Effect of Anti?Platelet Therapy on Peri?Operative Blood Loss in Patients Undergoing Off?Pump Coronary Artery Bypass Grafting

Purpose:The purpose of this study was to review the effect of the pre?operative use of clopidogrel and aspirin on peri?operative bleeding, blood product transfusion, and resource utilization after coronary artery bypass grafting (CABG). Materials and Methods: A total of 1200 patients who underwent off?pump CABG (OPCABG) between 2010 and 2012 were retrospectively studied. Patients were divided into three groups: group 1: discontinued aspirin and clopidogrel 6 days prior to surgery (n = 468), group 2: discontinued both drugs 3 to 5 days prior to surgery (n = 621), and group 3: discontinued both drugs 2 days prior to surgery (n = 111). The bleeding pattern and blood product transfusion were studied and compared between the groups. Patients having history of other drugs affecting the coagulation profile, other organ dysfunction, on?pump CABG, and the combined procedure were excluded from the study. Results: Group 2 patients had a higher rate of bleeding and a reduced mean value of hemoglobin (Hb) as compared to other groups. The same results were seen in blood and blood product transfusion. Patients of group 2 and group 3 were associated with higher blood loss in terms of drainage at 12 and 24 hours. Post?operatively, this was statistically significant. Re?exploration was statisitically significant in group 3 patients (9.01%) than in group 2 (2.58%) and group 1 (1.07%) patients. Conclusion: The pre?operative use of clopidogrel and aspirin in patients undergoing OPCABG showed limited clinical benefits; however, its use significantly increased the risk of bleeding and blood transfusion, thus increasing morbidity and resource utilization. Hence, clopidogrel and aspirin should be stopped at least 6 days prior to surgery.

Incidence of reexploration in cardiac surgery under cardiopulmonary bypass at Government Mohan Kumaramangalam Medical College Hospital, Salem

Background: Cardiac Surgery being the most modern and conceptualized surgery which involves cardiopulmonary bypass Clotting Mechanism, Temperature Control, Hemodilution, and Cardioplegic arrest, etc. The failure of any of these mechanisms ends up in a cascading effect of morbidity and mortality of the patients. The aim of the study: The present study was primarily undertaken to study the incidence off Reexploration in Cardiac Surgery among patients subjected to cardiopulmonary bypass, thereby identifying the factors contributing to Reexploration and adopting suitable measures to reduce the incidence of Reexploration. Materials and methods: Totally 25 patients who underwent cardiac surgery under cardiopulmonary bypass Department of Cardio-Thoracic Surgery, Government Mohan Kumaramangalam Medical College Hospital, Salem. Patients who had a problem of bleeding underwent Reexploration. Patients included in the study belonged to both sexes and age groups varying from 11 to 68 years. The patients were subjected to routine investigations. Results: It was as high as 25% among the patient belonging to three different age groups (20-30), (40-50) and (50-60). The incidence of Reexploration was 58.3% (14/24) among patients who were CPB time exceeded 120 minutes. The overall incidence of Reexploration following open heart surgery was 1.38% (7/25). Among the patients to underwent Reexploration. Patients who underwent open Heart Surgery accounted for 29.16% (7/25) of patients. The incidence of Mortality in this group Pon. A. Rajarajan. Incidence of reexploration in cardiac surgery under cardiopulmonary bypass at Government Mohan Kumaramangalam Medical College Hospital, Salem. IAIM, 2019; 6(4): 20-25. Page 21 was 28.57% (2/7) of patients. Among the 7 patients who had Reexploration 71.4% (5/7 of patients had an uneventful course after Reexploration). 7 Patients who had valve replacement surgery accounted for among the total of 25 patients who had an undergone Reexploration accounting for 29.1% of all cases of Reexploration. 71.4% (5/7) who had undergone Mitral Valve replacement patients accounted for 71.4% (5/7) of Reexploration. Aortic valve replacement patients accounted for 14.2% (1/7). Double Valve replacement patients accounted for 14.2% (1/7). Overall Mortality following Reexploration in this group was 71.42% (5/7). 7 Patients who had a Reexploration after Valve replacement Surgery 28.5% (2/7) of the patients were undergoing Mitral Valve Replacement for Restenosis. One patient who was Reexplored for Post-operative bleeding had a Left Ventricle Free Wall rupture following Mitral Valve Replacement. Conclusion: Attention towards meticulous hemostasis prior to closure is Mandatory. A sound surgical technique will reduce the incidence of bleeding from sites of Cannulation and Anastomosis. Adoption OFF PUMP CABG has shown to reduce the incidence of postoperative bleeding and Morbidity when compare to ON PUMPCABG.

