Beating heart versus conventional single-vessel reoperative coronary artery bypass

A Meta-Analysis of Early, Mid-term and Long-Term Mortality of On-Pump vs. Off-Pump in Redo Coronary Artery Bypass Surgery

We aimed to compare the early, mid-term, and long-term mortality between on-pump vs. off-pump redo coronary artery bypass grafting (CABG). We conducted a systematic search for studies comparing clinical outcomes of patients who underwent on-pump vs. off-pump redo CABG. We pooled the relevant studies quantitatively to compare the early (perioperative period, whether in hospital or within 30 days after discharge), mid-term (≥1 year and <5 years), and long-term (≥5 year) mortality of on-pump vs. off-pump redo CABG. A random-effect model was applied when there was high heterogeneity (I2 > 50%) between studies. Otherwise, a fixed-effect model was utilized. After systematic literature searching, 22 studies incorporating 5,197 individuals (3,215 in the on-pump group and 1,982 in the off-pump group) were identified. A pooled analysis demonstrated that compared with off-pump redo CABG, on-pump redo CABG was associated with higher early mortality (OR 2.11, 95%CI: 1.54–2.89, P < 0.00001). However, no significant difference was noted in mid-term mortality (OR 1.12, 95%CI: 0.57–2.22, P = 0.74) and long-term mortality (OR 1.12, 95%CI: 0.41–3.02, P = 0.83) between the two groups. In addition, the complete revascularization rate was higher in the on-pump group than the off-pump group (OR 2.61, 95%CI: 1.22–5.60, P = 0.01). In conclusion, the off-pump technique is a safe and efficient alternative to the on-pump technique, with early survival advantage and similar long-term mortality to the on-pump technique in the setting of redo CABG, especially in high-risk patients.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021244721.

Repeat Coronary Artery Bypass Grafting: A Meta-Analysis of Off-Pump versus On-Pump Techniques in a Large Cohort of Patients

BACKGROUND

Redo coronary artery bypass grafting (CABG) can be performed with either the off-pump (OPCAB) or the on-pump (ONCAB) technique.

METHOD

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), this meta-analysis compared the safety and efficacy of OPCAB versus ONCAB redo CABG.

RESULTS

Twenty-three (23) eligible studies were included (OPCAB, n=2,085; ONCAB, n=3,245). Off-pump CABG significantly reduced the risk of perioperative death (defined as in-hospital or 30-day death rate), myocardial infarction, atrial fibrillation, and acute kidney injury. The two treatment approaches were comparable regarding 30-day stroke and late all-cause mortality.

CONCLUSIONS

Off-pump redo CABG resulted in lower perioperative death and periprocedural complication rates. No difference was observed in perioperative stroke rates and long-term survival between the two techniques.

Outcomes after Off-Pump Reoperative Coronary Artery Bypass Grafting

Objective

Application of off-pump techniques to reoperative coronary artery bypass (redo CABG) has been limited by technical difficulty and potential for embolism of atheromatous debris from diseased grafts, resulting in myocardial infarction and rapid hemodynamic deterioration. We compared outcomes after off-pump (OPCAB) and on-pump (ONCAB) in redo CABG.

Methods

A retrospective chart review was performed for patients who underwent redo CABG at a single academic institution between January 1997 and December 2004. Outcomes were compared between groups based on intention to treat. Propensity scores were calculated for each patient using 23 preoperative risk factors. Logistic regression was applied for each end point as a function of group and propensity score.

Results

A total of 771 consecutive patients had redo CABG (639 ONCAB and 132 OPCAB); 22 patients (16.7%) were converted from OPCAB to ONCAB for hemodynamic in stability, severe adhesions, or graft injury; 7 patients (1.1%) were converted from ONCAB to OPCAB for severe aortic calcification. Propensity-matched comparison of outcomes after OPCAB versus ONCAB for redo CABG showed that OPCAB was associated with a reduction in postoperative complications, transfusion, atrial fibrillation, and length of stay. OPCAB patients received fewer grafts with similar use of left internal mammary artery conduit; conversion from OPCAB to ONCAB did not reduce the benefit of OPCAB.

Conclusions

OPCAB can be safely and effectively applied to reoperative CABG in selected cases.

Lung Injury after Cardiopulmonary Bypass

Pulmonary injury during cardiopulmonary bypass is common as patient factors (smoking, pain, pneumonia) and the effects of cardiopulmonary bypass combine to compromise lung function after cardiac surgery. Lung injury follows the propagation of an inflammatory response involving cytokines, complement, neutrophils, monocytes, activated endothelial cells and platelets. Neutrophils sequester in the lung in response to chemo-tactic agents and release injurious oxygen free radicals and specific enzymes resulting in widespread pulmonary injury.

To alleviate this lung injury a number of possible interventions exist. Off pump surgery may reduce the degree of systemic inflammation but respiratory impairment still occurs and the clinical advantage is uncertain. The use of leukocyte filtration can attenuate the acute inflammatory response with encouraging though variable results. Aprotinin, Pentoxyfilline, Nitric oxide, Aspirin and other agents have shown benefits in lung function after cardiopulmonary bypass induced lung injury.

Given the magnitude and diversity of the inflammatory response to cardiopulmonary bypass many possible interventions exist to attenuate lung injury resulting from extracorporeal circulation. Immediate clinical benefits are likely to result from successful amelioration of the processes involved.

Off-Pump Surgery: A Choice in Unstable Angina

The benefit and safety of off-pump coronary artery bypass surgery in patients with unstable angina was assessed retrospectively. From February 1996 to October 2001, 5,306 patients underwent multivessel off-pump coronary artery bypass, of whom 920 (17%) had unstable angina. In these 920 patients, ejection fractions ranged from 15% to 70%, 203 (22%) had an ejection fraction of 20%–35%, and 11 (1%) had an ejection fraction < 20%. Triple-vessel disease was present in 625 patients. Preoperative intraaortic balloon pump support was used in 28 patients. Operative approaches included mid sternotomy (86%), lower partial sternotomy (9%), and left anterior thoracotomy (2%). The number of grafts ranged from 1 to 5 with a mean of 2.43 ± 0.86, and 92.3% of patients received a left internal mammary artery graft. Twenty-two patients need intraoperative intraaortic balloon pumping. Ten patients (1%) suffered perioperative myocardial infarction. The mean hospital stay was 7.8 ± 4.3 days. Hospital mortality was 2/920 (0.22%). Intraaortic balloon pumping was helpful in these cases of unstable angina refractory to medical therapy. Off-pump coronary artery surgery was found to be safe and beneficial in these patients.

