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Sheikhy A, Fallahzadeh A, Sadeghian S, Forouzannia K, Bagheri J, Salehi-Omran A, Tajdini M, Jalali A, Pashang M, Hosseini K. Mid-term outcomes of off-pump versus on-pump coronary artery bypass graft surgery; statistical challenges in comparison. BMC Cardiovasc Disord 2021; 21:412. [PMID: 34454415 PMCID: PMC8403445 DOI: 10.1186/s12872-021-02213-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 08/18/2021] [Indexed: 11/19/2022] Open
Abstract
Background Despite several studies comparing off- and on-pump coronary artery bypass grafting (CABG), the effectiveness and outcomes of off-pump CABG still remain uncertain. Methods In this registry-based study, we assessed 8163 patients who underwent isolated CABG between 2014 and 2016. Propensity score matching (PSM), inverse probability of weighting (IPW) and covariate adjustment were performed to correct for and minimize selection bias.
Results The overall mean age of the patients was 62 years, and 25.7% were women. Patients who underwent off-pump CABG had shorter length of hospitalization (p < 0.001), intubation time (p = 0.003) and length of ICU admission (p < 0.001). Off-pump CABG was associated with higher risk of 30-days mortality (OR: 1.7; 95% CI 1.09–2.65; p = 0.019) in unadjusted analysis. After covariate adjustment and matching (PSM and IPW), this difference was not statistically significant. After an average of 36.1 months follow-up, risk of MACCE and all-cause mortality didn’t have significant differences in both surgical methods by adjusting with IPW (HR: 1.03; 95% CI 0.87–1.24; p = 0.714; HR: 0.91; 95% CI 0.73–1.14; p = 578, respectively). Conclusion Off-pump and on-pump techniques have similar 30-day mortality (adjusted, PSM and IPW). Off-pump surgery is probably more cost-effective in short term; however, mid-term survival and MACCE trends in both surgical methods are comparable. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02213-0.
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Affiliation(s)
- Ali Sheikhy
- Research Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Aida Fallahzadeh
- Research Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeed Sadeghian
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Khalil Forouzannia
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Jamshid Bagheri
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Abbas Salehi-Omran
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Masih Tajdini
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Arash Jalali
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Mina Pashang
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Kaveh Hosseini
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran.
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Lei Y, Gu T, Shi E, Wang C, Qin F. Myocardial protection and early outcome of different coronary surgical techniques for diabetic patients with triple vessels. Ann Saudi Med 2014; 34:375-82. [PMID: 25827693 PMCID: PMC6074552 DOI: 10.5144/0256-4947.2014.375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES For patients with diabetes and triple-vessel disease, coronary artery bypass grafting (CABG) surgery is a well-established procedure, but cardiopulmonary bypass support may also lead to severe complications to these patients. The aim of this study was to compare myocardial protection and early outcomes in patients with diabetes and triple-vessel disease following different coronary surgical techniques. DESIGN AND SETTINGS Prospective randomized trial of patients treated at the First Affiliated Hospital of China Medical University over a 3-year period (2011- 2013). METHODS In a single-center randomized trial, 668 patients with diabetes and triple-vessel disease were randomly assigned to off-pump (OPCAB) (number [n]=222), on-pump beating heart (OnP-BH) (n=223), and conventional CABG (OnP) (n=223) between January 2011 and October 2013. Myocardial injury was assessed by measuring the serial release of cardiac troponin I (cTnI) preoperatively, 1 hour, 12 hours, 24 hours, and 72 hours postoperatively. The early outcomes were compared among these 3 groups. RESULTS Preoperative characteristics of the patients in all 3 groups were similar. No significant difference was found regarding the number of anastomoses, the use of the internal thoracic artery, postoperative new-onset atrial fibrillation, hemodialysis, stroke, reoperation for bleeding, and infective complications in the 3 groups (P > .05). The complete revascularization, postoperative drainage loss, intra-aortic balloon pump support, blood requirements, postoperative myocardial infarction, pulmonary complications, gastrointestinal complications, inotropic requirements > 24 hours, ventilation > 24 hours, intensive care unit stay > 24 hours, and in-hospital stay > 7 days were significantly lower in the OPCAB group than in the other 2 groups (P < .05). In-hospital mortality was lower in the OPCAB group than in the other 2 groups, but no statistical difference was observed (P > .05). Preoperative cTnI in the 3 groups was similar (P > .05); however, the lowest cTnI value was noted in the OPCAB group, followed by the OnP group, and it was highest in the OnP-BH group 1 hour, 12 hours, 24 hours, and 72 hours postoperatively (P < .05). CONCLUSION OPCAB is superior to the OnP-BH and OnP techniques in terms of postoperative complications and myocardial protection in patients with diabetes and triple-vessel disease. Myocardial injury in the OnP-BH group was significantly higher than that in the OnP group.
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Affiliation(s)
| | - Tianxiang Gu
- Dr. Tianziang Gu, Department of Cardiac Surgery, China Medical University, First Affiliated Hospital, Shenyang, China, T: 86-24-83283455, F: 86-24-83283455,
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Yu L, Gu T, Shi E, Wang C, Fang Q, Zhang Y, Lu C. On-pump with beating heart or cardioplegic arrest for emergency conversion to cardiopulmonary bypass during off-pump coronary artery bypass. Ann Saudi Med 2014; 34:314-9. [PMID: 25811204 PMCID: PMC6152560 DOI: 10.5144/0256-4947.2014.314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Intraoperative conversion, especially under emergent circumstances during off-pump coronary artery bypass (OPCAB), is associated with a significantly higher rate of hospital mortality. This study compared the clinical early outcomes of patients emergently converting to cardiopulmonary bypass (CPB) with or without cardioplegic arrest and evaluated the efficacy of an on-pump beating heart technique for these critically ill patients. DESIGN AND SETTING A retrospective study of patients treated at The First Affiliated Hospital of China Medical University over an 8-year period (2005 to 2013). PATIENTS AND METHODS Between January 2005 and September 2013, 104 patients were emergently converted to CPB during OPCAB. In the first 55 patients (53%), the cardioplegic arrest was performed. In the most recent 49 patients (47%), the on-pump beating heart procedure was used without cardioplegic arrest. RESULTS There were no significant differences in their baseline clinical characteristics, number of anastomoses performed per patient, and reasons for conversions (P > .05). A significant reduction occurred in the observed mortality between the cardioplegic arrest group and the on-pump beating heart group (25.6% vs 6.1%, P=.008). A statistical difference was found between the cardioplegic arrest group and the on-pump beating heart group in the time of CPB, peak cardiac troponin I, duration of inotropic support, time to extubation, intensive care unit stay, postoperative hospital stay, incidence of new intra-aortic balloon pump support, and pulmonary complications (P < .05). The incidence of blood requirements, postoperative myocardial infarction, new-onset atrial fibrillation, hemodialysis, stroke, infective complications, and resurgery for bleeding were lower in on-pump beating heart group, but the difference did not reach statistical significance (P > .05). CONCLUSION The on-pump beating heart technique is the preferred method of emergency conversion to CPB during OPCAB. It has lower postoperative mortality and morbidity than the cardioplegic arrest.
