Off-pump coronary artery bypass grafting using continuous heparin infusion.

OBJECTIVES: Levels of anticoagulation during off-pump coronary artery bypass grafting (OPCAB) remain controversial. Prolonged activated clotting time (ACT) during OPCAB increases blood loss during surgery and can also cause paradoxical increase in postoperative myocardial infarction. Shorter ACT can increase thrombotic complication. Maintaining a steady ACT level is challenging. We have used continuous heparin infusion after initial bolus during OPCAB to maintain a steady low target ACT. The objective of the present study was to assess the effectiveness and safety of heparin infusion in maintaining a steady target ACT level. METHODS: This was a prospective study of consecutive OPCAB patients. ACT was measured after initial bolus dose of heparin. Once ACT of more than 200seconds was achieved, heparin infusion was started to maintain the required level of anticoagulation. CPK-MB was measured in operation room, 6 and 24hours postoperatively to rule out ischemic complication. RESULTS: ACT could be maintained in target range with heparin infusion in 80.1% patients (161/201). Of the 40 patients with one or more ACT reading less than 200seconds, 38 patients were managed by increasing the dose of heparin infusion and only 2 patients required additional bolus dose of heparin. CONCLUSIONS: Heparin infusion maintains a steady target ACT level and avoids peaks and troughs associated with bolus doses. Lower level of anticoagulation using continuous heparin infusion does not increase ischemic complications. This is the first ever study of use of heparin infusion during OPCAB. We may conclude that heparin infusion is a safe anticoagulation strategy for OPCAB.

Nicorandil Infusion During Off-Pump Coronary Artery Bypass Grafting Reduces Incidence of Intra-aortic Balloon Pump Insertion.

OBJECTIVE: Off-pump coronary artery bypass grafting in patients with left ventricular dysfunction has proven to be advantageous. However, it carries risk of emergency conversion to cardiopulmonary bypass. We have successfully used an intra-aortic balloon pump to prevent such conversion. The objective of the present study was to evaluate if intravenous nicorandil infusion reduces the incidence of intraoperative intra-aortic balloon pump insertion. METHODS: Consecutive cases of isolated off-pump coronary artery bypass surgery performed by a single surgeon were studied. Patients were divided into two groups. The first group did not receive nicorandil, and the second group received intraoperative nicorandil infusion (started in the operating room after central line insertion). RESULTS: A total of 375 patients were included in the study. Four patients in the non-nicorandil group and the patients in nicorandil group were on preoperative intra-aortic balloon pump and hence excluded from the study. After routine use of nicorandil infusion, incidence of intra-aortic balloon pump insertion during off-pump coronary artery bypass surgery decreased from 12.4% (21/169) to 2.9% (6/206). CONCLUSIONS: Nicorandil infusion significantly (P = 0.007) reduced the incidence of intra-aortic balloon pump insertion in our series. In patients with left ventricular dysfunction (ejection fraction ≤ 30%), this difference (P = 0.008) assumes a special significance as off-pump bypass surgery is considered high risk in this subset. Nicorandil is an inexpensive drug, and the reduction in cost of surgery by avoiding intra-aortic balloon pump insertion is an added advantage. The use of nicorandil infusion during off-pump coronary artery bypass may result in favorable patient outcomes by reducing invasive intra-aortic balloon pump insertion during off-pump coronary artery bypass grafting.

Off-pump Bilateral Internal Thoracic Artery Grafting.

BACKGROUND: The long-term benefit of bilateral internal thoracic grafts (BITA) is well established. BITA grafting is often avoided in diabetic, female, obese, elderly and other high-risk patients because of concerns for deep sternal wound infection. The objective of this study is to analyse early results of our BITA grafting and to establish the safety of BITA use in all patients. METHODS: All cases of isolated consecutive unselected CABG were included in this retrospective study. BITA were used in-situ - one was used to graft left anterior descending artery and the other was used as inflow for a composite graft with radial artery. Dual inflow using in situ BITA grafting allows easy bailout by using an additional vein graft. RESULTS: BITA was used in 574 patients out of 602 (95.35%). Incidence of early death was 1.33% (8/602), stroke 0.5% (3/602), reoperation for bleeding 0.17% (1/602). Deep sternal wound infection was not seen in any patient but nine patients (1.5%) had superficial wound infection which healed with dressing. CONCLUSION: We have used BITA in 95% of our unselected, consecutive off-pump CABG patients without any major wound complications. Our limited experience has shown off-pump CABG using BITA grafting can be safely adopted routinely with excellent early result.

Off-pump coronary artery bypass grafting in a low-volume center.

BACKGROUND: The advantages of off-pump coronary artery bypass grafting (OPCAB) are well documented; however, the conversion of OPCAB to cardiopulmonary bypass (CPB) is associated with higher morbidity and mortality. This issue is of particular concern in low-volume centers or centers that are beginning to use OPCAB. We present an OPCAB methodology that uses a maximum number of arterial grafts. METHODS: We routinely use OPCAB in every patient unless there is another associated condition. We used the following methods to improve the safety of OPCAB: (1) maintaining normothermia, (2) routine use of a pulmonary artery catheter, (3) routine use of a femoral arterial line, (4) routine use of a cell saver, and (5) complete revascularization. RESULTS: We included 173 consecutive patients in the study. All patients underwent OPCAB without any conversion to CPB. Hemodynamic compromise in 5 patients (2.89%) required insertion of an intra-aortic balloon pump (IABP). OPCAB was completed in all 5 patients after IABP insertion. Blood transfusions (BTs) were avoided in 55 patients (31.8%), and 68 patients (39.3%) required ≤2 units of blood. CONCLUSION: The OPCAB technique is still evolving. Low-volume centers have higher rates of conversion to CPB. Hypotension due to an impaired left ventricular function can be successfully treated by using an IABP. Although blood loss can be managed with BTs, use of a cell saver helps to reduce the number of BTs. We conclude that our technique of total arterial OPCAB using a cell saver can be safely performed in a low-volume center.