Early and Midterm Outcome of Redo Coronary Artery Bypass Grafting: On-Pump versus Off-Pump Bypass

BACKGROUND

Redo coronary artery bypass grafting (CABG) is still associated with increased morbidity and mortality as compared to the first-time operation. Further, the application of the off-pump technique to redo CABG is limited due to technical difficulties. The aim of this retrospective study was to analyze early and midterm results after redo CABG and compare the outcome of redo on-pump and off-pump CABG.

METHODS

From June 1996 to October 2011, elective redo CABG was performed in 32 patients. Mean age was 64.8 years (on pump 64.3 years vs. off pump 65.5 years; p=0.658), and 21 patients were male. Among these patients, 14 (43.8%) underwent on-pump CABG, and 18 (56.2%) underwent off-pump CABG.

RESULTS

Internal thoracic artery was used in 22 patients (68.8%), and total arterial revascularization was achieved in 17 patients (53.1%). The average number of distal anastomoses was 2.13, and the rate of incomplete revascularization was 43.8%. The rate of total arterial revascularization was higher in the off-pump group (14.3% vs. 83.3%, p<0.001), and the use of saphenous vein graft was more in the on-pump group (78.6% vs. 16.7%, p<0.001). Overall hospital mortality was 3.1% (n=1) and was comparable in both groups (on pump 7.1% vs. off pump 0%; p=0.249). Postoperative complications occurred in 9 patients (64.2%), and the rate of complications was high in the on-pump group without statistical significance (64.2% vs. 33.3%, p=0.082). The mean follow-up duration was 5.4 years, and overall survival at 10 years was 86.0%±10.5%. There was no significant difference in the 10-year survival rate between the two groups (79.6% vs. 100%, p=0.225).

CONCLUSION

Redo CABG can be safely performed with acceptable mortality. Redo off-pump coronary artery bypass is feasible with low mortality and morbidity, comparable target vessel bypass grafting, and long-term survival. The off-pump technique might be considered a safe option for redo CABG in high-risk patients.

Improved Short-Term Outcomes with Off-Pump Reoperative Coronary Artery Bypass Grafting

Objective

Reoperative coronary surgery patients are usually sicker and older, and the procedure is more technically demanding. Comparisons between coronary surgery with (coronary artery bypass [CAB] surgery on cardiopulmonary bypass [CPB]) and without (off-pump CAB [OPCAB]) the pump have been conducted; however, few studies showed results in reoperative cases. We investigate the potential superiority of one technique over the other in redo coronary surgeries.

Methods

Our institutional Society of Thoracic Surgery database was used to gather the data for 266 isolated reoperative coronary artery surgeries from January 2004 to July 2011. These were divided into the CAB surgery in CPB group (n = 204) and the OPCAB group (n = 62).

Results

Baseline characteristics of the two groups were similar, except for a significantly higher prevalence of cerebrovascular disease among the off-pump group ( P = 0.01). There was also a trend toward fewer vessels bypassed among the same group ( P = 0.07). Risk adjustment was done using multivariable analyses for detection of independent effects. The use of CPB was an independent predictor of increased rates of postoperative events (odds ratio, 3.9; P = 0.004) and atrial fibrillation (odds ratio, 5.9; P < 0.005) and longer intensive care unit (0.006) and hospital stay (0.004).

Conclusions

Redo OPCAB seems to offer favorable short-term outcomes compared with redo CAB. Our results suggest a reduced rate of overall postoperative events, decreased new postoperative atrial fibrillation, reduced hours stayed in the intensive care unit, and fewer days stayed from surgery to discharge. This was not associated with an increase in morbidity and mortality. A randomized study with a larger number of patients and with a longer follow-up is needed.

The impact of dexmedetomidine infusion in sparing morphine consumption in off-pump coronary artery bypass grafting

PURPOSE

Recovery from off-pump coronary artery bypass (OPCAB) has been reported to be more advantageous than conventional coronary artery bypass grafting with regard to both hospital and intensive care unit length of stay. Dexmedetomidine is a selective α-2 agonist that has been used successfully as an adjunct to narcotics in adult and pediatric cardiac surgery. The aim of this study was to assess the effect of dexmedetomidine on the recovery, total narcotic consumption, and total hospital and intensive care unit length of stay in patients undergoing OPCAB.

METHODS

The recovery, hospital and intensive care unit length of stay, as well as total morphine consumption of patients receiving dexmedetomidine infusion (0.5 µg/kg/h; dexmedetomidine group), after induction of general anesthesia, were compared with those receiving placebo (saline group).

RESULTS

The duration of intubation of patients in the dexmedetomidine group was significantly shorter than in the control group (289 ± 44 minutes in the dexmedetomidine group vs 530 ± 119 minutes in the control group). The total hospital and intensive care unit length of stay were significantly shorter in the dexmedetomidine group (P < .05). Also, total fentanyl and morphine consumptions were lower in the dexmedetomidine group than in the control group (P < .05).

CONCLUSION

Our study showed that dexmedetomidine might be an effective adjuvant in reducing both total hospital and intensive care unit length of stay in patients undergoing OPCAB. Dexmedetomidine might play a role in reducing total morphine and fentanyl consumption in OPCAB.

Reoperative coronary artery bypass surgery: avoiding repeat median sternotomy

BACKGROUND

Mortality and morbidity in reoperative coronary artery surgery are considered to be higher than those for initial surgery. Contributing factors include cardiac injury and damage to patent grafts in repeat median sternotomy. To avoid these complications, reoperative cases were performed off pump to avoid repeat median sternotomy.

METHODS

The study subjects were 79 patients who underwent reoperations while utilizing off-pump coronary artery bypass grafting to avoid the need for repeat median sternotomies. All operations were performed by the same surgeon in the period from January 1996 to December 2010.

RESULTS

The mean duration from initial surgery to reoperation was 6 years and 5 months. Reported reasons for reoperation were de novo coronary lesion in 16 patients, graft failure in 33 patients, and de novo coronary lesion plus graft failure in 47 patients. All cases underwent surgery off pump. The approach was left anterior small thoracotomy (35 patients), transdiaphragmatic approach (21 patients), left posterolateral thoracotomy (9 patients), left anterior small thoracotomy plus transdiaphragmatic approach (9 patients), left posterolateral thoracotomy plus transdiaphragmatic approach (4 patients), and small median sternotomy plus left anterior small thoracotomy (1 patient). There were no deaths among the 79 patients in whom repeat median sternotomy was avoided, and all grafts were patent.