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Affiliation(s)
| | - Tianxiang Gu
- Tianxiang Gu, MD, PhD, Deparment of Cardiac Surgery, The First Affiliated Hospital, China Medical University, Nanjingbei Street 155#, Shenyang, China, 110001, T: 86-24-83283455,
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Yu L, Gu T, Shi E, Wang C, Fang Q, Yu Y, Zhao X, Qian C. Off-pump versus on-pump coronary artery bypass surgery in patients with triple-vessel disease and enlarged ventricles. Ann Saudi Med 2014; 34:222-8. [PMID: 25266182 PMCID: PMC6074587 DOI: 10.5144/0256-4947.2014.222] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Off-pump coronary artery bypass grafting (OPCAB) is a popular treatment for patients with ischemic heart disease, especially for high-risk patients. However, whether OPCAB can lead to better clinical outcomes than on-pump coronary artery bypass grafting (ONCAB) in patients with enlarged ventricles remains controversial. This prospective randomized study was designed to characterize comparison of early clinical outcome and mid-term follow-up following ONCAB versus OPCAB in patients with triple-vessel disease and enlarged ventricles. DESIGN AND SETTINGS Prospective randomized trial of patients treated at The First Affiliated Hospital, China Medical University, over a 3-year period (2007-2010). METHODS A total of 102 patients with triple-vessel disease and enlarged ventricles (end-diastolic dimension >=6.0 cm) were randomized to OPCAB or ONCAB between July 2007 and December 2010. The in-hospital out.comes were analyzed. The study included a mid-term follow-up, with a mean follow-up time of 49.40 (12.88 months). RESULTS No significant differences were recorded in the baseline clinical characteristics of ONCAB and OPCAB groups. A statistical difference was found between the two groups at the time of extubation, intensive care unit stay, hospital stay, blood requirements, incidence of intra-aortic balloon pump support, pulmonary complications, stroke, reoperation for bleeding, and inotropic requirements > 24 hours (P < .05). The number of anastomoses performed per patient, the incidence of postoperative ventricular arrhythmia, myocardial infarction, new-onset atrial fibrillation, hemodialysis, infective complications, recurrent angina, and percutaneous reintervention were similar between the 2 groups (P > .05). The left ventricular end-diastolic dimension was significantly smaller at 6 months' follow-up in the 2 groups than it was before operation ( < .05). No differences in hospital mortality and mid-term mortality between OPCAB and ONCAB groups were found. During the follow-up, no patient in either group had undergone repeat coronary artery bypass grafting. CONCLUSION No differences in early and mid-term mortality were found between OPCAB and ONCAB in patients with triple-vessel disease and enlarged ventricles. However, OPCAB seems to have a beneficial effect on postoperative complications.
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Affiliation(s)
| | - Tianxiang Gu
- Tianxiang Gu, MD, PhD, Dept. of Cardiac Surgery,, he First Affiliated Hospital,, China Medical University,, Nanjingbei street 155#,, Shenyang, China, 110001, T: 86-24-83283455, F: 86-24-83283455,
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Hueb W, Lopes NH, Pereira AC, Hueb AC, Soares PR, Favarato D, Vieira RD, Lima EG, Garzillo CL, Paulitch FDS, César LAM, Gersh BJ, Ramires JAF. Five-year follow-up of a randomized comparison between off-pump and on-pump stable multivessel coronary artery bypass grafting. The MASS III Trial. Circulation 2010; 122:S48-52. [PMID: 20837925 DOI: 10.1161/circulationaha.109.924258] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary artery bypass graft surgery with cardiopulmonary bypass is a safe, routine procedure. Nevertheless, significant morbidity remains, mostly because of the body's response to the nonphysiological nature of cardiopulmonary bypass. Few data are available on the effects of off-pump coronary artery bypass graft surgery (OPCAB) on cardiac events and long-term clinical outcomes. METHODS AND RESULTS In a single-center randomized trial, 308 patients undergoing coronary artery bypass graft surgery were randomly assigned: 155 to OPCAB and 153 to on-pump CAB (ONCAB). Primary composite end points were death, myocardial infarction, further revascularization (surgery or angioplasty), or stroke. After 5-year follow-up, the primary composite end point was not different between groups (hazard ratio 0.71, 95% CI 0.41 to 1.22; P=0.21). A statistical difference was found between OPCAB and ONCAB groups in the duration of surgery (240±65 versus 300±87.5 minutes; P<0.001), in the length of ICU stay (19.5±17.8 versus 43±17.0 hours; P<0.001), time to extubation (4.6±6.8 versus 9.3±5.7 hours; P<0.001), hospital stay (6±2 versus 9±2 days; P<0.001), higher incidence of atrial fibrillation (35 versus 4% of patients; P<0.001), and blood requirements (31 versus 61% of patients; P<0.001), respectively. The number of grafts per patient was higher in the ONCAB than the OPCAB group (2.97 versus 2.49 grafts/patient; P<0.001). CONCLUSIONS No difference was found between groups in the primary composite end point at 5-years follow-up. Although OPCAB surgery was related to a lower number of grafts and higher episodes of atrial fibrillation, it had no significant implications related to long-term outcomes. Clinical Trial Registration-URL: http://www.controlled-trials.com. Unique identifier: ISRCTN66068876.
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Affiliation(s)
- Whady Hueb
- Heart Institute of the University of São Paulo, São Paulo, Brazil.
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Buffolo E, Branco JNR, Gerola LR, Aguiar LF, Teles CA, Palma JH, Catani R. Off-Pump Myocardial Revascularization: Critical Analysis of 23 Years’ Experience in 3,866 Patients. Ann Thorac Surg 2006; 81:85-9. [PMID: 16368342 DOI: 10.1016/j.athoracsur.2005.07.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2005] [Revised: 07/07/2005] [Accepted: 07/12/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Surgical myocardial revascularization without cardiopulmonary bypass (CPB) is not new, with the first consecutive series of patients appearing in the early eighties. There has been increased interest in this alternative approach, especially in patients with comorbidities. There is controversy regarding advantages, risks, and usefulness of this method of myocardial revascularization. We herein report a consecutive series of 3,866 patients, from the first case in September 1981 to the last in November 2004, analyzing applicability, mortality, morbidity, and surgical technique. METHODS From September 1981 to November 2004, 3,866 consecutive patients were revascularized without CPB. This figure represents an overall applicability of 30.8% considering a total of 12,553 revascularization procedures performed during this time. There were 2,822 males (73%) with ages from 12 to 93 years (median, 62 +/- 14). Mean grafts per patient was 1.9, and the internal mammary artery was used in 87.3% of cases. The main indications for surgery were chronic coronary insufficiency (89% of cases) and failure of angioplasty or stenting. RESULTS Hospital mortality was 1.9%, with low incidence of cerebrovascular accident (5 cases in the entire series). Morbidity, considering major postoperative complications, occurred in 12.5% of the patients. The applicability of the off-pump technique was 18% of cases in the beginning of our experience, increasing to 49% in the last 5 years with the use of stabilizers and maneuvers to expose posterior coronary branches. CONCLUSIONS Off-pump coronary surgery is an alternative method of myocardial revascularization that should be considered for every patient. The preference of this technique over conventional revascularization should be based on the surgeon's own experience, on the patient's preoperative condition and on the coronary anatomy. Off-pump myocardial revascularization represents an important development in coronary artery surgery. Over the years it has evolved into a valid form of surgery with the same safety as the conventional operation and with more advantages in high risk patients.
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Affiliation(s)
- Enio Buffolo
- Department of Cardiovascular Surgery, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil.