Double Off-Pump Coronary Artery Bypass Surgery via Lateral Thorocotomy in a Case with Pre-sternal Reconstruction after Esophageal Cancer Resection / 日本心臓血管外科学会雑誌

A 71-year-old man with double vessel disease (left anterior descending artery and right coronary artery) was surgically treated by off-pump coronary artery bypass grafting. He had undergone pre-sternal subcutaneous gastric tube reconstruction and mediastinal radiation therapy 19 years previously due to esophageal cancer. The gastric tube prevented the median sternotomy that is commonly necessary for cardiac surgery. In cases with difficulties of median sternotomy, left anterolateral thoracotomy and the use of the subclavian artery as inflow root for bypass grafting are available. Both radial arteries were harvested as graft conduit, because of prospective severe adhesion of left internal thoracic artery due to previous radiation. The radial artery was anastomosed on the back side of the left subclavian artery with side-to-end fashion. Y-shaped composite graft was made with the other arterial graft. Both ends were anastomosed to the left anterior descending artery and the right posterior descending branch on the beating heart status without cardiopulmonary bypass. Intra-operative SPY images showed good patency of both bypass grafts. The post-operative course was eventful. The catheter angiography revealed all graft patency 5 years after the surgery.

Postoperative Atrial Fibrillation Following Off-pump Coronary Artery Bypass Grafting / 日本心臓血管外科学会雑誌

It has been demonstrated that atrial fibrillation (AF) frequently occurs after coronary artery bypass grafting (CABG) and may cause cerebral infarction. The purpose of this research is to clarify the risk factors of AF in patients who underwent off-pump CABG (OPCABG). In this study, 142 patients (111 men and 31 women) were enrolled with an average age of 67 years old (range, 33-83). According to multivariate analysis, age and the preoperative peak early (E)/late (A) diastolic velocities ratio (E/A) were the independent predictors of postoperative AF. Patients who suffered from postoperative AF required a significantly longer hospital stay.

Renal Function Before and After Coronary Artery Bypass Grafting (CABG): Off Pump vs. On Pump.

Coronary Artery Bypass Grafting (CABG) is associated with a significant morbidity and mortality and several factors have been identified as predictive of complications. These include renal dysfunction and in particular renal replacement therapy. More than 600,000 coronary artery graft procedures are performed annually in the United States. Of those patients with coronary arterial disease 10% patients undergo CABG surgery. To explore the association of renal function between off-pump and on-pump-CABG. To evaluate the degree of impairment of renal function in on-pump, 80 patients (off-pump group = 50, on-pump group = 30) who underwent CABG were recruited from cardiac surgery dept. of National Heart Foundation and Research Institute Mirpur Dhaka and National Institute of Cardiovascular Disease (NICVD). Subjects were selected according to exclusion and inclusion criteria. Purpose and procedure of the study were explained in detail and informed written consent was taken from the study subjects. All the information of the study subject including history, clinical finding were recorded in a preformed data sheet. Serum urea and creatinine were significantly higher in on-pump group patients 12 hours after CABG. Serum urea was significantly higher and serum creatinine was slightly in onpump group in comparison to off-pump group. The mean urea and creatinine were found significantly higher in on-pump group in comparison to off-pump group and CCr was slightly higher lower in on-pump but not significantly decreased.

Trans-esophageal echocardiography in off-pump coronary artery bypass grafting.

