍ 597) or without (A2, n ؍ 2,233) side-clamping, and group B, with (B1, n ؍ 460) or without (B2, n ؍ 1,533) side-clamping. Patients in group A (n ؍ 2,830) were operated on with and patients in group B (n ؍ 1,993) were operated on without cardiopulmonary bypass (CPB). Univariate and multivariate analyses were applied to identify independent predictors of higher incidence of CVAs.
Total Arterial Off-Pump versus On-Pump Coronary Revascularization:. Comparison of Early Outcome
Journal of Cardiac Surgery, 2004
Background and aim: To assess differences in the early outcome after complete arterial myocardial revascularization with (ONCAB) or without cardiopulmonary bypass (OPCAB). Methods: Out of 870 consecutive CABG procedures 58 OPCAB and 91 ONCAB patients receiving exclusive arterial grafts were analyzed. OPCAB patients had more single-vessel (p < 0.0001), less triple-vessel (p < 0.0001) or left main disease (p = 0.0021), higher angina class (p = 0.003), unstable angina (p < 0.0001) or previous PTCAs (p < 0.0001). Results: ONCAB was associated with longer operations (182.5 ± 38 vs. 147 ± 56 min; p = 0.0001) and more anastomoses/patient (3.2 ± 1 vs. 2 ± 0.9; p < 0.0001), but incomplete revascularization was similar in both groups (11% vs. 17%; p = ns). ITA use was identical, whereas single left internal thoracic artery (LITA) use (25.9% vs.1%; p < 0.0001) and LITA jump anastomoses (10.3% vs. 7.7%; p < 0.0001) were more frequent in OPCAB. Radial artery (RA) use (89% vs. 46.6%; p < 0.0001) and RA jump anastomoses (57.1% vs. 12.1%; p < 0.0001) were more frequent in ONCAB. Mortality, arrhythmias, cerebro-vascular accidents (CVA), and renal failure were similar, but ventilatory support shorter (8.8 ± 11.8 vs. 15.6 ± 9.4 h; p < 0.0001) and cardiac enzyme release smaller (p < 0.0001) after OPCAB with a trend toward less myocardial infarction (1.7% vs. 7.7%; p = 0.12) and low output (1.7% vs. 8.8%; p = 0.089), and more respiratory complications (10.3% vs. 2.2%; p = 0.056). Conclusions: Arterial OPCAB patients have less extensive CAD, but more severe symptoms. Early outcome is similar concerning mortality, arrhythmias, CVA, renal failure, or ICU and hospital stay, but with shorter ventilatory support and lower cardiac enzymes with a trend toward lower myocardial infarction and low output, but higher respiratory complication rates after OPCAB.
Anaortic Techniques Reduce Neurological Morbidity After Off-Pump Coronary Artery Bypass Surgery
Heart, Lung and Circulation, 2008
Background: Stroke remains one of the most devastating complications of cardiac surgery. Advocates of off-pump coronary revascularisation (OPCAB) maintain that post-operative neurologic morbidity is reduced by avoiding aortic cannulation and cross-clamping, and by eliminating the systemic effects of cardiopulmonary bypass. We sought to determine whether completing off-pump coronary surgery without any aortic manipulation ("anaortic" technique) afforded any additional neurological protection, as compared to off-pump grafting in which the aorta was utilised for graft inflow.
Towards stroke-free coronary surgery: the role of the anaortic off-pump bypass technique
2020
Coronary artery and cerebrovascular disease represent a major cause of cardiovascular morbidity and mortality worldwide. Despite technological advancements in percutaneous interventions, surgical revascularization remains the preferred strategy in patients with left main or multivessel disease and in those with complex lesions with high SYNTAX score. As a result, an increasing number of older patients with diffuse atherosclerotic extracoronary disease are referred for coronary artery bypass grafting (CABG). Cerebrovascular complications after isolated coronary surgery occurs in 1-5% of patients; the magnitude of injury ranges from overt neurologic lesions with varying degree of permanent disability to “asymptomatic” cerebral events detected by dedicated neuro-imaging, nevertheless associated with significant long term cognitive and functional decline. Thromboembolic events due to manipulation of an atherosclerotic aorta are universally recognized as the leading etiology of early pos...
Stroke after conventional versus minimally invasive coronary artery bypass
The Annals of Thoracic Surgery, 2002
Background. Postoperative stroke is a serious complication after coronary artery bypass grafting with cardiopulmonary bypass (on-pump), and portends higher morbidity and mortality. It is unknown whether an off-pump cardiopulmonary bypass (OPCAB) approach may yield a lower stroke rate over conventional on-pump coronary artery bypass grafting.