On-pump coronary artery bypass graft operation: is one cross-clamp application better than two? (original) (raw)
Coronary artery bypass surgery with intermittent aortic cross-clamping
European Journal of Cardio-Thoracic Surgery, 1992
Despite the generally accepted use of cardioplegia for myocardial protection during cardiac revascularization and other operations, non-cardioplegic methods have been used by many surgeons throughout the world. We have prospectively studied 229 patients consecutively subjected to isolated coronary artery bypass surgery from March 1990 to February 1991 by a single surgeon who used intermittent aortic cross-clamping for construction of the distal anastomoses. The mean age of the patients was 58.9 + 8.9 years. One hundred and nine patients (47.6%) with unstable angina were subjected to urgent or emergent surgery and 129 (56.3%) had a previous myocardial infarction. The mean number of grafts per patient was 3.0. The ischaemic time per graft was 6.5 + 1.4 min. At least one internal mammary artery was used in 98% of the cases (1.4 internal mammary artery grafts/patient). Hospital mortality was 0.9% (two patients, in neither case related to the procedure). Only nine patients (3.9%) required inotropes and none needed intra-aorti@counterpulsation. The analysis of serum enzymes specific of myocardial lesion showed a CPK-MB/CPK ratio of 10.5 f 10.2 after surgery, 6.4 f 6.6% at 24 h after surgery, and 6.9 f 2.6% by the 5th day. Only four patients (1.7%) had ECG criteria of myocardial infarction. These results were compared retrospectively with those of the 40 immediately preceding patients (December 1989 to February 1990), in whom crystalloid cardioplegia had been used. There were no differences between the two groups with regard to age, prevalence of unstable angina and of previous myocardial infarction, and technique used. The mean aortic cross-clamp time was 50.0 + 11.5 min. There was no mortality in this group and four patients (10% ; p = NS) required inotropic support. One patient (2.5%) sustained a myocardial infarction. There were no differences in enzyme levels to those in the former group. These results, in a non-selected group of patients, appear to demonstrate that intermittent aortic cross-clamping for short periods (< 10 min) affords good myocardial protection and is a simple and safe method to use during revascularization procedures.
Heart, Lung and Circulation, 2011
Background: The main criticism of surgery in the SYNTAX trial was increased rate of stroke when compared to percutaneous coronary intervention. We aimed to determine whether avoiding aortic manipulation would decrease the rate of stroke. Method: We performed a meta-analysis of seven studies comparing coronary artery bypass grafting (CABG) with and without manipulation of the ascending aorta. Results: When anaortic off-pump coronary artery bypass grafting (OPCAB) was compared with conventional CABG, the rate of stroke was 0.38% vs. 1.87% (p < 0.0001). When anaortic OPCAB was compared with OPCAB using a side-clamp or proximal graft anastomosis device the rate of stroke was 0.31% vs. 1.35% (p = 0.003). Conclusion: Avoiding aortic manipulation during CABG may decrease the rate of peri-operative stroke.
The Annals of Thoracic Surgery, 2003
Background. It is unknown whether coronary artery bypass grafting without cardiopulmonary bypass and with exclusive use of arterial grafts (arterial off-pump CABG) offers any significant short-term advantages over standard CABG with cardiopulmonary bypass. Accordingly, we performed a comparison of the short-term outcomes of arterial off-pump and standard CABG patients matched for preoperative risk and number of grafts.
Incidence of stroke in onpump versus offpump coronary artery bypass grafting a metanalysis
Background and Aims: Conventional coronary artery bypass grafting (CCABG) has been associated with high incidence of stroke, especially for the high degree of aortic manipulation. Off-pump CABG (OPCAB) theoretically represents a valid option, since the avoidance of aortic manipulation can prevent the embolization of atherosclerotic debris. There is a lot of controversy about the outcomes of CCABG compared to OPCAB. The aim of this metanalysis is to examine the incidence of stroke within 30 days from the surgical procedure.
Reoperative off-pump coronary artery bypass grafting: current outcomes, concerns and controversies
Expert Review of Cardiovascular Therapy, 2010
Choice of conduit remains the Achilles heel of coronary artery bypass grafting. Conduit choice is crucial as it is deemed to influence the long-term outcomes. While the important survival advantage of a left internal mammary artery graft over vein grafts is universally accepted, controversy reigns supreme regarding the next best conduit. There is plenty of evidence to suggest that arterial grafts are not only superior in terms of patency and survival, but they also protect the native coronary arteries against further progression of atherosclerotic disease. Total arterial coronary grafting, utilizing various configurations of bilateral internal mammary arteries, radial artery and occasionally right gastroepiploic artery is a safe and reproducible strategy. However, concerns about additional operative time, enhanced technical complexity, graft spasm with hypoperfusion, competitive flow, increased risk of bleeding, deep sternal wound infection, and most importantly lack of randomized trial data have prevented the universal adoption of total arterial coronary grafting. This review evaluates the currents outcomes of total arterial coronary grafting and summarizes the concerns and controversies associated with this strategy.