The two features of off-pump coronary artery bypass (OPCAB) grafting that lead to haemodynamic instability are, transient occlusion of the coronary arteries during distal anastomosis construction and displacement of the heart to provide access to the distal coronary arteries. The position of the heart as seen by trans-oesophageal echocardiography (TOE) can often provide an indication as to how much compression of the right or left ventricle has occurred. If either chamber is not filling, repositioning of the heart will be necessary. Close observation of the heart with TOE during periods of coronary occlusion may facilitate detection of worsening cardiac function as evidenced by weakening contraction, ventricular dilatation, or increasing mitral or tricuspid regurgitation. Haemodynamic change are more pronounced with displacement of the heart to access posterior than the anterior coronary arteries. Cardiac manipulations along with transient occlusion of coronary arteries during distal anastomosis may cause transient hypotension with increased filling pressures. TOE is helpful in this scenario as it helps to differentiate between cardiac dysfunction secondary to myocardial ischaemia (in which regional wall motion abnormalities will be present) from a much more common scenario where the increase in filling pressure is secondary to extra-cardiac compression and provides the ability to detect mitral regurgitation with a colour flow Doppler as well as assess the right heart function.

Comparison between Regional Cerebral Oxygen Saturation and Jugular Bulb Venous Oxygen Saturation in Patients Undergoing OPCAB Surgery / 대한마취과학회지

BACKGROUND: Hypoperfusion during manipulation of the heart in off-pump coronary artery bypass (OPCAB) surgery may lead to postoperative neurological complications. Therefore, it will be necessary to monitor cerebral function during OPCAB surgery. In this study, we compared regional cerebral oxygenation (rSO2) by near-infrared spectroscopy (NIRS) with jugular bulb venous oxygen saturation (SjvO2) and assessed whether rSO2 measured by NIRS could be an alternative method of SjvO2 during OPCAB surgery. METHODS: A total of 20 patients who underwent OPCAB surgery were studied. A fiberoptic catheter was placed in the right jugular bulb to measure SjvO2 while a cerebral oximeter based on NIRS, INVOS 5100B was used to monitor rSO2. Radial arterial and jugular bulb blood samples were drawn simultaneously from baseline every hour during operation. The values of rSO2 were compared with SjvO2 values. RESULTS: For all data points (n = 78) for all patients combined, rSO2 values were significantly correlated with SjvO2 values (r = 0.513, P < 0.0001). There were significant correlations between arterial carbon dioxide and values of SjvO2 (r = 0.393, P = 0.0002) and rSO2 (r = 0.432, P < 0.0001). CONCLUSIONS: We concluded that NIRS correlates with SjvO2 in this patient population. These findings suggest that near-infrared spectroscopy may be useful in assessing cerebral oxygenation during OPCAB surgery.

Current Status of the Surgical Treatment of Ischemic Heart Disease / 한양의대학술지

The management of patients with ischemic heart disease is rapidly evolving. During the past several years, refinement of techniques related to mechanical revascularization (ie, percutaneous coronary intervention and coronary artery bypass grafting) for ischemic heart disease have resulted in improved patient outcomes and, subsequently, an increase in the number of patients undergoing therapeutic coronary artery interventions. Despite advances in cardiopulmonary bypass and myocardial protection, postoperative adverse events after coronary artery bypass grafting (CABG) are mostly related to the use of cardiopulmonary bypass, global cardiac arrest, and hypothermia. Through the recent development of effective devices for target vessel exposure and stabilization, off-pump coronary artery bypass grafting (OPCAB) has gained widespread use as an alternative technique and is now challenging conventional on-pump CABG as the standard for surgical therapy in multivessel disease. Use of the left internal thoracic artery (ITA) for the left anterior descending coronary artery with supplemental saphenous vein grafts has been the standard CABG. Development of a lower saphenous vein graft patency rate compared with that of ITA has encouraged surgeons to examine CABG with total arterial grafts to improve the long-term outcome of myocardial revascularization. Total arterial revascularisation offers further advantages over conventional CABG. The use of in situ or composite bilateral ITA grafts eliminates the need to manipulate on the aorta, which is a major cause of stroke after CABG. Total arterial revascularisation is compatible with, and may indeed facilitate, the rapidly increasing techniques of OPCAB. These recent advances in the field of CABG have resulted in improved patient outcome and improved long-term myocardial revascularization outcome.