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7
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Murphy GJ, Rogers CS, Lansdowne WB, Channon I, Alwair H, Cohen A, Caputo M, Angelini GD. Safety, efficacy, and cost of intraoperative cell salvage and autotransfusion after off-pump coronary artery bypass surgery: A randomized trial. J Thorac Cardiovasc Surg 2005; 130:20-8. [PMID: 15999036 DOI: 10.1016/j.jtcvs.2004.12.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We evaluated, in a randomized controlled trial, the safety and effectiveness of intraoperative cell salvage and autotransfusion of washed salvaged red blood cells after first-time coronary artery bypass grafting performed on the beating heart. METHODS Sixty-one patients undergoing off-pump coronary artery bypass grafting surgery were prospectively randomized to autotransfusion (n = 30; receiving autotransfused washed blood from intraoperative cell salvage) or control (n = 31; receiving homologous blood only as blood-replacement therapy). Homologous blood was given according to unit protocols. RESULTS The groups were well matched with respect to demographic and comorbid characteristics. Patients in the autotransfusion group had a significantly higher 24-hour postoperative hemoglobin concentration (11.9 g/dL; SD, 1.41 g/dL) than those in the control group (10.5 g/dL; SD, 1.37 g/dL) (mean difference, 1.02 g/dL; 95% confidence interval, 1.60-0.44 g/dL; P = .0007), as well as a 20% reduction in the frequency of homologous blood product use (11/31 vs 5/30; P = .095). Autotransfusion of washed red blood cells was not associated with any derangement of thromboelastograph values or laboratory measures of clotting pathway function (prothrombin time, activated partial thromboplastin time, and fibrinogen levels), increased postoperative bleeding, fluid requirements, or adverse clinical events. There was no statistical difference between groups in the total operation, hospitalization, and management costs per patient (median difference, USD 1015.90; 95% confidence interval, -USD 2260 to USD 206; P = .11). Conclusions Intraoperative cell salvage and autotransfusion was associated with higher postoperative hemoglobin concentrations, a modest reduction in transfusion requirements, no adverse clinical or coagulopathic effects, and no significant increase in cost compared with controls. This study supports its routine use in off-pump coronary artery bypass grafting surgery.
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Affiliation(s)
- G J Murphy
- Bristol Heart Institute, University of Bristol, Bristol BS2 8HW, UK
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Tarrío RF, Cuenca JJ, Gomes V, Campos V, Herrera JM, Rodríguez F, Valle JV, Portela F, García-Carro J, Adrio B, Vázquez F, Juffé A. Off-pump total arterial revascularization: our experience. J Card Surg 2005; 19:389-95. [PMID: 15383048 DOI: 10.1111/j.0886-0440.2004.04078.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Thanikachalam M, Lombardi P, Tehrani HY, Katariya K, Salerno TA. The History and Development of Direct Coronary Surgery without Cardiopulmonary Bypass*. J Card Surg 2004; 19:516-9. [PMID: 15548184 DOI: 10.1111/j.0886-0440.2004.04088.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The history of direct myocardial revascularization without cardiopulmonary bypass dates to 1961 in the dawn of coronary artery surgery. With the introduction and development of techniques of extracorporeal circulation around the same time, beating heart surgery was largely abandoned. Over the subsequent decades, cardiopulmonary bypass and electromechanical cardioplegic arrest became popular as means of revascularization in a bloodless and motionless field. While coronary artery surgery on the arrested heart remained undisputed for decades, myocardial revascularization on the beating heart was pursued by a few pioneering surgeons around the world, based on the belief that coronary revascularization could be performed equally well without the detrimental effects of cardiopulmonary bypass and electromechanical arrest. Various concepts and techniques developed during the 1980s by these pioneers enabled minimally invasive coronary surgery to be performed in the early 1990s. This break from the mainstream allowed selective myocardial revascularization using a minimal incision and no cardiopulmonary bypass to develop and constructed a base for future extensive revascularizations off-pump. With the subsequent explosion of new techniques for coronary exposure and myocardial stabilization, complete revascularization without cardiopulmonary bypass became possible with consistent results. Emerging from the preview of only a few surgeons just a decade ago, off-pump surgery is currently one of the accepted modalities for complete myocardial revascularization worldwide. This paradigm shift in the approach to myocardial revascularization has led to exiting new future possibilities, such as beating heart totally endoscopic coronary artery surgery.
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Affiliation(s)
- Mohan Thanikachalam
- Division of Cardiothoracic Surgery, University of Miami, Jackson Memorial Hospital, Miami, Florida, USA
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Ricci M, Karamanoukian HL, Dancona G, Bergsland J, Salerno TA. On-pump and off-pump coronary artery bypass grafting in the elderly: predictors of adverse outcome. J Card Surg 2001; 16:458-66. [PMID: 11925026 DOI: 10.1111/j.1540-8191.2001.tb00550.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To establish the role that coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) may have in improving perioperative outcomes of patients 70 years of age and older. BACKGROUND Coronary revascularization in elderly patients is associated with morbidity and mortality rates higher than those observed in younger patients. The impact of CABG without CPB on perioperative outcomes has not been clearly established. METHODS This retrospective, nonrandomized study consisted of 1,872 CABG patients. Of these, 1389 underwent CABG with CPB (CPB group) and 483 patients underwent CABG without CPB (off-pump group). Preoperative variables and outcomes were compared between the two groups. Multivariate logistic regression analysis was used to identify independent predictors of mortality, stroke, and adverse outcome. RESULTS Demographics, Canadian Cardiovascular Society staging, operative priority, and other preoperative variables were comparable between the two groups. The prevalence of previous myocardial infarction was higher in the CPB group (62.6% vs 56.7%; p < 0.005), whereas the prevalence of calcified aorta and preoperative renal failure were higher in the off-pump group (5.4% vs 9.5%; p = 0.04 and 1.7% vs 3.3%; p = 0.04, respectively). Although the graft/patient ratio was higher in the CPB group (3.4 vs 1.9), these patients displayed more extensive coronary artery involvement. At univariate analysis, patients in the off-pump group had a higher rate of freedom from complications (88.2% vs 81.3%; p < 0.005) and a lower incidence of stroke (2.1% vs 4.2%; p = 0.034) than patients in the CPB group. Although there was a trend for a higher actual mortality in the off-pump group (4.8% vs 3.7%; p = ns), the risk adjusted mortality in this group was lower (1.9% vs 2.1%). Multivariate analysis showed that while the use of CPB correlated independently with an increased risk of overall complications, it was not associated with a higher probability of death or stroke. CONCLUSIONS This investigation suggests that elderly patients undergoing CABG may benefit from off-pump revascularization, as the use of CPB correlated independently with an increased risk of overall complications. However, CPB did not emerge as an independent predictor of death or stroke at multivariate analysis.
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Affiliation(s)
- M Ricci
- Division of Cardiothoracic Surgery, Jackson Memorial Hospital/University of Miami, Florida 33136, USA
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Ascione R, Iannelli G, Lim KH, Imura H, Spampinato N. One-stage coronary and abdominal aortic operation with or without cardiopulmonary bypass: early and midterm follow-up. Ann Thorac Surg 2001; 72:768-74; discussion 775. [PMID: 11565656 DOI: 10.1016/s0003-4975(01)02798-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The aim of this study was to compare hospital, early, and late clinical outcomes for patients undergoing one-stage, coronary and abdominal aortic surgical intervention with and without cardiopulmonary bypass. METHODS From March 1990 to September 1999, 42 consecutive patients underwent combined operations at a single institution. Cardiopulmonary bypass and cardioplegic arrest were used during coronary revascularization in the first 20 patients (on-pump group), and the next 22 patients received the one-stage operations on the beating heart (off-pump group). RESULTS Baseline characteristics were similar between groups. Three cardiac-related hospital deaths occurred in the on-pump group and one such death in the off-pump group (p = 0.25). Cardiac-related events, pulmonary complications, inotropic support, blood loss and transfusion requirements, intensive care unit stay, and hospital stay were significantly reduced in the off-pump group (all, p < 0.05). The actuarial survival rates in the on-pump and off-pump groups were 80% and 95%, respectively, at 1 year (p = 0.13) and 75% and 89%, respectively, at 3 years (p = 0.22). Freedom from cardiac-related events at 1-year follow-up was 91% in the off-pump group and 65% in the on-pump group (p < 0.05). No difference in cardiac-related events between groups was observed at 3 years. CONCLUSIONS Off-pump coronary surgical procedures decrease postoperative complications in high-risk patients undergoing simultaneous coronary and abdominal aortic operations compared with the conventional one-stage procedure. The early benefits achieved with off-pump surgical intervention are not at the expense of the long-term clinical outcome.
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Affiliation(s)
- R Ascione
- Department of Cardiovascular Surgery, University Federico II of Naples, Italy.