CONCLUSIONS

Reoperative coronary artery surgery that avoids repeat median sternotomy can prevent cardiac injury and damage to patent grafts. Furthermore, it does not require blood transfusion. Thus, it is an effective method of reducing mortality and morbidity even in reoperative cases.

Patients With Severe Asymptomatic Carotid Artery Stenosis Do Not Have a Higher Risk of Stroke and Mortality After Coronary Artery Bypass Surgery

Background and Purpose—

Stroke development is a major concern in patients undergoing coronary artery bypass grafting (CABG). Whether asymptomatic severe carotid artery stenosis (CAS) contributes to the development of stroke and mortality in such patients remains uncertain.

Methods—

A retrospective analysis of 878 consecutive patients with documented carotid duplex ultrasound who underwent isolated CABG in our institution from January 2003 to December 2009 was performed. Patients with severe CAS (n=117) were compared with those without severe CAS (n=761) to assess the rates of stroke and mortality during hospitalization for CABG. The 30-day mortality rate was also assessed.

Results—

Patients with severe CAS were older and had a higher prevalence of peripheral arterial disease and heart failure. Patients with severe CAS had similar rates of in-hospital stroke (3.4% versus 3.6%; P =1.0) and mortality (3.4% versus 4.2%; P =1.0) compared with patients without severe CAS. The 30-day rate of mortality was also similar between the 2 cohorts (3.4% versus 2.9%; P =0.51).

Conclusions—

Severe CAS alone is not a risk factor for stroke or mortality in patients undergoing CABG. The decision to perform carotid imaging and subsequent revascularization in association with CABG must be individualized and based on clinical judgment.

Deleterious effects of cardiopulmonary bypass in coronary artery surgery and scientific interpretation of off-pump's logic

Cardiopulmonary bypass (CPB) has been suggested to be a cause of complex systemic inflammatory response that significantly contributes to several adverse postoperative complications. In the last few years, off-pump coronary artery bypass grafting (OPCAB) has gained widespread attention as an alternative technique to conventional on-pump coronary artery bypass grafting (ONCAB). However, a degree of uncertainty regarding the relative merits of ONCAB and OPCAB continues to be a significant issue. Surgeons supporting off-pump surgery, state that the avoidance of the CPB leads to significantly reduced myocardial ischemia-reperfusion injury, postoperative systemic inflammatory response and other biological derangements, a feature that may improve the clinical outcomes. However, perfection in perioperative care, surgical technique and methods of attenuating the untoward effects of CPB has resulted in better clinical outcome of ONCAB as well. Possible reasons of these controversial opinions are that high-quality studies have not comprehensively examined relevant patient outcomes and have enrolled a limited range of patients. Some studies may have been too small to detect clinically important differences in patient outcomes between these two modalities. We present a review of the available scientific interpretation of the literature on OPCAB with regard to safety, hemodynamic changes, inflammation, myocardial preservation and oxidative stress. We also sought to determine from different reported retrospective and randomized control studies, the initial and the long-term benefits of this approach, despite the substantial learning curve associated with OPCAB.

Functional status of patients during subacute recovery from coronary artery bypass surgery

BACKGROUND

Patients recovering from coronary artery bypass (CAB) surgery are particularly vulnerable to impaired functional status because in addition to the direct effects of heart disease on cardiac performance, many surgical factors may contribute to loss of function.

OBJECTIVES

The purposes of this study were to describe functional status across multiple domains using performance-based and self-report assessments and to determine the relationship among different domains of functional status in patients recovering subacutely (<6 months) from CAB surgery.

METHODS

The participants in this study (n = 25) had undergone CAB surgery in the past 6 months. This cross-sectional descriptive study measured functional status in several domains using self-report and performance-based assessments.

RESULTS

The study results indicate that participants had deficits in health-related quality of life, activities of daily living performance, endurance/aerobic capacity, and cognitive/memory ability. Several correlations between the scores for outcome measures in different domains were found in this study.

CONCLUSIONS

Impaired functional status occurs in patients recovering subacutely from CAB surgery. Different aspects of functional status are related, and an understanding of these relationships may help to improve the medical management of patients after CAB surgery.

Coronary reoperation with and without cardiopulmonary bypass

Redo coronary artery bypass grafting (CABG) is still associated with increased morbidity and mortality compared to primary operation. Myocardial protection is one of the key issues in redo on pump CABG and is still a matter of debate. Off pump redo CABG seems to be an attractive alternative as native coronary blood flow remains and cross clamping of the aorta is avoided. The aim of this retrospective study was to compare the outcome of redo CABG with and without CPB. From 1/1998 to 5/2004 redo CABG was performed in 195 patients (pts): 162 male (83.1%) and 33 female (16.9%) pts, age 66 +/- 9 years. In 160 pts, CPB with isolated antegrade myocardial protection was used for redo CABG. Off pump redo CABG was performed in 35 pts (30 male (85.7%) and 5 female (14.3%), age 67 +/- 8 years). Perioperative overall mortality rate was 3.6% (n = 7) and comparable in both groups (on pump 3.8% versus off pump 2.9%; p = 0.90), as well as perioperative myocardial infarction, intraaortic balloon pump implantation rate and secondary morbidity. Complete revascularization was achieved in 139 pts (86.9%) after on pump CABG and in 17 pts (48.6%) of the off pump group (p < 0.01). The average number of grafts was significantly higher in the on pump group (2.8 +/- 0.78 versus 1.6 +/- 0.6; p = 0.04).Furthermore, 20 pts (12.5%) in the on pump group died during follow-up (50 +/- 16 months). Five pts (25.0%) died due to cardiac reasons. In the off pump group 3 pts (8.6%) died during follow-up (44 +/- 13 months), noncardiac related. Overall survival was 83.8% in the on pump group and 88.6% in the off pump group (p = 0.92). On pump redo CABG and off pump redo CABG can be safely performed with low mortality and morbidity. Off pump redo CABG might be limited due to incomplete revascularization.

Transabdominal off-pump coronary artery bypass grafting using the right gastroepiploic artery

BACKGROUND

: Anastomosis of the right gastroepiploic artery to vessels of the inferior wall of the heart can be performed using a transabdominal approach without sternotomy and without cardiopulmonary bypass.

METHODS

: From July 1999 to December 2004, 18 patients presenting with only right coronary artery disease were operated on by the transabdominal approach using a pedicled right gastroepiploic artery graft. In 14 patients, it was a redo operation. In all redo patients, a patent graft to the anterior wall was present. Median EuroSCORE was 5 (range 1-13). The right descending posterior artery was grafted in 10 patients, the right coronary artery in 8 patients.

