Off-pump total arterial revascularization: our experience

Myocardial Revascularization Exclusively With Bilateral Internal Thoracic Arteries in T-Graft Configuration: Effects on Late Survival

BACKGROUND

We studied long-term survival using bilateral internal thoracic artery (BITA) grafting in a T-configuration exclusively versus using single internal thoracic artery (SITA) grafting in patients with multivessel disease.

METHODS

Consecutive coronary operations performed at a single center between 1996 and 2014 were reviewed. Long-term survival among patients receiving coronary revascularization exclusively with BITA grafting in a T-configuration (n = 2,098) versus SITA grafts plus other types of conduits (saphenous vein graft [SVG] and radial artery [RA]) grafts (n = 1,659). In patients who underwent BITA grafting, the left internal thoracic artery (LITA) was grafted mainly to the left anterior descending artery, whereas the right internal thoracic artery (RITA) was used more commonly to graft the circumflex (Cx) artery and the right coronary system as T-grafts. A total of 485 pairs of patients were matched using propensity scores. Cox proportional hazard models were generated to examine the association of arterial BITA grafting with mortality.

RESULTS

Patients in the BITA group were more likely to be younger (BITA, 63.7 ± 9.1 versus SITA, 65.0 ± 9.9; p < 0.0001). At 30 days, patients who underwent BITA grafting experienced reduced unadjusted mortality (BITA, 1.2% versus SITA, 4.4%; p < 0.0001). At 10 years, patients who underwent BITA grafting experienced superior unadjusted survival (BITA, 82.6% ± 1.8% versus SITA, 76.1% ± 1.3%; p = 0.001). Cox regression analysis in the entire study cohort showed that BITA grafting was associated with improved survival (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.58-0.87; p < 0.001). In the propensity-score-adjusted analysis, patients who underwent BITA grafting had similar in-hospital mortality (BITA, 1.6% versus SITA, 2.9%; p = 0.196). Patients who underwent BITA grafting still showed improved survival at 10 years (BITA, 81.0% ± 4.1% versus SITA, 71.8% ± 2.5%; p = 0.039).

CONCLUSIONS

This study suggests that coronary artery operations exclusively with BITA grafting in a T-configuration may be associated with better long-term survival than grafting with SITA plus other types of conduits.

Off-pump coronary artery bypass grafting using a bilateral internal mammary artery Y graft

Objective

To evaluate the outcome of off-pump coronary artery bypass grafting (OPCABG) using a bilateral internal mammary artery (BIMA) Y configuration graft to achieve total arterial myocardial revascularization.

Methods

From October 2002 to December 2008, 208 patients (196 males and 12 females) underwent OPCABG using a BIMA Y configuration graft. The average age of the patients was 56.5 ± 11.3 years, with an age range of 33–78 years. A total of 167 (80.2%) cases had triple-vessel disease. Left main stem disease was found in 33 (15.9%) cases, and double-vessel disease was found in 8 (3.9%) cases. The semi-skeletonization technique was used to harvest the two internal mammary arteries (IMAs), and then the free right internal mammary artery was connected end-to-side to the left internal mammary artery (LIMA) in situ to complete the Y configuration graft. Off-pump and sequential anastomosis methods were used to perform coronary artery bypass surgery in all patients. Graft patency was assessed intra-operatively with the HT311 transit time flowmeter.

Results

A total of 728 distal anastomoses were performed in 208 patients, with the average being 3.5 ± 1.3 per person. No one died or experienced recurrent angina within 30 days after the operation.

Conclusions

OPCABG using the BIMA Y graft was safe and effective to achieve total arterial revascularization. This method avoids surgical operation on the ascending aorta and other incisions.

Total Arterial Off-pump Coronary Revascularization with a Bilateral Internal Mammary Artery Y Graft (208 cases)

Objective:

The aim was to evaluate the early outcome of off-pump coronary artery bypass grafting (OPCABG) with a bilateral internal mammary artery (BIMA) Y configuration graft to achieve total arterial myocardial revascularization.