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Czerny M, Baumer H, Kilo J, Zuckermann A, Grubhofer G, Chevtchik O, Wolner E, Grimm M. Complete revascularization in coronary artery bypass grafting with and without cardiopulmonary bypass. Ann Thorac Surg 2001; 71:165-9. [PMID: 11216739 DOI: 10.1016/s0003-4975(00)02230-x] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The feasibility of complete revascularization on the beating heart without cardiopulmonary bypass (CPB) as compared with the standard operation with CPB in elective low-risk patients with multivessel disease has not been clearly demonstrated in a prospective trial. METHODS Eighty selected low-risk patients were enrolled. In preoperative study with coronary angiography, the decision was made whether complete revascularization without CPB could be performed. Patients were randomly assigned to receive CABG either with (n = 40) or without CPB (n = 40). Randomization criteria were age, sex, and left ventricular ejection fraction. Completeness of revascularization as well as short- and mid-term clinical outcome in a 13.4 +/- 6.5 month follow-up period were monitored. RESULTS Twenty-six of 40 (65%) patients undergoing CABG without CPB underwent complete revascularization. In 5 of these patients (12.5%) suitable vessels were discarded for technical reasons and 9 patients (22.5%) were switched to CABG with CPB owing to the deeply intramyocardial course of target vessels (n = 5) or to hemodynamic instability (n = 4). In the group of patients operated on with CPB, 34 of 40 patients (85%) received complete revascularization. In 6 patients (15%) suitable vessels were discarded for technical reasons. Mean number of bypass grafts was 3.1 +/- 0.8 with CPB and 2.6 +/- 0.5 without CPB (p = 0.043). Clinical outcome and hospital stay were comparable in both groups. No patient died during the study period. No myocardial infarction was observed. Three patients undergoing CABG without CPB underwent successful PTCA 3 months after surgery. CONCLUSIONS CABG without the use of CPB is effective for complete revascularization in the majority of selected low-risk patients. Nevertheless, it has to be stated that the rate of incomplete revascularization in this early series of CABG without CPB is higher, and compromises the basic principle of complete revascularization.
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Affiliation(s)
- M Czerny
- Department of Cardiothoracic Surgery, University of Vienna Medical School, Austria
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Resano FG, Stamou SC, Lowery RC, Corso PJ. Complete myocardial revascularization on the beating heart with epicardial stabilization: anesthetic considerations. J Cardiothorac Vasc Anesth 2000; 14:534-9. [PMID: 11052434 DOI: 10.1053/jcan.2000.9452] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To describe an anesthetic management protocol for patients undergoing cardiac surgery with multiple coronary artery bypass grafts without cardiopulmonary bypass (off-pump CABG surgery) by median sternotomy with mechanical stabilization. DESIGN Retrospective nonrandomized analysis. SETTING Tertiary care hospital. PARTICIPANTS Sixty-six consecutive patients on whom off-pump CABG surgery by median sternotomy was attempted. INTERVENTIONS Anesthesia was induced with a combination of etomidate and fentanyl; pancuronium bromide was given for muscle relaxation; and anesthesia was maintained with isoflurane, desflurane, or sevoflurane in 100% oxygen. Maintenance of normothermia was attempted by keeping the room temperature at 70 degrees F, warming all fluids to 41 degrees C, and using 2.5 L/min of fresh gas flows and a heat and humidity exchanger. When available, a convective forced-air blanket was used to cover patients' head and shoulders. Patients who were not slated for revascularization of the circumflex vessels and who had good ventricular function received central venous pressure monitoring (26%); all other patients received a pulmonary artery catheter. MEASUREMENTS AND MAIN RESULTS Of the 66 patients, 36% required an epinephrine infusion at a mean rate of 1.45+/-2.05 microg/min intraoperatively to maintain hemodynamic stability; 25% required inotropic support for < 12 hours in the intensive care unit. CONCLUSION Institution of systematic hemodynamic management was associated with the successful completion of the surgical procedure in 61 patients (92%). Only 5 patients required conversion to regular CABG surgery with cardiopulmonary bypass.
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Affiliation(s)
- F G Resano
- Section of Cardiac Surgery, Washington Hospital Center, DC 20010-2975, USA
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14
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Shennib H, Korkola SJ, Bousette N, Giaid A. An automated interrupted suturing device for coronary artery bypass grafting: automated coronary anastomosis. Ann Thorac Surg 2000; 70:1046-8. [PMID: 11016372 DOI: 10.1016/s0003-4975(00)01792-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to have a preliminary assessment of the safety and efficacy of an automated vascular suturing device. METHODS The device (Heartflo, Perclose/Abbott Labs, Redwood City, CA), which delivers 10 interrupted 7-0 polypropylene sutures between side-to-side arteriotomies, was evaluated in animals (8 Yorkshire pigs). RESULTS Tissue edge capture and quality of anastomosis were highly rated. Time of anastomoses averaged 22 minutes. This time was prolonged primarily due to suture management, tying of interrupted sutures, and learning curve effects. Six of the anastomoses were hemostatic and two required an additional stitch each. Angiography and histology of the anastomosis confirmed patency and quality of the anastomosis. CONCLUSIONS Our preliminary results indicate that the Heartflo automated anastomotic device is safe and effective. Preclinical and clinical studies to validate its acute and long-term effectiveness will commence shortly.
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Affiliation(s)
- H Shennib
- Center for Innovative Cardiovascular Therapy, Roosevelt and Beth Israel Hospital, New York, New York, USA.
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15
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Affiliation(s)
- H Shennib
- Center for Innovative Cardiovascular Therapy, Heart Institute at St. Luke's Roosevelt and Beth Israel Hospitals, New York, New York 10003, USA.
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Cuenca JJ, Herrera JM, Rodríguez-Delgadillo MA, Paladini G, Campos V, Rodríguez F, Valle JV, Portela F, Crespo F, Juffé A. [Total arterial myocardial revascularization with both mammary arteries without extracorporeal circulation]. Rev Esp Cardiol 2000; 53:632-41. [PMID: 10816171 DOI: 10.1016/s0300-8932(00)75141-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Tector has described the off-pump total arterial revascularization technique, using multiple anastomosis with both internal thoracic arteries. To reduce surgical morbid-mortality, we have proposed the use of this technique without extracorporeal circulation. PATIENTS AND METHODS From April, 1998 the off-pump <<Tector>> technique was performed in 92 patients, 74 male (80%) and 18 female (20%), with a mean age of 64.9+/-8.1 years (42-78). Preoperative angiography demonstrated triple-vessel disease in 58 (63%) patients, and left main disease was present in 19 (20.5%) patients. Forty patients (43.5%) showed unstable angina, 24 patients (26%) significant peripheral vascular disease, and 26 (28%) diabetes mellitus. Both internal thoracic arteries were harvested using the skeletonization technique and were used like a <<T or T>> graft. The flow in the graft was measured using a flowmeter, and in 24 (26%) patients by angiographic study. RESULTS A total of 274 distal anastomoses were performed, 122 (44.6%) in the lateral or inferior wall, and 69 (25.2%) were sequential, with an average of 2.98 bypass/patient. In 59.8% of the patients a triple bypass was performed, 22% double bypass, 17% cuadruple bypass and 1 patient a quintuple bypass. During the initial six hours 64.9% of patients were extubated. Only one patient (1.1%) needed intraaortic ballon pumping and 3 (3.2%) inotropics during the postoperative course. Hospital mortality was 3 (3.2%) patients. Reoperation for bleeding was needed in just one patient (1.1%), and 78.3% of patients were not transfused. Mediastinitis occurred in 3 patients (3.2%). Postoperative stroke was not observed. At 7.7+/-2.8 months of mean follow-up all patients were free of symptoms and the global patency rate of 94%. CONCLUSIONS Off-pump Tector technique appears to be safe, offering a complete arterial revascularization and showing a reduction of surgical morbidity.