Current Status of the Surgical Treatment of Ischemic Heart Disease / 한양의대학술지

The management of patients with ischemic heart disease is rapidly evolving. During the past several years, refinement of techniques related to mechanical revascularization (ie, percutaneous coronary intervention and coronary artery bypass grafting) for ischemic heart disease have resulted in improved patient outcomes and, subsequently, an increase in the number of patients undergoing therapeutic coronary artery interventions. Despite advances in cardiopulmonary bypass and myocardial protection, postoperative adverse events after coronary artery bypass grafting (CABG) are mostly related to the use of cardiopulmonary bypass, global cardiac arrest, and hypothermia. Through the recent development of effective devices for target vessel exposure and stabilization, off-pump coronary artery bypass grafting (OPCAB) has gained widespread use as an alternative technique and is now challenging conventional on-pump CABG as the standard for surgical therapy in multivessel disease. Use of the left internal thoracic artery (ITA) for the left anterior descending coronary artery with supplemental saphenous vein grafts has been the standard CABG. Development of a lower saphenous vein graft patency rate compared with that of ITA has encouraged surgeons to examine CABG with total arterial grafts to improve the long-term outcome of myocardial revascularization. Total arterial revascularisation offers further advantages over conventional CABG. The use of in situ or composite bilateral ITA grafts eliminates the need to manipulate on the aorta, which is a major cause of stroke after CABG. Total arterial revascularisation is compatible with, and may indeed facilitate, the rapidly increasing techniques of OPCAB. These recent advances in the field of CABG have resulted in improved patient outcome and improved long-term myocardial revascularization outcome.

A Case of Non-Occlusive Mesenteric Ischemia after Off-Pump CABG and Abdominal Aortic Aneurysm Replacement / 日本心臓血管外科学会雑誌

Fatal intestinal necrosis developed following off-pump CABG and implantation of a bifurcated vascular prosthesis in a 70-year-old man with unstable angina pectoris and abdominal aortic aneurysm. A CT scan with three-dimensional reconstruction (3D-CT), showed no narrowing or obstruction of the SMA. The patient was scheduled to undergo an extensive resection of the intestine on the 23rd postoperative day. The pathological diagnosis was nonocclusive mesenteric ischemia (NOMI). He died of multiple organ failure on the 38th postoperative day. Early diagnosis of NOMI is essential to lower mortality and postoperative morbidity. Invasive angiography is the gold standard in diagnosis. 3D-CT, a non-invasive method, is an increasingly useful technique, which may allow identification of vascular anatomy and pathology with sufficient detail for diagnosis. Several other causes of acute abdomen, other than mesenteric ischemia, can be ruled out. Therefore, 3D-CT might be useful in screening for NOMI.

Nonocclusive Mesenteric Ischemia after Off-Pump CABG / 日本心臓血管外科学会雑誌

An 81-year-old woman developed abdominal pain after off-pump CABG (OPCAB) for unstable angina pectoris. X-ray film and CT scan showed paralytic ileus the day after surgery. A presumptive diagnosis of mesenteric ischemia was made and exploratory laparotomy was performed. During surgery, however, there was no sign of mesenteric ischemia. The patient still complained of abdominal pain after the laparotomy, so selective angiography of the mesenteric artery was performed. The angiography showed remarkable vasospasm of the superior mesenteric artery (SMA) and diagnosis of nonocclusive mesenteric ischemia (NOMI) was made and continuous intra-arterial perfusion of papaverine into the SMA was started. Control angiography during papaverine perfusion showed a clear reduction of vasospasm. Thereafter, the patient developed diffuse peritonitis due to intestinal gangrene on postoperative day 12 and was compelled to undergo extensive resection of the intestine and sigmoidectomy. She could not be weaned from the ventilator due to respiratory insufficiency and died of multiple organ failure about 5 months after OPCAB. NOMI can develop even in OPCAB, in which cardiopulmonary bypass is not required. Therefore maintenance of stable hemodynamics intraoperatively, careful management of the postoperative state and early diagnosis and therapy are essential to prevent NOMI.