Materials and Methods:

From October 2002 to December 2008, 208 patients (196 male and 12 female patients) underwent OPCABG by only using a BIMA Y configuration graft. The average age of the patients was 56.5±11.3 years, with the age range being 33–78 years. A total of 167 (80.2%) cases had triple-vessel disease. Left main stem disease was found in 33 (15.9%) cases, and double-vessel disease was found in 8 (3.9%) cases. The semiskeletonization skill was used to harvest the two IMAs, and then the free right internal mammary artery was anastomosed end-to-side to the in situ left internal mammary artery to composite a Y configuration graft. Off-pump and sequential anastomosis methods were used to perform coronary artery bypass surgery for the patients. Graft patency was assessed by using the HT311 transit time flowmeter (USA Transonic Systems Inc.), intraoperatively.

Results:

We performed distal anastomoses of the grafts in 728 patients, the average being 3.5±1.3 per person. No one died and got recurrent angina within 30 days after operation.

Conclusion:

OPCABG by using the BIMA Y graft was safe and effective to achieve total arterial revascularization, and avoid surgical operation on the ascending aorta, and other incisions.

MINI-off-pump coronary artery bypass graft: long-term results

In an effort to decrease the risks and costs associated with coronary artery bypass graft, in 1978 we repopularized off-pump coronary artery bypass graft (OPCABG) and expanded the technique, addressing lesions of the circumflex system and applying it to diverse clinical scenarios. In this article we describe our experience with 40 patients who received coronary revascularization through a MINI-OPCABG (Benetti technique) operation. Follow-up was achieved by direct communication with the patients or their family during 144 months. The interviews investigated survival, symptoms, long-term medical management and the need for reintervention. This group of patients had no operative mortality and 18 patients (45%) were extubated in the operating room. One patient (2.5%) experienced a perioperative myocardial infarction. During follow-up, two patients received percutaneous coronary intervention, one in the right coronary artery, the other in the circumflex system. A total of seven patients (17.5%) died. Overall, cumulative patient survival at 144 months was 82.5% (33 cases). Of the seven patients who died, four (10.0%) died of cardiac causes and 68.5% were free of symptoms. Technological advances will help to overcome the anatomical difficulties of this surgical technique, and when simplified, will allow it to be reproduced, offering patients a minimally invasive surgical alternative for the treatment of coronary disease, avoiding the limitations of percutaneous transluminal coronary angioplasty and coronary artery bypass graft.

[Perioperative treatment of a man receiving a left-lung transplant combined with coronary revascularization without use of extracorporeal circulation: with a brief review of pathophysiology and the literature]

Patients with significant coronary artery disease were once traditionally rejected as candidates for lung transplants because of higher risk of morbidity and mortality. We report the case of a man who received a left lung transplant and coronary revascularization without extracorporeal circulation in a combined surgical procedure after being diagnosed with significant coronary disease during the preoperative study for acceptance as a candidate for lung transplantation. We review the history of such combination procedures, which are changing clinicians' attitudes as to appropriate therapeutic approaches to take for complex patients. We also discuss the possible advantages of performing surgery without extracorporeal circulation. To our knowledge, this is the first report of a combined procedure that took place in a Spanish hospital.

Total arterial off-pump coronary revascularization using bilateral internal thoracic arteries in triple-vessel disease: surgical technique and clinical outcomes

BACKGROUND

This was a single-institutional study about total arterial off-pump coronary artery bypass graft surgery (OPCABG) using bilateral internal thoracic arteries in triple-vessel disease.

