[Total arterial bypass operations with complete sternotomy in the awake patient]

Activation of Coagulation and Fibrinolysis after Off-Pump Coronary Artery Bypass Grafting with or without Endotracheal General Anesthesia

Objective

In this study, we measured the activity of coagulation and fibrinolysis and clarified the presence of certain differences between off-pump coronary artery bypass grafting (OPCAB) cases and awake off-pump coronary artery bypass grafting (AOCAB) cases to evaluate whether AOCAB is actually safe from the viewpoint of coagulability.

Methods

8 underwent OPCAB and 6 underwent AOCAB. The following factors inducing coagulation and fibrinolysis were measured for upto 5 days after the operation: platelet counts, prothrombin time, activated partial thromboplastin time, fibrinogen, fibrin degeneration products, D-dimer, thrombin-antithrombin III complex (TAT), α2-plasmin inhibitor-plasmin complex, prothrombin fragment 1, 2 (F1+2), thrombomodulin, β-thromboglobulin (β-TG), and platelet factor-4.

Results

At 5 days after the operation, fibrin degeneration products, D-dimer, α2–plasmin inhibitor-plasmin complex, and F1 + 2 levels of the OPCAB group were significantly higher compared with their baseline values and those of the AOCAB group. At 5 days after the operation, thrombin-antithrombin III complex levels of the OPCAB group were significantly higher than those of the AOCAB group. Fibrinogen levels of the OPCAB group were significantly higher than their baseline values at 3 days after the operation (POD3) and 5 days after the operation (POD5).

Conclusions

In this study, the hypercoagulable state at POD5 was suggested in the patients in the OPCAB group, but not in those in the AOCAB group. Further study is necessary to confirm these results, and future studies would evaluate the potential benefit of AOCAB procedure from the viewpoint of perioperative coagulability.

Awake cardiac surgery using a novel anesthetic technique

PURPOSE

We describe the first published cases of awake cardiac surgery in Canada. In addition, a novel anesthetic technique consisting of combined femoral block/high epidural thoracic anesthesia is presented.

CLINICAL FEATURES

Two patients, both 65 yr of age and with good left ventricular function, were scheduled to undergo off-pump coronary artery bypass grafting (OPCAB) for two grafts each. Anesthesia consisted of combined femoral 3:1 block and high thoracic epidural anesthesia. Both surgeries proceeded without hemodynamic or respiratory complications; in both cases, opening of the pleural spaces was treated with insertion of thoracic drainage tubes. Both patients were transferred to the postanesthesia care unit immediately after surgery and six hours later to the cardiac surgical ward. Both patients were discharged from the hospital within five days of surgery.

CONCLUSION

We conclude that awake OPCAB is feasible using a combined femoral block/high thoracic epidural anesthesia technique which allows cardiac surgery and harvesting of the saphenous vein. Further clinical experience is required to define the technical limitations of this technique before randomized studies should be undertaken to better define the role of awake procedures in the future of cardiac surgery.

Operative techniques in awake coronary artery bypass grafting

BACKGROUND

Off-pump coronary artery bypass grafting was implemented to reduce trauma of surgical coronary revascularization by avoiding extracorporeal circulation. High thoracic epidural anesthesia further reduces intraoperative stress and postoperative pain. In addition, this technique even allows awake coronary artery bypass grafting, avoiding the drawbacks of mechanical ventilation and general anesthesia in high-risk patients.

METHODS

Thirty-four patients underwent awake coronary artery bypass grafting with left internal thoracic artery to left anterior descending coronary artery by partial lower ministernotomy (n = 20), H-graft technique (n = 2), or rib cage-lifting technique (n = 2). In 9 cases we performed double bypass grafting, and in 1 case we performed triple-vessel coronary artery revascularization through complete median sternotomy. In addition to clinical outcomes, visual analog scale pain scores were recorded on days 1, 2, and 3 after surgery.

RESULTS

Thirty-one patients remained awake throughout the whole procedure. Three patients required secondary intubation because of incomplete analgesia (n = 1) or pneumothorax (n = 2). Procedure time was 90 +/- 31 minutes, and recovery room stay was 4.2 +/- 0.6 hours. There were no in-hospital deaths or serious postoperative complications. In 1 case a graft occlusion was documented on predischarge angiography. Early postoperative pain was low (visual analog scale score of 30 +/- 6).

CONCLUSION

These data demonstrate the feasibility and safety of various surgical coronary revascularization techniques without general anesthesia. Continuation of thoracic epidural analgesia provides good pain control and fast mobilization postoperatively. Surprisingly, the awake coronary artery bypass grafting procedure was well accepted by the patients.

Coronary artery bypass grafting in the awake patient: three years' experience in 137 patients

OBJECTIVE

Our experience with 137 patients operated on without general anesthesia is reviewed to explore the validity of our surgical strategy.

METHODS

Between October 1998 and January 2002, 137 patients underwent coronary artery bypass grafting with high thoracic epidural anesthesia. There were 47 female and 90 male patients, ranging in age from 37 to 92 years (mean, 68 +/- 12 years). Two patients underwent reoperation. Nineteen patients had contraindications for general anesthesia. Target vessels involved were the left anterior descending artery in 122, the right coronary artery in 6, the left anterior descending artery plus right coronary artery in 7, and the left anterior descending artery plus circumflex artery in 2 patients. Coronary artery bypass was performed through limited access in 74 patients (H-graft in 42 and rib cage lifting in 32 patients) and through a median sternotomy in 63 patients. Cardiopulmonary bypass was not used.

RESULTS

In 39 (28.4%) patients pneumothorax was observed during surgical intervention. There was no mortality. Of the 137 patients, 132 (96.3%) completed the procedure awake. In 58 patients the intensive care unit was not used. Eight patients were discharged from the hospital on the day of their operation. Mean length of hospitalization was 1 day (range, 0-3 days). One hundred thirty-one patients were followed up for a period of 3 months and 3 years after their operations, and 94.7% of the patients were symptom free. Control angiograms were obtained in 41 patients. Graft patency was 100%, with one radial artery graft spasm.

CONCLUSIONS

Our initial experience confirms the feasibility and safety of performing coronary artery bypass grafting in the conscious patient without general anesthesia. Further study is required to define the possible extent and limitations of this strategy.