The Journal of Thoracic and Cardiovascular Surgery, 2008
Patients undergoing reoperative coronary artery bypass have increased mortality and morbidity compared with those undergoing primary coronary bypass. The experience in applying off-pump techniques to coronary reoperations is limited. In this article we report a 10-year experience using various techniques of reoperative off-pump coronary bypass. Methods: Between January 1996 and December 2005, 332 patients underwent reoperative off-pump coronary artery bypass grafting. Data were collected regarding the preoperative, intraoperative, and postoperative clinical course of all patients. These were compared with similar data obtained from patients who had undergone conventional coronary reoperation during this period. Results: Two hundred ninety-six (89.2%) male and 36 female patients underwent reoperative off-pump coronary artery bypass. Of these, 265 (79.8%) patients underwent multivessel bypass through a median sternotomy, an anterolateral thoracotomy was performed in 63 (19%) patients, and a posterolateral thoracotomy was performed in 4 (1.2%) patients. The early mortality for patients undergoing off-pump surgery was lower than for those undergoing conventional reoperations (3.3% vs 5.5%, P 5 .066). Those who had undergone off-pump reoperations had less need for prolonged ventilation or prolonged inotropic support and had shorter intensive care unit and hospital stays than patients who had undergone redo coronary artery bypass grafting. Conclusion: For many patients requiring coronary reoperations, off-pump techniques are safe and feasible. Complete revascularization was achieved in at least 75% of patients in an unselected population, with mortality and perioperative event rates that are comparable with those of conventionally performed coronary reoperations. C oronary artery bypass grafting (CABG) is a well-established therapy for patients with coronary artery disease, and the results of primary operations are relatively good. However, many patients have recurrent symptoms, and some require reoperation. Although some authors have observed similar rates of mortality and morbidity for both primary coronary artery surgery and reoperative coronary bypass, 1 many other groups have found that mortality and morbidity are higher during coronary reoperation. 2,3 Traditionally, coronary reoperation has been performed during cardiopulmonary bypass with the aorta crossclamped and the heart arrested by means of cardioplegia (redo CABG). Recently, techniques of performing coronary artery surgery off pump have been developed. At this institution, we are routinely performing primary off-pump CABG (OPCABG), 4 with excellent results. 5 The reports of the application of off-pump techniques to coronary reoperations (redo OPCABG) for either single-vessel or multivessel disease are few. 6-10 The aim of this retrospective study was to analyze our experience with redo OPCABG.
Off-pump coronary artery bypass grafting: Misperceptions and misconceptions
World journal of methodology, 2014
Coronary artery bypass grafting (CABG) continues to be one of the most commonly performed cardiac surgical procedures worldwide. Conventional CABG performed on cardiopulmonary bypass termed on-pump CABG is regarded as the gold standard. However, on-pump CABG results in several physiologic derangements including but not limited to thrombocytopenia, activation of complement factors, immune suppression, and inflammatory responses leading to organ dysfunction. Furthermore, manipulating an atherosclerotic ascending aorta during cannulation and cross-clamping can predispose to embolization and stroke risk. Recognition of these detrimental effects of on-pump CABG resulted in resurgence of off-pump CABG nearly two decades ago. Off-pump CABG since its resurgence has been a subject of intensive scrutiny and speculation. Despite numerous retrospective nonrandomized studies, prospective randomized trials, and meta-analyses validating the safety and efficacy of off-pump CABG, opponents of the te...
Assessing the benefits of anaortic off-pump coronary artery bypass grafting
Frontiers in cardiovascular medicine, 2024
Introduction: The procedure called the "aorta no-touch" (NT) or anaortic technique in off-pump coronary artery bypass grafting (OPCAB) is designed to reduce the perioperative risk of stroke. We have observed an increased frequency of anaortic OPCAB procedures at our institution. The main purpose of the present study is to investigate the effectiveness of anaortic OPCAB in reducing the perioperative risk of stroke. Methods: From April 2011 to July 2023, a total of 2,236 patients underwent isolated OPCAB at our single center. The patients were divided into the anaortic group (NT, n = 762) and the aortic group (A, n = 1,474). The NT group was propensity score-matched (PSM) with the A group at a 1:1 ratio (NT n = 640; A n = 640), and matching was performed based on 26 covariates with preoperative clinical characteristics. Results: In both the unmatched and matched cohorts of the NT and A groups, there were no significant differences observed in new stroke rates (NT vs. A; unmatched, 1.0% vs. 1.2%, p = 0.624; matched, 0.9% vs. 1.3%, p = 0.789). The univariable logistic analysis did not identify the anaortic technique as an independent factor negatively associated with new stroke events (OR = 0.81, 95% CI = 0.35-1.86, p = 0.624). Conclusion: The present study did not find the anaortic technique to reduce the perioperative risk of stroke in OPCAB. Hence, further large studies are needed to identify patient cohorts in which anaortic OPCAB is significantly beneficial.