RESULTS

: There was no hospital mortality and no conversion to sternotomy. Hospital morbidity consisted only of a right pleural hemothorax and a superficial wound infection. No blood transfusion was necessary in 16 (89%) patients. Hospital stay averaged 6 days.Follow-up is complete and averaged 2 years (range 0.5-5.5 years). There was no late mortality. Seventeen patients (94%) were asymptomatic. One patient who experienced return of angina 1 year after the procedure underwent a percutaneous transluminal coronary angioplasty of the right coronary artery. Thirteen patients underwent a stress test at median follow-up of 14 months without signs of myocardial ischemia.

CONCLUSIONS

: Off-pump coronary bypass grafting using a right gastroepiploic artery by the transabdominal approach is a safe and effective procedure with a low hospital morbidity and excellent follow-up. In redo operations, this technique excludes the risk of damaging patent grafts to the left coronary system.

Redo Minimally Invasive Direct Coronary Artery Bypass Grafting

BACKGROUND

Conventional redo coronary artery bypass grafting is associated with an increased risk of mortality and morbidity as a result of manipulation of patent grafts, mediastinitis, and the presence of pericardial adhesions. Minimally invasive direct coronary artery bypass grafting may be an alternative approach in selected patients.

METHODS

From January 1997 to October 2003, 46 patients (mean age, 66 +/- 7.4 years) underwent minimally invasive direct coronary artery bypass grafting using the left internal thoracic artery to the left anterior descending artery on the beating heart as a reoperation. Patients after previous cardiac operation by means of median sternotomy without use of the left internal thoracic artery presenting with a significant left anterior descending artery stenosis ("culprit lesion") were included. Predicted mortality was 13.6% (range, 2.4% to 72.8%) as calculated by the logistic Euroscore; ejection fraction was 0.531 (range, 0.14 to 0.81). Surgical results were analyzed for mortality, morbidity, duration of the procedure, hospital stay, and event-free survival.

RESULTS

Mean operating time was 103 +/- 34 minutes. There were two in-hospital deaths (4.6%), one for malignant ventricular arrhythmia (Euroscore, 60.9%) and the second as a result of severe gastrointestinal bleeding (Euroscore, 29.2%). One patient (2.3%) was successfully reoperated on because of perianastomotic hematoma using the same approach after 6 days. Patients were discharged after 9.4 +/- 2.6 days. There were no other serious adverse events, no stroke, and no myocardial infarction. During follow-up (37 +/- 21 months, complete in 92.1%), 1 patient experienced angina and 6 patients died. The actuarial 4-year survival is 74.8% (95% confidence interval, 51% to 92%), and the actuarial 4-year event-free survival including freedom from angina, major adverse cardiac events, and reintervention is 81% (95% confidence interval, 54% to 97%).

CONCLUSIONS

Minimally invasive direct coronary artery bypass grafting can be considered as an alternative approach for redo coronary artery bypass grafting in selected patients.

Transabdominal Off-Pump Coronary Artery Bypass Grafting Using the Right Gastroepiploic Artery

Background

Anastomosis of the right gastroepiploic artery to vessels of the inferior wall of the heart can be performed using a transabdominal approach without sternotomy and without cardiopulmonary bypass.

Methods

From July 1999 to December 2004, 18 patients presenting with only right coronary artery disease were operated on by the transabdominal approach using a pedicled right gastroepiploic artery graft. In 14 patients, it was a redo operation. In all redo patients, a patent graft to the anterior wall was present. Median EuroSCORE was 5 (range 1–13). The right descending posterior artery was grafted in 10 patients, the right coronary artery in 8 patients.

Results

There was no hospital mortality and no conversion to sternotomy. Hospital morbidity consisted only of a right pleural hemothorax and a superficial wound infection. No blood transfusion was necessary in 16 (89%) patients. Hospital stay averaged 6 days. Follow-up is complete and averaged 2 years (range 0.5–5.5 years). There was no late mortality. Seventeen patients (94%) were asymptomatic. One patient who experienced return of angina 1 year after the procedure underwent a percutaneous transluminal coronary angioplasty of the right coronary artery. Thirteen patients underwent a stress test at median follow-up of 14 months without signs of myocardial ischemia.

Conclusions

Off-pump coronary bypass grafting using a right gastroepiploic artery by the transabdominal approach is a safe and effective procedure with a low hospital morbidity and excellent follow-up. In redo operations, this technique excludes the risk of damaging patent grafts to the left coronary system.

Gastroepiploic Artery Minimally Invasive Grafting in Reoperative Patients With Patent Mammaries

BACKGROUND

Patients with patent grafted bilateral internal thoracic arteries may require repeat myocardial revascularization because of either progression of disease in a nongrafted native vessel or failure of a saphenous vein graft. In order to avoid extensive dissection and possible damage of the internal thoracic arteries, we elected to proceed with an off-pump minimally invasive direct coronary artery bypass grafting (MIDCABG) approach using the pedicled right gastroepiploic artery. This paper summarizes our midterm angiographic results.

METHODS

From 1996 to 2003, 15 patients were reoperated on using this approach in our department. Internal thoracic artery grafts always revascularized the anterior and lateral territories and were angiographically patent. Indications for repeated surgery were: (1) coronary disease progression in 8 patients; (2) occlusion of the saphenous vein graft in 6 patients; and (3) anastomotic stenosis of a pedicled right gastroepiploic artery in 1 patient. Off-pump grafting of the pedicled right gastroepiploic artery was targeted at the posterior descending artery in 14 patients, and at the left anterior descending artery in 1 patient.

RESULTS

Thirty-day mortality was 6.5% (1 of 15 patients). With a mean follow-up of 56 +/- 20 months, angina-free survival was 79%. At angiographic control (mean, 38 months), the pedicled right gastroepiploic artery was patent in 13 patients. One patient had an occluded right gastroepiploic artery graft at 23 months and another patient showed progression of disease distal to the right gastroepiploic artery anastomosis at 28 months.

CONCLUSIONS

Off-pump MIDCABG repeat revascularization with a pedicled right gastroepiploic artery is an effective method of revascularization for patients with patent bilateral internal thoracic arteries.

Hospital and mid-term outcomes in elderly patients under-going off-pump coronary artery bypass grafting--comparison with younger patients--

BACKGROUND

Clinical outcomes and problems following off-pump coronary artery bypass grafting (OPCAB) in elderly patients have not been clarified.

