Current results in off pump surgery.

OBJECTIVE: We reviewed our experience with myocardial revascularization without cardiopulmonary by-pass (CPB) to evaluate early- and mid-term results compared with those obtained using CPB. METHODS: From May 21, 1997 to November 1998, 747 patients had isolated myocardial revascularization, 480 without CPB (Group A) and 267 with CPB (Group B). Exposure of the target vessels was obtained with four slings (two passed through the transverse sinus and two behind the inferior vena cava) and four deep pericardial sutures on the mobile pericardium around the left atrium (Lima stitches). The number of anastomoses/patient (when two or more conduits were used) was higher in Group B (3.1 +/- 1.0 vs 2.6 +/- 0.7, P < 0.001). More marginal branches were grafted in Group A (258 vs 239), but the percentage was higher in Group B (P < 0.001). Crude and risk adjusted mortality was similar in both groups, as well as cerebrovascular accident (CVA) and acute myocardial infarction incidences. Patients in Group A woke earlier, had less inotropes, lower creatinkinase myocardial band (CK-MB) peak, lower bleeding and less transfusion, shorter Intensive Care Unit (ICU) and postoperative stay in hospital than patients in Group B. 266 anastomoses were checked; of these 98.5% were patent and 97.0% were patent and not restrictive. CONCLUSIONS: Myocardial revascularization without CPB can provide good early- and mid-term results in selected patients. Primary endpoints (death and acute myocardial infarction) were similarly independent from the technique used. Some of the secondary endpoints were favorable in Group A: however their importance is minor. Even if we feel that some high risk patients with severe comorbidities can benefit from CPB surgery; this aspect is difficult to demonstrate scientifically.

Left anterior small thoracotomy (LAST): mid-term results in single vessel disease.

BACKGROUND: Left anterior descending artery grafting using the left internal mammary artery via a left anterior small thoracotomy (LAST) gained new popularity in 1994. We review our experience in 250 of 512 patients who underwent a LAST in single vessel left anterior descending artery disease from November 1994 to October 1997. METHODS: Left anterior descending artery stabilization was obtained pharmacologically and mechanically. Two patients (0.8%) had percutaneous transluminal coronary angioplasty at a mean of 23 +/- 5 days; 172 (68.8%) patients had early postoperative angiography. RESULTS: Eight conduits were occluded (patency rate 95.3%). There was only one late death. Cumulative angiography and Doppler flow evaluation showed that 96.8% of the anastomoses were patent and 95.6% were both patent and nonrestrictive. At a mean follow-up of 16.3 +/- 9.3 months, 9 (3.6%) patients had redo-surgery due to anastomotic/conduit failure and 249 (99.6%) patients were alive and asymptomatic. No patients had acute myocardial infarction. The 35-month actuarial survival rate was 99.6% +/- 0.4%, and the event-free survival rate for the entire experience was 93.7% +/- 1.3%. If only the last 157 patients are considered, at 18 months event-free survival was higher than in the entire group of patients (96.4% +/- 1.4% vs 93.7% +/- 1.3%, p = 0.05). CONCLUSIONS: New instrumentation has made the operation easier and has contributed to its spread, along with increased experience and the end of the learning curve. At the moment we consider the LAST a more anatomical and physiological surgical approach to single vessel coronary disease.