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Affiliation(s)
- J J Cuenca
- Servicio de Cirugía Cardíaca, Hospital Juan Canalejo, A Coruña
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Shiga T, Terajima K, Matsumura J, Sakamoto A, Ogawa R. Minor cardiac troponin T release in patients undergoing coronary artery bypass graft surgery on a beating heart. J Cardiothorac Vasc Anesth 2000; 14:151-5. [PMID: 10794333 DOI: 10.1016/s1053-0770(00)90009-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To determine whether and to what extent coronary artery bypass graft (CABG) surgery without extracorporeal circulation is associated with cardiac troponin T (TnT) release. DESIGN Prospective study. SETTING A single university hospital. PARTICIPANTS Twenty-three patients scheduled for minimally invasive CABG surgery. Sixteen patients received one coronary anastomosis, and seven received two. INTERVENTIONS TnT and creatine kinase-MB (CK-MB) levels were determined immediately before induction of anesthesia (baseline) and at 0, 12, and 24 hours after surgery. Hemodynamic measurements were made, and 5-lead electrocardiograms with continuous automated ST-segment trends were analyzed. MEASUREMENTS AND MAIN RESULTS All patients had a good cardiac outcome. Median cumulative coronary artery occlusion time was 27 minutes (range, 10 to 49 minutes). TnT levels were undetectable in 91.3% of patients at baseline when a detection limit of 0.01 ng/mL was employed. TnT and CK-MB showed significant elevations at 12 and 24 hours versus baseline. Postoperatively, TnT was detectable in 91.3% of patients, and 17.4% suffered minor myocardial damage, as evidenced by an abnormal increase in TnT greater than 0.2 ng/mL, excluding those exhibiting myocardial infarction. ST segment changes developed in seven patients, persisting for 13.0 minutes (range, 9.5 to 15.8 minutes) and disappearing immediately after coronary artery clamp release. There were no significant correlations between cumulative coronary occlusion time and peak TnT or CK-MB levels. CONCLUSIONS TnT was detected after surgery in most patients, and significant TnT levels indicative of myocardial injury (>0.2 ng/mL) were detected in only 17% of patients, probably as a result of brief periods of coronary artery occlusion.
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Affiliation(s)
- T Shiga
- Department of Anesthesiology, Nippon Medical School, Tokyo, Japan
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Shiga T, Terajima K, Matsumura J, Sakamoto A, Ogawa R. Local cardiac wall stabilization influences the reproducibility of regional wall motion during off-pump coronary artery pass surgery. J Clin Monit Comput 2000; 16:25-31. [PMID: 12578092 DOI: 10.1023/a:1009976130084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Myocardial ischemia is a risk factor during off-pump coronary artery bypass procedures. The development of new regional wall motion abnormalities assessed by transesophageal echocardiography (TEE) is a very sensitive sign of myocardial ischemia. To facilitate anastomosis, the epicardial area of the anastomosis site is often immobilized by a "stabilizer." This study was designed to investigate whether cardiac wall stabilization with an epicardial stabilizer could affect the interpretation of wall motion during coronary anastomosis without cardiopulmonary bypass. METHODS The TEE videotapes of 15 adult patients were investigated. Left ventricular (LV) transgastric short and long axis views were divided according to a modified 16-segment method. LV wall motion was scored using a 5-grade scale by two independent blinded investigators during pre-occlusion, occlusion, and reperfusion of anastomosed coronary arteries. The wall motion scores of a stabilized segment combined with two adjacent segments were compared with those of non-stabilized segments. Interobserver agreement was assessed using the weighted kappa statistic. RESULTS A total of 216 segments were analyzed by two investigators. The interobserver kappa coefficient in pre-occlusion and reperfusion periods was 0.87, 0.87 and 0.86, 0.87, respectively, indicating high agreements without stabilizer. During the occlusion period in stabilized and non-stabilized segments, it was 0.59 and 0.76, respectively, showing significantly less reproducibility in the presence of stabilizer. CONCLUSION Cardiac wall stabilization affects the reproducibility in the interpretation of regional wall motion during off-pump coronary artery bypass surgery. Caution should be used when monitoring for myocardial ischemia using TEE during coronary artery bypass surgery with epicardial stabilizer.
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Affiliation(s)
- T Shiga
- Department of Anesthesiology, Nippon Medical School, Sendagi 1-1-5, Bunkyo-ku, Tokyo 113-8603, Japan. shiga/
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Lloyd CT, Ascione R, Underwood MJ, Gardner F, Black A, Angelini GD. Serum S-100 protein release and neuropsychologic outcome during coronary revascularization on the beating heart: a prospective randomized study. J Thorac Cardiovasc Surg 2000; 119:148-54. [PMID: 10612774 DOI: 10.1016/s0022-5223(00)70230-3] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Our purpose was to establish whether coronary revascularization on the beating heart without cardiopulmonary bypass is less harmful to the brain than conventional surgery with cardiopulmonary bypass as indicated by measures of cognitive function or by changes in serum concentrations of S-100 protein, a recognized biochemical marker of cerebral injury. METHODS We conducted a prospective randomized trial in which the assessors of the outcome measures were blind to the treatment received. Sixty patients without known neurologic abnormality, undergoing coronary revascularization, were prospectively randomized to 1 of 2 groups: (1) cardiopulmonary bypass (32 degrees C-34 degrees C) and cardioplegic arrest (on pump) with intermittent antegrade warm blood cardioplegia or (2) surgery on the beating heart (off pump). Neuropsychologic performance was assessed before and 12 weeks after the operation. Serum S-100 protein concentration was measured at intervals up to 24 hours after the operation. RESULTS The groups had similar preoperative characteristics. There were no deaths or major neurologic complications in either group, nor was there any difference between groups in the chosen index of neurologic deterioration. Serum S-100 protein concentrations were higher in the on-pump group at 30 minutes, but any such difference between groups had disappeared 4 hours later. The extent of the changes in S-100 protein was unrelated to the index of neuropsychologic deterioration. CONCLUSIONS The changes in S-100 protein concentration suggest that the brain and/or blood-brain barrier may be more adversely affected during coronary artery surgery with cardiopulmonary bypass than during surgery on the beating heart, but that this may not be reflected in detectable neuropsychologic deterioration at 12 weeks.
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Affiliation(s)
- C T Lloyd
- Bristol Heart Institute, Department of Anaesthesia, University of Bristol, Bristol Royal Infirmary, Bristol, United Kingdom
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20
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Ascione R, Lloyd CT, Underwood MJ, Lotto AA, Pitsis AA, Angelini GD. Economic outcome of off-pump coronary artery bypass surgery: a prospective randomized study. Ann Thorac Surg 1999; 68:2237-42. [PMID: 10617009 DOI: 10.1016/s0003-4975(99)01123-6] [Citation(s) in RCA: 134] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Emphasis on cost containment in coronary artery bypass surgery is becoming increasingly important in modern hospital management. The revival of interest in off-pump (beating heart) coronary artery bypass surgery may influence the economic outcome. This study examines these effects. METHODS Two hundred patients undergoing first-time coronary artery bypass surgery were prospectively randomized to either conventional cardiopulmonary bypass and cardioplegic arrest or off-pump surgery. Variable and fixed direct costs were obtained for each group during operative and postoperative care. The data were analyzed using parametric methods. RESULTS There was no difference between the groups with respect to pre- and intraoperative patient variables. Off-pump surgery was significantly less costly than conventional on-pump surgery with respect to operating materials, bed occupancy, and transfusion requirements (total mean cost per patient: on pump, $3,731.6+/-1,169.7 vs off-pump, $2,615.13+/-953.6; p < 0.001). Morbidity was significantly higher in the on-pump group, which was reflected in an increased cost. CONCLUSIONS Off-pump revascularization offers a safe, cost-effective alternative to conventional coronary revascularization with cardiopulmonary bypass and cardioplegic arrest.