METHODS AND RESULTS

The surgical results of elderly patients aged 75 years or older (n=50; 38 males, mean age, 78.8 years) were reviewed and compared with those of younger patients (n=95; 79 males, mean age, 63.0 years). The EuroSCORE score was 6.9+/-3.5 in the elderly group and 3.0+/-2.4 in the younger group (p<0.0001). There were no hospital deaths in either group. There was no significant difference in the postoperative complication rate except for atrial fibrillation (40.0% elderly vs 24.2% younger, p=0.0479). Postoperative intensive care unit and hospital stays did not differ. The frequency of blood transfusion was significantly higher in the elderly group (78.0% elderly vs 37.2% younger, p<0.0001). During the mean follow-up of 18.6+/-8.8 months, there was 1 sudden death in the elderly group, but no cardiac deaths in either group. The 32-month cardiac event-free and survival rates were similar for the 2 groups.

CONCLUSION

OPCAB provides satisfactory clinical outcomes for elderly as well as younger patients.

Coronary Revascularization Without Cardiopulmonary Bypass Versus the Conventional Approach in High-Risk Patients

BACKGROUND

The premise of coronary revascularization without cardiopulmonary bypass (off-pump coronary artery bypass graft [CABG]) proposes that patient morbidity and, potentially, mortality can be reduced without compromising the excellent results of conventional revascularization techniques (on-pump CABG). High-risk patients may benefit the most from off-pump CABG. The aim of this study was to compare early and mid-term clinical outcomes after off-pump CABG with on-pump CABG in a subset of high-risk patients.

METHODS

Between January 1, 2000 and December 31, 2000, 513 high-risk patients with a Parsonnet's risk scores of 20 or higher underwent CABG; 38.6% (n = 198) underwent on-pump CABG, and 61.4% (n = 315) had off-pump CABG. Logistic regression was used to calculate the probability of being selected for on-pump CABG given a set of preoperative risk factors. Propensity scores or the probability of being selected for on-pump CABG were computed. Relative risks, heterogeneity among strata, and interactions between surgery type and the propensity score were assessed by a multivariate Cox proportional-hazards regression for the outcomes mortality and major adverse cardiac events (death, acute myocardial infarction, stroke, reoperative CABG, percutaneous coronary intervention).

RESULTS

Operative mortality was lower after off-pump versus on-pump CABG between the two groups after controlling for preoperative risk factors using the propensity score (odds ratio = 2.10; 95% confidence intervals = 1.02 to 4.36, p = 0.04). In the Cox-regression analysis, off-pump CABG was associated with an improved survival rate compared with on-pump CABG (p = 0.03). Off-pump CABG was associated with a comparable event-free survival (p = 0.14) compared with on-pump CABG.

CONCLUSIONS

Off-pump CABG can be performed with a reasonably low morbidity and lower early and late mortality in high-risk patients. Off-pump CABG may be a better operative strategy in this subset of patients.

Reoperative Coronary Artery Bypass Grafting: Analysis of Early and Late Outcomes

BACKGROUND

The purpose of this study was to evaluate early and late results of reoperative coronary artery bypass grafting compared with those of first coronary artery bypass grafting.

METHODS

From November 21, 1994, to December 31, 2001, 4,381 patients underwent isolated coronary revascularization: among these patients, 274 (6.3%) underwent a redo. Applying the propensity score, 239 redo patients (group R) were matched with 239 who underwent the first revascularization (group F).

RESULTS

Early mortality was 2.1% (group F) and 4.2% (group R), not significantly different. Group R showed significantly higher creatine kinase myocardial band release, length of intensive care unit stay, and incidence of incomplete myocardial revascularization than group F. In group R, off-pump patients showed higher incidence of incomplete revascularization. Redo was a risk factor for abnormal (>19 IU/L) creatine kinase myocardial band release (odds ratio, 1.7; p = 0.0066) and incomplete myocardial revascularization (odds ratio, 2.4; p = 0.0060). Five-year clinical outcome was significantly worse in group R, except for freedom from redo or percutaneous transluminal coronary angioplasty. Redo was an independent variable for lower freedom from death of any cause, cardiac death, acute myocardial infarction, cardiac events, and any event. Patients with higher creatine kinase myocardial band release or incomplete myocardial revascularization showed lower freedom from cardiac-related events. Incidence of incomplete myocardial revascularization and creatine kinase myocardial band release were significantly higher in group R by both univariate and multivariate analysis. This could explain the worse late outcome of redo patients.

CONCLUSIONS

Complete revascularization without damaging the heart, whichever technique is used, is the target of redo surgery, to achieve the same quality of results obtained in the first operation.

Predictors of atrial fibrillation after off-pump coronary artery bypass graft surgery

OBJECTIVE

Atrial fibrillation is the most common complication after coronary artery bypass graft surgery. This arrhythmia may lead to hemodynamic compromise, prolonged hospitalization, and increased risk for cerebral thromboembolism. Older age is the only variable consistently associated with the development of postoperative atrial fibrillation; however, no strong predictive model exists. The purpose of this study was to identify perioperative characteristics associated with new-onset atrial fibrillation in patients undergoing off-pump coronary artery bypass grafting.

DESIGN

Prospective, observational.

SETTING

University tertiary care hospital.

PARTICIPANTS

One hundred sixty consecutive patients undergoing off-pump coronary artery bypass grafting.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Incidence of postoperative atrial fibrillation was the major outcome. Atrial fibrillation occurred in 33 patients (20.6%). Multivariate analysis identified reintervention (odds ratio 26.8), revascularization of the ramus medianus (odds ratio 3.9), and age (odds ratio 1.069 per year) as the only independent predictors of postoperative atrial fibrillation. All patients were in sinus rhythm at hospital discharge. One hospital death was noted.

CONCLUSIONS

Despite the less invasive approach, the incidence of postoperative atrial fibrillation is high after off-pump coronary artery bypass grafting. Older age, grafting of the ramus medianus, and a redo operation were predictors of new-onset postoperative atrial fibrillation. It is possible that left atrial stretching with heart dislocation during revascularization of the lateral wall could lead to postoperative atrial fibrillation.

Off-Pump Surgery and Alternatives to Standard Operation in Redo Coronary Surgery

BACKGROUND

Reoperative coronary artery bypass grafting (CABG) has been associated with higher mortality and morbidity than first-time CABG. Off-pump surgery has been introduced in an effort to reduce morbidity associated with traditional on-pump CABG. However, these techniques present unique challenges in the reoperative setting. A review of our experience was undertaken to determine safety, efficacy, and technical challenges in beating heart reoperative CABG.