A Case of Off-Pump Coronary Artery Bypass Grafting in a Patient with Idiopathic Thrombocytopenic Purpura / 日本心臓血管外科学会雑誌

A 63-year-old man with unstable angina and idiopathic thrombocytopenic purpura (ITP) underwent off-pump coronary artery bypass grafting after being admitted to our hospital because of angina pectoris. Coronary angiography performed on admission showed 90% stenosis of the left main coronary artery. High dose transvenous γ globulin therapy was performed for 3 days before surgery. The number of platelets, which was 2.3×10⁴/mm³ on admission increased to 4.1×10⁴/mm³ before surgery. Ten units of platelets were transfused intraoperatively, with little perioperative hemorrhage and no increased incidence of bleeding complications. The postoperative course was uneventful. High dose transvenous γ globulin therapy and operation without cardiopulmonary bypass were useful in facilitating the treatment of this ITP coronary artery bypass patient.

Off-Pump Coronary Artery Bypass Grafting via Left Thoracotomy in a Patient with Esophageal Cancer / 日本心臓血管外科学会雑誌

A 71-year-old man with early-stage esophageal cancer underwent off-pump coronary artery bypass grafting (CABG) through left thoracotomy to avoid sternotomy to allow subsequent esophageal surgery. The patient had severe double vessel coronary artery disease (the left anterior descending artery and the right coronary artery). Esophageal pull-out resection and reconstruction with the transverse colon over the sternum were planned after recovery from CABG. Therefore, we performed off-pump CABG via left thoracotomy using a saphenous vein Y-graft. Proximal anastomosis was placed in the descending aorta, and the distal anastomoses were completed with a stabilizer and an apical retraction device. Postoperative angiograms showed both grafts were patent and had suitable layout for subsequent esophageal surgery. In conclusion, off-pump CABG via left thoracotomy is an appropriate option for myocardial revascularization, if median sternotomy is contraindicated.

Off-Pump Coronary Artery Bypass Grafting Using Coronary Shunt Tubes / 日本心臓血管外科学会雑誌

Between February 1999 and November 1999, 33 patients (age 67.0±7.6 years old) underwent off-pump CABG using coronary shunt tubes. The number of graft anastomoses per patient was 2.8±0.8. The operative mortality was 0%. There was no incidence of on-pump conversion, low cardiac output syndrome, IABP insertion, mediastinitis or stroke. The maximum CPK-MB during the perioperative period was 25.9±18.8IU/<i>l</i>. One patient had perioperative myocardial infarction probably due to native coronary artery spasm. In patients with off-pump CABG, the intubation time, the ICU stay and the hospital stay were shorter. The number of patients who were extubated in the operating room was higher and the cost was lower than those with on-pump CABG. An early phase study revealed patency ratios of 85% (the previous term) and 97% (the latter term). Off-pump CABG is a safe and effective means of revascularization with no mortality, minimal morbidity and good short-term patency.

Off-pump CABG and Right Axillo-bifemoral Artery Bypass in a Patient with Totally Calcified Ascending Aorta and Leriche's Syndrome / 日本心臓血管外科学会雑誌

A 40-year-old man was admitted because of coronary heart disease with a totally calcified ascending aorta and Leriche's syndrome. Establishing a cardiopulmonary bypass seemed to be difficult because neither the ascending aorta nor femoral artery was suitable as a cannulation site. It was not until a prosthetic conduit for revascularization of the lower extremities was anastomosed to the right axillary artery in preparation for the conversion from off-pump to on-pump that off-pump CABG was performed. Subsequently revascularization of the lower extremities was completed. The patient had a satisfactory postoperative course. Off-pump CABG is useful for patients with a severely calcified ascending aorta and occlusive lesions below the descending aorta.