METHODS

We retrospectively reviewed the records of 569 multivessel CABG patients (10% female) who underwent total arterial (bilateral internal thoracic arteries) OPCABG between January 2002 and December 2006. Mean age was 63.9 +/- 8.9 years. All patients included underwent OPCABG as an elective procedure. Postoperative angiograms were evaluated during a postoperative follow-up period. Early and midterm outcomes, including overall patient survival, freedom from readmission and reintervention, freedom from the combined endpoint of cardiac events and quality of life, were evaluated. Multivariate analysis was used to find determinants of late death. Overall survival and freedom from combined endpoints were determined by the Kaplan-Meier method.

RESULTS

The average number of distal anastomoses per patient was 3.18 +/- 0.4. The average operation time was 209.7 +/- 41.7 minutes. Thirty-day mortality was 0.88% (5 of 569). Overall patency rate for all grafts studies was 94.3% (632 of 670). Mean follow-up time was 810 days (range, 8 days to 61 months). Cumulative patient survival at 4 years was 93.3% +/- 1.9%. Significant predictors of late mortality were age (hazard ratio, 1.06; 95% confidence interval: 1.01 to 1.12), previous stroke (hazard ratio, 6.5; 95% confidence interval: 1.8 to 23.5), and moderate to severe left ventricle ejection fraction (hazard ratio, 3.3; 95% confidence interval: 1.2 to 8.8). Freedom from hospital readmission and reintervention at 4 years was 91.7% +/- 3.5%. Freedom from combined endpoint (death, hospital readmission, and reintervention) at 4 years was 86.9% +/- 3.6%. There was a marked improvement in patients' quality of life at follow-up (Duke Activity Status Index score > 45 in more than 70% patients).

CONCLUSIONS

Total arterial (bilateral internal thoracic arteries) OPCABG is feasible with a safe outcome in terms of hospital mortality. At follow-up the incidence of death, hospital readmission and reintervention and patients' quality of life are acceptable with favorable graft patency rates.

Impact of off-pump coronary artery bypass surgery on graft patency: current best available evidence

For more than three decades cardiac surgeons have been used to perform delicate coronary anastomoses on cardiopulmonary bypass (CPB). However, the price of a still and bloodless field is ultimately paid by the patients in the form of sequelae of negative effects of CPB including blood trauma, activation of a series of inflammatory responses, nonpulsatile flow, and possible embolization of air or debris. In an attempt to avoid these deleterious effects of CPB, off-pump coronary artery bypass surgery (OPCAB) has been rediscovered and refined. Although abundant evidence is available to suggest that excellent results can be achieved when CPB is avoided, concerns have been raised about quality of anastomosis and graft patency rates after OPCAB surgery. We are currently practicing in an era of evidence-based medicine that mandates the prospective randomized controlled trial (RCT) as the most accurate tool for determining a treatment benefit compared with a control population. This review article attempts to evaluate the current best available evidence from RCTs on the impact of OPCAB surgery on graft patency.

Arterial grafting for myocardial revascularization: how better is it?

PURPOSE OF REVIEW

Arterial conduits are becoming popular in cardiac surgery. Clinical studies and long-term follow-ups have proven that this technique provides satisfactory long-lasting results. The purpose of this review is to give an overview of the main articles from recent literature and compare the latest results.

RECENT FINDINGS

Arterial conduits are currently used in cardiac surgery and clinical follow-ups are confirming some advantages in performing multiple arterial revascularization compared to the saphenous vein and the mammary artery. Mid-term follow-ups are encouraging the use of the radial artery as the second conduit of choice after the internal mammary artery. Moreover, off-pump cardiac surgery is an alternative to perform extensive myocardial revascularization in selected patients. Use of in-situ mammary arteries and off-pump surgery has already been described as the ideal solution to guarantee the 'no touch aorta technique'. Recent results lead us to use the radial artery and the gastroepiploic artery as complement composite grafts to perform total arterial myocardial revascularization during off-pump coronary surgery.

SUMMARY

Arterial grafting provides satisfactory results. The second graft of choice after the mammary artery is the radial artery, but long-term results are still not available. To reduce the risk of major neurological complications, selected patients benefit from off-pump arterial revascularization.