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Affiliation(s)
- R Ascione
- Bristol Heart Institute, Bristol Royal Infirmary, United Kingdom
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21
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Barriuso Vargas C, Mulet Meliá J, Ninot Sugrañes S, Sureda Barbosa C, Bahamonde Romano JA, Castellá Pericas M. [Coronary surgery without extracorporeal circulation and Octopus cardiac stabilizer]. Rev Esp Cardiol 1999; 52:741-4. [PMID: 10523890 DOI: 10.1016/s0300-8932(99)74999-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Between june and july, 1998, surgical myocardial revascularization without cardiopulmonary by-pass through a conventional sternotomy with the use of the "Octopus" heart stabilizer was performed in 6 patients (mean age 63 years, range 49-74 years). All patients received an internal thoracic artery graft. Three of them had also a saphenous vein graft on the distal right coronary artery. An intracoronary shunt was used in four patients and all the anastomoses were accomplished in a completely immobilized area of epicardium. Mean postoperative hemorrhage was 200 ml (50-300 ml) and ICU and total hospital stay were 2 and 6 days respectively. At the first follow-up control, one month post-op, all six patients are free of symptoms without medication. We believe the "Octopus" tissue stabilization system outperforms other heart stabilization devices in our hands and it can be used safely in selected groups of patients.
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Affiliation(s)
- C Barriuso Vargas
- Servicio de Cirugía Cardiovascular, Hospital Clínic de Barcelona, Universidad de Barcelona
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22
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Dagenais F, Cartier R. Pulmonary hypertension during beating heart coronary surgery: intermittent inferior vena cava snaring. Ann Thorac Surg 1999; 68:1094-5. [PMID: 10510027 DOI: 10.1016/s0003-4975(99)00799-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Pulmonary hypertension during beating heart coronary artery bypass grafting may compromise the possibility of safely completing the procedure off-pump. To obviate such a problem, we describe a simple technique by which the inferior vena cava is progressively snared to decrease pulmonary pressure.
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Affiliation(s)
- F Dagenais
- Department of Surgery, Montreal Heart Institute, Quebec, Canada
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Goh K, Inaba M, Yamamoto H, Akasaka N, Sasajima T. Vascular clamp for hemostasis and stabilization during minimally invasive direct coronary artery bypass. Ann Thorac Surg 1999; 68:585-6. [PMID: 10475445 DOI: 10.1016/s0003-4975(99)00620-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
A soft vascular clamp was used for hemostasis and stabilization of the operative field during minimally invasive direct coronary artery bypass (MIDCAB). The instrument was gently applied so that it clamps the coronary artery by grasping the adjacent myocardium. The method offered dry and stable operative field without a special instrument or technique. The surgical results have been satisfactory. We found application of the vascular clamp to be very helpful for MIDCAB.
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Affiliation(s)
- K Goh
- First Department of Surgery, Asahikawa Medical College, Japan.
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Singer RL. Rationale and Surgical Techniques for Emerging Procedures in Cardiac Surgery. Semin Cardiothorac Vasc Anesth 1999. [DOI: 10.1177/108925329900300202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
New techniques continue to emerge in cardiac surgery. This article reviews the history, rationale, techniques, and controversies regarding a variety of novel ap proaches to minimally invasive chest surgery. The suc cess of video-assisted thoracoscopy heralded the mod ern era of these techniques and also serves to illustrate its limitations. Minimally invasive cardiac procedures are outlined with a discussion of the benefits and risks, as well as the media and marketing pressures on surgeons. In addition, robot-assisted surgery and future trends are presented.
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Affiliation(s)
- Raymond L. Singer
- Division of Cardiothoracic Surgery, Lehigh Valley Hospital, Allentown, PA
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25
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Rousou JA, Engelman RM, Flack JE, Deaton DW. Fenestrated felt facilitates anastomotic stability and safety in "off-pump" coronary bypass. Ann Thorac Surg 1999; 68:272-3. [PMID: 10421166 DOI: 10.1016/s0003-4975(99)00489-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Metal stabilizing devices used in beating heart surgery, although largely effective, occasionally slip or cause lacerations of epicardial veins or myocardium, resulting in blood loss that requires time-consuming corrective maneuvers. The use of a fenestrated felt as a cushion in conjunction with the stabilizers eliminates slipping and/or trauma, thus facilitating coronary anastomoses on the beating heart.
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Affiliation(s)
- J A Rousou
- Department of Surgery, Baystate Medical Center, Springfield, Massachusetts 01107, USA
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Ascione R, Lloyd CT, Gomes WJ, Caputo M, Bryan AJ, Angelini GD. Beating versus arrested heart revascularization: evaluation of myocardial function in a prospective randomized study. Eur J Cardiothorac Surg 1999; 15:685-90. [PMID: 10386418 DOI: 10.1016/s1010-7940(99)00072-x] [Citation(s) in RCA: 145] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Conventional coronary artery bypass grafting (CABG) is both safe and effective. Nevertheless, the use of cardiopulmonary bypass (CPB) and cardioplegic arrest are associated with several adverse effects. Over the last 2 years there has been a revival of interest in performing CABG on the beating heart. In this prospective randomized study we evaluated the efficacy and safety of on and off pump coronary revascularization on myocardial function. METHODS Eighty patients (65 males, mean age 61+/-9.7 years) undergoing first time CABG were prospectively randomized to: (i) conventional revascularization with CPB at normothermia and cardioplegic arrest with intermittent warm blood cardioplegia (on pump) or (ii) beating heart revascularization (off pump). Troponin I (Tn I) release was serially measured as a specific marker of myocardial damage. Haemodynamic measurements as well as inotropic requirement, incidence of arrhythmia and postoperative myocardial infarction were also recorded. RESULTS There were no significant differences between the two groups in terms of age, sex, extent of disease, left ventricular function and number of grafts. There were no deaths or intraoperative myocardial infarctions in either group. Tn I release was constantly lower in the off pump group and this was significant at 1, 4, 12 and 24 h postoperatively. Furthermore, in this group there was a significantly reduced incidence of arrhythmias. Inotropic requirements were less in the off pump group but this did not reach statistical significance. CONCLUSION These results suggest that off pump coronary revascularization is a safe and effective strategy for myocardial revascularization. Myocardial injury as assessed by Tn I release is also reduced when compared with conventional coronary revascularization with CPB and cardioplegic arrest.
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Affiliation(s)
- R Ascione
- Bristol Heart Institute, Bristol Royal infirmary, UK
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Abstract
The range of minimal-access cardiac surgery approaches has many implications in intraoperative management. A modified anesthetic regimen is required to deal with the type of surgical exposure, hemodynamic instability, whether cardiopulmonary bypass is used, and early extubation. Intraoperative considerations include hemodynamic monitoring, one-lung ventilation, pharmacological stabilization of the myocardium, pacing, hypothermia, bleeding, and rapid emergence with a minimum of postoperative mechanical ventilation. As a result, anesthetic methods and intraoperative management were modified to meet these specific needs of minimally invasive cardiac procedures.
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Affiliation(s)
- P E Krucylak
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO 63110, USA
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Shennib H, Bastawisy A. Coronary artery bypass grafting on the beating heart: a simple technique for subluxating the heart. Ann Thorac Surg 1999; 67:870-1. [PMID: 10215259 DOI: 10.1016/s0003-4975(99)00089-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Coronary artery bypass grafting on the beating heart is becoming a widely applied procedure. It necessitates proper cardiac stabilization without impairment of hemodynamics. We describe a simple and effective technique to bring the anterolateral coronary arteries to a midline position for the purpose of performing a coronary artery bypass graft on the beating heart. A surgical glove tied to a tube is positioned underneath the left ventricle. Injection of warm saline into the glove will gradually displace the heart and rotate the lateral wall of the ventricle to a midline position. In spite of our use of mechanical stabilizers to decrease mobility of the anastomotic site, compression of the left ventricle is avoided because the water bed created by the injected glove absorbs the movement of the left ventricle and prevents its compression and any potential drop in cardiac output.