METHODS

From January 1999 through April 2003 reoperative CABG procedures performed by a single surgeon were treated on an "intention to treat" basis without cardiopulmonary bypass. A standardized operative technique employing suction stabilization and exposure devices were used for sternotomy procedures with stabilization devices employed for limited access single-vessel revascularization.

RESULTS

Eighty-six of eighty-seven (99%) consecutive patients undergoing reoperative CABG had the procedure initiated off-pump. There were 24 of 62 females/males (28%/72%) with a mean age of 64.3 (34 to 92). Eighty-one of eighty-six (94.2%) procedures were successfully completed off-pump. Five (5.8%) conversions were due to hemodynamic instability, inability to dissect dense adhesions (2), inability to locate an intramyocardial LAD (1). The procedures were performed via a median sternotomy in 67 patients (78%) and by limited anterior or lateral thoracotomy in 19 patients (22%). The operative mortality was 2 of 86, predicted risk 6.7%. There was no mortality in the converted patients. Postoperative length of stay was 5.5 days. There were no strokes or perioperative myocardial infarctions. Complications included reoperation for bleeding in 2.2%. Sixty-one of sixty-six (92.4%) patients were able to be extubated in the operating room. The rate of transfusion was 23 in 86 patients (26.5%), and atrial fibrillation was 5 in 86 patients (5.8%).

CONCLUSION

Off-pump CABG can technically be performed safely in most patients presenting for reoperative CABG. Outcomes appear to be improved compared with published outcomes of reoperative on-pump CABG surgery.

Chronologic distribution of stroke after minimally invasive versus conventional coronary artery bypass

OBJECTIVES

We sought to investigate whether the chronologic distribution of the onset of stroke occurring after coronary artery bypass graft surgery (CABG) without cardiopulmonary bypass (off-pump CABG) is different from the conventional on-pump approach (CABG with cardiopulmonary bypass).

BACKGROUND

Off-pump CABG has been associated with a lower stroke rate, compared with conventional on-pump CABG. However, it is unknown whether the chronologic distribution of the onset of stroke is different between the two approaches.

METHODS

We evaluated the chronologic distribution of postoperative stroke in patients undergoing CABG from June 1996 to August 2001 (n = 10,573). Preoperative risk factors for stroke were identified using the Northern New England preoperative estimate of stroke risk. Multivariate logistic regression analysis was used to determine the independent predictors of early stroke and to delineate the association between the surgical approach and the chronologic distribution of the onset of stroke.

RESULTS

Stroke occurred in 217 patients (2%, n = 10,573). A total of 44 (20%) and 173 (80%) of these patients had stroke after off-pump CABG and on-pump CABG, respectively. The median time for the onset of stroke was two days (range 0 to 11 days) after on-pump CABG versus four days (range 0 to 14 days) after off-pump CABG (p < 0.01). On-pump CABG was associated with a higher risk of early stroke (odds ratio 5.3, 95% confidence interval 2.6 to 10.9; p < 0.01) compared with off-pump CABG.

CONCLUSIONS

Compared with off-pump CABG, on-pump CABG is associated with an earlier onset of postoperative stroke during the recovery phase, suggesting different mechanisms in the pathogenesis of stroke between the two surgical approaches.

Off‐Pump Versus On‐Pump Reoperative CABG Via a Left Thoracotomy for Circumflex Coronary Artery Revascularization

OBJECTIVE

Reoperative CABG via a left thoracotomy (RCLT) has become a useful approach for revascularization of the circumflex coronary territory for patients who are at high risk for conventional approach. This study compares the results of RCLT using cardiopulmonary bypass (CPB) with those of a beating heart technique (OPCAB).

METHODS

Thirty-two patients who underwent RCLT over the past 10 years were included. Fourteen patients undergoing on-pump RCLT (CPB) were compared to 18 patients undergoing off-pump RCLT (OPCAB). Baseline characteristics of the study groups were similar. Follow-up was 100% complete. A single graft was performed in all patients except one who had two grafts.

RESULTS

There were no deaths or perioperative myocardial infarctions in either group. The incidence of atrial fibrillation (CPB: 29% vs. OPCAB: 11%) and the percentage of patients requiring ventilator support longer than 24 hours (21% vs. 6%) was not significantly different between the groups. However, allogeneic blood product utilization (0.9 +/- 1.2 vs. 0.3 +/- 0.7 units, p = 0.04), ICU stay (65 +/- 79 vs. 28 +/- 16 hours, p = 0.04) and total hospital length of stay (8 +/- 4 vs. 5 +/- 1 days, p = 0.001) were significantly lower in the OPCAB group. Average follow-up for the entire cohort was 33 +/- 9.8 months (range 2-102 months). Three-year survival was 74 +/- 9% with 9 deaths (28%) during the follow-up, but only 3 (9%) were cardiac related. Reinterventions were indicated in 6 patients (19%) (PTCA; 5, CABG: 1). Follow-up was longer for the CPB group (51 +/- 33 vs. 19.5 +/- 14 months, p = 0.001). Three-year survival (CPB 69 +/- 13%, OPCAB: 82 +/- 12%, p = 0.47) and reintervention rates (CPB: 3 [21%], OPCAB: 3 [17%], p = 0.33) were similar between the groups.

CONCLUSIONS

RCLT is an effective and safe approach for circumflex artery revascularization with excellent short- and mid-term results using either technique. The OPCAB technique is associated with reduced blood product utilization and shorter ICU and hospital length of stay and, therefore, is more cost-effective.

Off-pump coronary artery bypass graft surgery: the incidence of postoperative atrial fibrillation

Atrial fibrillation (AF) occurs in one quarter to one third of patients after coronary artery bypass graft surgery (CABG). Conventional CABG uses cardiopulmonary bypass, a process that is itself associated with a systemic vascular inflammatory response that contributes to postoperative morbidity. The avoidance of cardiopulmonary bypass is associated with a significant reduction in the inflammatory response and in the release of markers of myocardial necrosis when compared with conventional CABG. There is speculation that off-pump CABG may reduce the incidence of postoperative AF through reduced trauma, ischaemia, and inflammation. Current data, however, do not emphatically answer the question of whether the incidence of post-CABG AF is reduced by off-pump surgery. The evidence from both observational and randomised studies is conflicting and many studies have weaknesses in design, conduct, or interpretation. It remains an attractive hypothesis that postoperative AF is reduced by off-pump CABG but more robust data are required.

Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease: impact of strategy on midterm outcome

BACKGROUND

In a previous study, we demonstrated that patients with multivessel disease benefit during the first postoperative month from elimination of cardiopulmonary bypass (CPB). We evaluated the midterm results of the same patients excluding the first postoperative month from the analysis.

METHODS

From May 1997 to November 2000, 1,802 patients with multivessel disease survived the first postoperative month; 906 were operated on without (group A) and 896 with (group B) CPB. Follow-up ranged from 23 to 65 months (mean, 42 +/- 12 months). Four-year actuarial freedom from the following events was evaluated: death from any cause; cardiac death; acute myocardial infarction (AMI) in any territory; AMI in a grafted area; redo percutaneous transluminal coronary angioplasty (PTCA); redo PTCA in a target vessel; cardiac events (death from a cardiac cause, acute myocardial infarction on grafted vessel, redo PTCA on target vessel); and any event.

RESULTS

No statistical difference was found between groups A and B with regard to freedom from any death (95.3 +/- 0.8 vs 95.7 +/- 0.7, p = 0.5160); from cardiac death (97.3 +/- 0.6 vs 97.5 +/- 0.6, p = 0.5345); from AMI (98.4 +/- 0.4 vs 98.7 +/- 0.4, p = 0.4655); from AMI in a grafted area (98.9 +/- 0.4 vs 98.7 +/- 0.4, p = 0.9374); from redo PTCA (97.9 +/- 0.5 vs 97.7 +/- 0.6, p = 0.8485); from redo PTCA in a grafted area (98.7 +/- 0.4 vs 98.5 +/- 0.5, p = 0.8774); from target cardiac events (95.8 +/- 0.7 vs 95.9 +/- 0.8, p = 0.6070); and from any event (92.9 +/- 0.9 vs 93.4 +/- 1.0, p = 0.3721).

CONCLUSIONS

After exclusion of the first postoperative month, myocardial revascularization without CPB has midterm results similar to myocardial revascularization with CPB. In particular, failure of revascularization does not depend on intraoperative strategy.

Coronary reoperations: recurrence of angina and clinical outcome with and without cardiopulmonary bypass

BACKGROUND

We compared our experience of minimal tissue dissection and target vessel revascularization without cardiopulmonary bypass (CPB) with the standard procedure of total dissection of the heart and complete revascularization with CPB in patients who had elective reoperative coronary artery bypass grafting (redo-CABG).

METHODS

We analyzed recurrence of angina and clinical outcome in 118 patients who had elective redo-CABG between January 1995 and April 2002. Seventy-four patients had redo-CABG with CPB, and 44 patients had redo-CABG without CPB.

RESULTS

Perioperative outcome was comparable with regard to morbidity and mortality rates. At follow-up, the mean Canadian Cardiovascular Society score was 1.3 +/- 0.6 in patients who had redo-CABG with CPB and 1.7 +/- 0.8 in patients who had redo-CABG without CPB (p = 0.02). At follow-up, patients who had redo-CABG without CPB had a higher rate of recurrence of angina (log rank = 0.001) and higher use of nitrates (p = 0.015). Target vessel revascularization was an independent predictor of recurrence of angina in younger patients (< 75 years; p = 0.012) but not in the elderly (> or = 75 years; p = 0.142).

CONCLUSIONS

In elective redo-CABG patients, minimal tissue dissection and target vessel revascularization without cardiopulmonary bypass did not add significant benefit with regard to perioperative morbidity and mortality. The unsatisfactory relief of symptoms does not seem to justify target vessel revascularization by a less invasive approach. Therefore, this technique should be offered exclusively to patients at high risk with complete revascularization using CPB, such as the elderly.

New approaches to redo-coronary bypass grafting

Patients presenting with recurrent symptoms after coronary artery bypass graft surgery (CABG) continue to be a significant therapeutic challenge for the interventional cardiologist and cardiac surgeon. Percutaneous transcatheter angioplasty and repeat CABG, directed at vein graft degeneration and progression of native atherosclerotic disease, carry substantially worse outcomes than primary procedures. Recent minimally invasive, surgical advances using minimal-access incisions, arterial conduits, and off-pump techniques are demonstrating improved hospital outcomes compared with conventional CABG. These sternotomy-sparing, beating heart surgical approaches combined with recent advances in drug-eluting stents to provide complete revascularization may provide the best cardiac event-free survival for symptomatic CABG patients in the future.

Systematic organ protection in coronary artery surgery with or without cardiopulmonary bypass

Coronary artery bypass grafting with cardiopulmonary bypass (CPB) is known to be associated with a systemic inflammatory response, which contributes to the development of postoperative complications including multiple organ dysfunction. Off-pump coronary surgery has been shown to attenuate the inflammatory injury compared to the conventional approach, thereby reducing the incidence of postoperative cardiopulmonary, renal, or neurological dysfunction. It is believed that off-pump experience may greatly impact on improving the outcome of coronary surgery in certain high-risk patients. Moreover, a better understanding of the underlying mechanism would also help to improve our current CPB management. Accumulating evidence to date indicates that a balance between pro- and antiinflammatory responses is crucial in limiting the extent of such systemic inflammatory injury following surgical myocardial revascularization.

Perioperative advantages of off-pump coronary artery bypass grafting

For the first time in Japan, off-pump coronary artery bypass grafting (OPCAB) was compared with the conventional on-pump technique, retrospectively examining the morbidity associated with coronary artery bypass grafting (CABG) and assessing the efficacy of OPCAB. In 2000, 158 patients underwent CABG: 95 patients (60%) had OPCAB (Group I) and 63 patients (40%) had conventional CABG (Group II). The operating time, length of intensive care unit (ICU) stay, ventilation time, postoperative bleeding, transfusion, postoperative renal function, occurrence of stroke, and early graft patency were examined in both groups. There were no hospital deaths in either group. The operating time, ICU stay, and ventilation time were significantly (p < 0.0001, p = 0.013, and p < 0.0001, respectively) shorter in Group I (351 +/- 85 min, 3.0 +/- 1.4 days, and 5.1 +/- 2.8h) than in Group II (449 +/- 112 min, 3.6 +/- 1.8 days, and 13.7 +/- 18.0 h). The postoperative blood loss within 12h and the transfusion volume were significantly (p = 0.0004 and p < 0.0001, respectively) smaller in Group I (480 +/- 210 ml and 300 +/- 490ml) than in Group II (720 +/- 430ml and 1,230 +/- 1,180 ml). Peak serum blood urea nitrogen and creatinine concentrations (excluding patients with preoperative chronic renal failure, ie a preoperative serum creatinine > 1.5 mg/dl) were significantly (p < 0.0001 and p < 0.0001, respectively) lower in Group I (16.2 +/- 15.2mg/dl and 0.81 +/- 0.72 mg/dl) than in Group II (19.2 +/- 7.6 mg/dl and 0.92 +/- 0.28 mg/dl). There were no perioperative strokes in Group I, but 6.4% of Group II patients suffered a stroke. There was no significant difference in graft patency between the groups (95.6% vs 94.9%). OPCAB reduced the mortality and morbidity of coronary revascularization, with a shorter operating time and more rapid recovery from surgery.