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Affiliation(s)
- H Shennib
- Department of Cardiothoracic Surgery, McGill University, Montreal, Quebec, Canada.
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Goldstein JA, Safian RD, Aliabadi D, O'Neill WW, Shannon FL, Bassett J, Sakwa M. Intraoperative angiography to assess graft patency after minimally invasive coronary bypass. Ann Thorac Surg 1998; 66:1978-82. [PMID: 9930480 DOI: 10.1016/s0003-4975(98)01235-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Intraoperative angiography was performed to confirm graft patency immediately after minimally invasive coronary bypass operations. METHODS In 26 patients who had internal mammary artery grafting, intraoperative coronary angiography was performed with a portable digital fluoroscope. RESULTS High-resolution angiograms were obtained in all cases. Angiography documented vasospasm of the graft or native vessel in 9 patients (graft in 3, native in 2, graft and native in 4 others), which responded promptly to intracoronary vasodilators in all. Angiography identified technically unsuspected and clinically silent fixed stenoses (>50%) in 11 patients, attributable to graft kinking in 2, anastomotic obstruction in 6 (total occlusion in 4), and stenosis of the left anterior descending artery just distal to the anastomosis in three cases (total occlusion in one). In 9 of 11 patients, fixed stenoses were sufficiently severe to warrant intraoperative intervention by surgical revision (n = 5) or angioplasty via the graft (n = 4). CONCLUSIONS Intraoperative angiography after minimally invasive coronary artery bypass operations can immediately identify dynamic and fixed obstructions and facilitate their prompt treatment, thereby ensuring that each patient leaves the operating room with an optimal surgical result.
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Affiliation(s)
- J A Goldstein
- Division of Cardiology, William Beaumont Hospital, Royal Oak, Michigan 48073-6769, USA.
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Burfeind WR, Duhaylongsod FG, Samuelson D, Leone BJ. The effects of mechanical cardiac stabilization on left ventricular performance. Eur J Cardiothorac Surg 1998; 14:285-9. [PMID: 9761439 DOI: 10.1016/s1010-7940(98)00199-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Mechanical cardiac stabilization is beneficial for precise coronary anastomoses on the beating heart. However, the effect of mechanical cardiac stabilization on hemodynamics, left ventricular performance, and the degree of injury to underlying tissue are uncertain. METHODS Twelve swine (20-30 kg) underwent median sternotomy and a mechanical stabilizing device (United States Surgical, Norwalk, CT) was positioned astride a segment of left anterior descending coronary artery (LAD). Coronary blood flow was measured by Doppler. Sonomicrometry crystals were placed distal to the stabilizer in a region of myocardium subtended by the LAD, and a left ventricular micromanometer was inserted. Regional myocardial function was determined using the preload recruitable stroke work (PRSW) relationship. Data were acquired at three time points: 20 min before (PRE) and after placing the stabilizer (EXPT); and 20 min after removing the stabilizer (POST). Tissue subjacent to the stabilizer was then biopsied. Means +/- standard deviation are reported. RESULTS The mechanical stabilizer caused a decrease in cardiac output from 4.2+/-1.5 to 3.6+/-1.3 l/min (P < 0.05), which returned to baseline values after its removal. Regional myocardial function (percent systolic shortening and MW and x-intercept of the PRSW relationship) was unchanged. Blood pressure, heart rate, and LAD blood flow remained constant. Histologic findings included a layer of myocyte necrosis less than 1 mm in depth immediately beneath the stabilizer. CONCLUSIONS These data demonstrate that mechanical stabilization of the LAD may temporarily decrease cardiac output. This is not attributed to impaired contractility or ischemia, but is secondary to direct ventricular compression with reduced stroke volume. Injury to underlying tissue is negligible.
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Affiliation(s)
- W R Burfeind
- Department of Surgery, DUMC-3457, Durham, NC 27710, USA
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Waldenberger FR, Haisjackl M, Holinski S, Lengsfeld M, Konertz W. Centrifugal pumps as left ventricular assist for coronary revascularization on a beating heart. Artif Organs 1998; 22:698-702. [PMID: 9702322 DOI: 10.1046/j.1525-1594.1998.06049.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
During recent years, coronary bypass surgery has progressed toward minimizing invasiveness. One important feature of this approach is performing surgery on a beating heart. During the crucial phase of such surgery, the mechanical support of the heart with a left ventricular assist device (LVAD) is a possible option. During the period from October 1, 1994 until June 30, 1997, we employed a centrifugal pump system in 118 cases of coronary artery bypass graft (CABG) procedures with LVAD support (mechanically supported CABG [SUPPCAB]). A total of 179 distal anastomoses with an average of 1.5 +/- 0.5 coronary anastomoses per patient was performed. Three types of pumps were used: 23 BioPump, 87 Isoflow, and 8 Capiox systems. The median time on mechanical support was 44 min (range, 16-116 min). The mean flow rate during support time was 3.5 +/- 0.8 L/min, which results in a calculated flow of 1.7 +/- 0.6 L/min/m2 body surface area (BSA). The average flow was 3.2 +/- 0.8 L/min with the BioPump and 3.7 +/- 0.8 L/min with the Isoflow pump, respectively (p < 0.01). The mean arterial pressure during mechanical support was 75 +/- 12 mm Hg. In 2 patients, the pump system was kept running postoperatively in the ICU. Eight of the patients received operations under resuscitation or in cardiogenic shock. Nine (7.9%) of the patients did not survive the early postoperative phase. For coronary revascularization of the anterolateral and diaphragmatic parts of the heart, the SUPPCAB procedure is feasible with excellent mechanical support of the heart by centrifugal pumps. Especially in high risk cases, this procedure can be recommended.
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Affiliation(s)
- F R Waldenberger
- Department of Cardiac Surgery, University Hospital Charité, Humboldt University at Berlin, Germany
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Heijmen RH, Borst C, van Dalen R, Verlaan CW, Mouës CM, van der Helm YJ, Gründeman PF. Temporary luminal arteriotomy seal: II. Coronary artery bypass grafting on the beating heart. Ann Thorac Surg 1998; 66:471-6. [PMID: 9725387 DOI: 10.1016/s0003-4975(98)00449-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND This study assessed the feasibility of applying a temporary luminal arteriotomy seal during end-to-side coronary artery bypass grafting on the beating heart. METHODS In 18 consecutive pigs, the left internal mammary artery was grafted to the left anterior descending coronary artery, and the arteriotomy was temporarily sealed luminally by a 200-microm-thick polyurethane seal. Endothelial denudation, medial necrosis, and intimal hyperplasia were measured quantitatively and compared with conventionally sutured anastomoses (n=4 pigs). RESULTS Insertion and retrieval of the seal required 28+/-12 and 11+/-6 seconds, respectively. Including the arteriotomy, coronary artery occlusion was limited to about 80 seconds. The seal provided a bloodless arteriotomy in all anastomoses with unimpeded coronary artery blood flow. Endothelial denudation was limited to two thirds of the circumference of the coronary artery. No medial necrosis was found. Intimal hyperplasia at the suture line was small, although more pronounced when compared with conventionally sutured anastomoses. CONCLUSIONS In off-pump, beating-heart coronary artery bypass grafting, the temporary luminal arteriotomy seal provided a bloodless arteriotomy with negligible obstruction to coronary artery blood flow, and with a minimum of arterial wall damage. It is conceivable that this seal may expand the indications for coronary surgical procedures without cardiopulmonary bypass.