Coronary artery bypass surgery by the transdiaphragmatic approach

BACKGROUND

The transdiaphragmatic approach is useful for reoperative coronary artery bypass grafting involving the right coronary artery because it does not require median sternotomy or cardiopulmonary bypass.

METHODS

Twenty-one patients underwent coronary artery bypass surgery by the transdiaphragmatic approach. The ratio of first operations to reoperations was 7:14. The cause of reoperation was occlusion of a saphenous vein graft in 4 patients, right gastroepiploic artery graft failure in 3 patients, and a new sclerotic lesion in the right coronary artery in 7 patients. When the radial artery or saphenous vein was used, grafting extended from the origin of the gastroduodenal artery to the right coronary artery.

RESULTS

None of the patients died during surgery. The sites of anastomoses were as follows: right coronary artery in 11 patients, right posterior descending artery in 9 patients, and the atrioventricular node artery in 1 patient. The following types of grafts were used: right gastroepiploic artery in 17 patients, saphenous vein in 2 patients, and radial artery in 2 patients.

CONCLUSIONS

When reoperative coronary surgery involving the right coronary artery is necessary, the transdiaphragmatic technique is effective because it does not damage patent grafts placed during the primary operation.

Comparison of two stabilizer concepts for off-pump coronary artery bypass grafting

BACKGROUND

This study was designed to evaluate the efficacy of two different stabilizer concepts for off-pump coronary artery bypass grafting.

METHODS

Between 2000 and 2001, 100 consecutive patients who underwent off-pump coronary artery bypass grafting were randomly assigned to two stabilization systems: the Medtronic Octopus 3 (n = 50) and the Genzyme Immobilizer (n = 50). During operation, two-dimensional cardiac surface motion was assessed by intravital microscopy using orthogonal polarization spectral imaging in 20 vessels at the anterior wall. Postoperative angiography of 47 vessels revealed anastomotic quality.

RESULTS

Patient demographics were similar in both groups regarding age, sex, ejection fraction, and New York Heart Association functional class. In 7 patients the randomized Immobilizer was rejected by the surgeon for lateral or posterior wall revascularization and subsequently switched to the Octopus device. Patients received 1.8 +/- 0.7 grafts in the Octopus and 1.6 +/- 0.5 in the Immobilizer group (p = not significant). Two-dimensional cardiac surface motion was significantly less using the Immobilizer (109.7 +/- 32.4 microm versus 423.5 +/- 129.6 microm; p < 0.001). Time required for anastomosis was significantly shorter in the Immobilizer group (11.3 +/- 3.5 versus 14.9 +/- 2.4 minutes; p < 0.001). Postoperative angiography showed no vessel occlusions but two anastomotic stenoses in each group.

CONCLUSIONS

Both stabilizers have been shown useful for off-pump coronary artery bypass grafting. The Immobilizer system showed better epicardial immobilization of the anterior wall resulting in shorter anastomosis times. However, because the Octopus 3 handling is more flexible and allows easier access to all vessels, it is the device of choice for posterior wall revascularization in our institution.

Pulmonary dysfunction after cardiac surgery

Postoperative lung injury is one of the most frequent complications of cardiac surgery that impacts significantly on health-care expenditures and largely has been believed to result from the use of cardiopulmonary bypass (CPB). However, recent comparative studies between conventional and off-pump coronary artery bypass grafting have indicated that CPB itself may not be the major contributor to the development of postoperative pulmonary dysfunction. In our study, we review the associated physiologic, biochemical, and histologic changes, with particular reference to the current understanding of underlying mechanisms. Intraoperative modifications aiming at limiting lung injury are discussed. The potential benefits of maintaining ventilation and pulmonary artery perfusion during CPB warrant further investigation.

Creative arterial bypass grafting can be performed on the beating heart

BACKGROUND

To demonstrate that compromise is unnecessary in either the design or performance of beating heart surgery, we report our experience, over 1 year, of total arterial revascularization where composite or creative grafting was utilized.

METHODS

We performed 321 off-pump coronary artery bypass operations, of which, 290 (90%) were done with only arterial conduits. The mean number of distal anastomoses was 2.48, with a range of 1 to 5. There were no aortic anastomoses. One hundred eighty-nine patients (65%) were male, and 101 (35%) were female, with a mean age of 67 years. Comorbidities included chronic renal failure (CRF), 21 (7%); diabetes, 92 (32%); obesity, 68 (23%); hypertension, 212 (73%); chronic obstructive pulmonary disease, 189 (65%); cerebral vascular accident (CVA), 39 (13%); smoking, 164 (56%); and hypercholesterolemia, 151 (52%). The mean ejection fraction was 56%, with a range of 21% to 71%. All procedures were performed with external stabilizers with or without vacuum assist. The complete arterial revascularizations included a T-graft (internal thoracic [ITA]/radial arteries [RA]), 130 (45%); a sequential graft (ITA +/- RA), 118 (41%); a U-graft (coronary-coronary graft perfused by the ITA or right gastroepiploic artery), 5 (2%); an I-graft (ITA/RA), 4 (1%); an X-graft (ITA/RA), 2 (12); and a Y-graft (ITA/RA), 31 (10%).

RESULTS

The postoperative incidence of atrial fibrillation was 80 of 290 (27%); CVA, 5 of 290 (2%); bleeding resulting in take-back, 5 of 290 (2%); CRF, 8 of 290 (3%); deep sternal infection, 4 of 290 (1%); and readmission (30-day) for angina, 4 of 290 (1%). The observed perioperative (30-day) mortality was 9 of 290 (3.1%), with the STS predicted rate of 3.82%.

CONCLUSIONS

Our experience indicates that once the operating surgeon has learned to safely expose the lateral and inferior walls of the heart, the type of conduit and the method of revascularization should be no different than that used with cardiopulmonary bypass. However, we still recommend conventional methods of revascularization (on-pump with saphenous vein conduits) for the ischemic patient.