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Affiliation(s)
- R H Heijmen
- Department of Cardiology, Utrecht University Hospital, The Netherlands
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Abstract
The principal technical challenge in "off-pump" coronary surgery is to perform an accurate coronary anastomosis on a beating heart. For the purpose of training our residents in performing off-pump coronary artery anastomoses, we have developed a mechanical heart simulator in which trainees can practice performing these anastomoses repeatedly until a satisfactory level of skill and confidence is attained.
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Affiliation(s)
- M B Izzat
- Department of Surgery, The Chinese University of Hong Kong.
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Pagni S, Salloum EJ, Tobin GR, VanHimbergen DJ, Spence PA. Serious wound infections after minimally invasive coronary bypass procedures. Ann Thorac Surg 1998; 66:92-4. [PMID: 9692445 DOI: 10.1016/s0003-4975(98)00353-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Minimally invasive coronary artery bypass grafting has become an increasingly accepted therapy for selected patients with single-vessel coronary artery disease. Reported morbidity has focused on anastomotic problems, but the occurrence of serious wound complications after these procedures has not been well documented. METHODS We reviewed our institutional experience with 35 patients to look for the incidence of serious wound complications. RESULTS Three patients had serious wound problems after minithoracotomy for coronary artery bypass graft procedures. This represents an overall 9% wound morbidity rate and a 100% rate in the obese women. CONCLUSIONS Wound complications at the incision site after minithoracotomy coronary artery bypass graft procedures seem to occur distinctly in obese women with redundant breasts.
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Affiliation(s)
- S Pagni
- Division of Thoracic and Cardiovascular Surgery, Jewish Hospital, University of Louisville, Kentucky 40202, USA
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Heijmen RH, Borst C, van Dalen R, Gründeman PF, Verlaan CW. Temporary luminal arteriotomy seal for bypass grafting. Ann Thorac Surg 1998; 65:1093-9. [PMID: 9564934 DOI: 10.1016/s0003-4975(98)00118-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND To enable off-pump coronary operations in a bloodless surgical field without ischemic complications, we developed and assessed a temporary luminal arteriotomy seal in a porcine carotid artery bypass graft model. METHODS In 16 consecutive pigs (25 kg, 32 anastomoses) the arteriotomy was sealed luminally by a polyurethane elliptic convex seal. Endothelial denudation, medial necrosis, and intimal hyperplasia were measured quantitatively and compared with those seen in conventionally sutured anastomoses. RESULTS The median occlusive time upon insertion or retrieval was 90 and 82 seconds, including the arteriotomy and securing the anastomosis, respectively. Once properly positioned, the seal provided a bloodless arteriotomy in all anastomoses. Microsurgical suturing was performed without leakage of the seal and with unimpeded flow. In the recipient artery, endothelial denudation was limited to one third of its circumference. No medial necrosis was found. Intimal hyperplasia at heel and toe was not significantly different from that seen in conventionally sutured anastomoses. CONCLUSIONS During end-to-side bypass grafting, the temporary luminal arteriotomy seal provided a bloodless surgical field without interfering with recipient artery blood flow and with minimal damage to the arterial wall.
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Affiliation(s)
- R H Heijmen
- Heart Lung Institute, Department of Cardiology, Utrecht University Hospital, The Netherlands
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Waldenberger FR, Haisjackl M, Lengsfeld M, Holinski S, Konertz W. Koronarchirurgie am schlagenden Herzen während mechanischer Linksherzassistenz (SUPPCAB). Eur Surg 1998. [DOI: 10.1007/bf02619843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
It is estimated that approximately 25% of cardiac surgery will be performed through minimal access by the year 2000. While original efforts focused on performing minimally invasive cardiac surgery totally thoracoscopic, and with cardiopulmonary bypass, more recent realistic approaches rely on small targeted incisions and video assisted techniques on the beating heart. Current instrumentations which provide segmental stabilization of the heart eliminate the need for cardioplegic arrest and cardiopulmonary bypass. While early results are encouraging, intermediate and long term clinical outcome and graft patency remain to be determined.
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Affiliation(s)
- H Shennib
- McGill University, The Montreal General Hospital, Quebec, Canada
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Abstract
Long-standing efforts to assess quality in medical care have been intensified by the striking expansion of managed care plans. Agencies such as the Joint Commission on Accreditation of Health Care Organizations and the National Committee on Quality Assurance have formalized the evaluation of health plan quality using criteria of structure, process, and outcome. A review of attempts to apply these criteria to individual physicians and to disease-specific interventions such as myocardial revascularization demonstrates the great difficulty of reliable quality assessment in this evolving surgical field. Cardiac surgeons must continue their work in deriving valid socioeconomic and clinical conclusions from The Society of Thoracic Surgeons and Veterans Affairs databases. This may prevent the precipitate adoption of newer treatment methods driven by entrepreneurial technology companies and large group purchasers of care. These entities tend to focus on economics rather than patient welfare. New technologies may also delude patients into insisting on treatment featuring short-term convenience and comfort despite less satisfactory long-term results. "Black box" methodology providing practice profiles and physician report cards must have critical validation.
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Affiliation(s)
- C R Hanlon
- American College of Surgeons, Chicago, Illinois 60611, USA.
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Soulez G, Gagner M, Therasse E, Basile F, Prieto I, Pibarot P, Laflamme C, Lamarre L, Shennib H. Catheter-assisted totally thoracoscopic coronary artery bypass grafting: a feasibility study. Ann Thorac Surg 1997; 64:1036-40. [PMID: 9354523 DOI: 10.1016/s0003-4975(97)00719-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The purpose of this study is to examine the feasibility of performing totally thoracoscopic internal mammary-to-coronary artery bypass grafting with the assistance of radiologically guided catheter intervention. METHODS Fourteen dogs were subjected to mobilization of the internal mammary artery and anastomosis of it to the left anterior descending coronary artery over an angiographic catheter inserted into the internal mammary artery under fluoroscopy. The anastomosis was completed over the catheter using sutures and the application of fibrin glue. Eight animals underwent the anastomosis after their sacrifice. The other 6 animals were put on closed chest cardiopulmonary bypass and had their anastomosis done after intraaortic balloon occlusion and cardioplegic arrest of the heart. All animals had an angiographic and pathologic examination at the completion of the anastomosis. RESULTS Anastomosis was completed in all dogs. Three anastomoses leaked and two were noted to be stenosed at completion of the anastomosis. One leak was sealed by application of fibrin glue. Both stenotic anastomoses were caused by suturing of the back wall when a short angiographic catheter could not be positioned across the anastomosis. CONCLUSIONS Minimally invasive totally thoracoscopic mammary-to-coronary artery bypass grafting with catheter assistance is feasible. Technical improvement and appropriate instrumentation are required to minimize anastomotic failure.
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Affiliation(s)
- G Soulez
- Department of Radiology, Hotel-Dieu de Montreal Hospital, and McGill University, Montreal, Quebec, Canada
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Abstract
BACKGROUND There is increasing interest in performing minimally invasive coronary artery bypass grafting. To evaluate the current level of acceptance and utility of this procedure a survey of 162 cardiothoracic surgeons was conducted. RESULTS Currently only 16% of surveyed surgeons performed more than 10 minimally invasive coronary artery bypass grafting procedures. Most were less than 55 years old and in private practice. The majority predicted that it will be indicated in less than 25% of coronary artery bypass grafting cases and considered minimally invasive coronary artery bypass grafting a modification of existing techniques rather than investigational. Most believed exposure and stabilization of the coronary arteries on the beating heart to be the most challenging part and expressed concern with quality of the anastomosis. CONCLUSIONS We conclude that minimally invasive coronary artery bypass grafting is rapidly gaining acceptance in younger surgeons as techniques are improved. Despite concerns with adequacy of anastomosis the procedure is not considered investigational and follow-up is not rigorous.
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Affiliation(s)
- H Shennib
- Division of Cardiothoracic Surgery, Montreal General Hospital, McGill University, Quebec, Canada
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