Early graft patency after off-pump and on-pump coronary bypass surgery: a prospective randomized study.

AIMS: Uncertainty persists regarding the impact of the off-pump technique on coronary bypass graft patency. The primary objective of this study was to assess coronary artery bypass graft patency in patients randomized to off-pump and on-pump multivessel coronary artery bypass grafting (CABG). Secondary objectives were clinical outcomes and neuropsychological functioning. METHODS AND RESULTS: One hundred and fifty patients were randomized to off-pump (n = 75) or on-pump CABG (n = 75). Graft patency was assessed by multidetector computed tomography 5 weeks after surgery. The two groups were similar regarding patients' characteristics and logistic Euroscore (3.6 vs. 3.7%). Mean number of grafts performed was 3.5 ± 0.6 and 3.5 ± 0.6 in off-pump and on-pump, respectively (P = 0.7). Raw graft patency rate was 89.9% in off-pump and 95.0% in on-pump (OR 2.2, 95% CI 1.07-4.44; P = 0.03). Nineteen (27%) off-pump and 9 (13%) on-pump patients had at least one occluded graft (P = 0.04) and the proportion of patent grafts per patient was 0.91 ± 0.2 in off-pump vs. 0.96 ± 0.1 in on-pump (P = 0.06). However, after adjusting by heparin dose, graft patency was not statistically different between groups (OR 0.87, 95% CI 0.25-2.98, P = 0.83). At 30 days, there was no statistically significant difference in major adverse events and neuropsychological functioning between off-pump and on-pump groups. One-year follow-up showed similar functional class and positive treadmill exercise tests. CONCLUSIONS: Under the conditions this trial was conducted, CABG performed off-pump had lower overall graft patency rate than on-pump, which was not statistically different after controlling for total heparin dose. Thirty-day complications, neuropsychological functioning, and one-year clinical and functional outcomes were not statistically different between the two techniques.

Off-pump coronary artery bypass surgery in women.

OBJECTIVE: Gender is a well-known risk factor for mortality and morbidity after coronary artery bypass grafting and various reasons have been proposed to explain the poorer results observed in women. The study objective was to determine whether female gender was still an operative risk factor with the adoption of off-pump coronary artery bypass surgery. METHODS: Of 2123 consecutive patients who underwent isolated CABG between November 2002 and December 2007, 1966 (92.6%) (481 women and 1485 men) were operated without cardiopulmonary bypass and form the study population. Women were older (69.0 vs. 64.7 years; p = 0.001) and had more severe angina (CCS class 3.1 vs. 2.7; p = 0.001), smaller body surface area (1.6 vs. 1.8 m2; p = 0.001), higher body mass index and greater incidence of diabetes (48.3% vs. 34.2%; p = 0.005) than men. There were no statistically significant differences in the incidence of three-vessel disease (69.5% vs. 71.9%) or left main disease (22.2% vs. 27.0%) but ejection fraction was higher in women (61.3% vs. 59.0%; p = 0.01). Risk factors for in-hospital mortality were identified by univariate analysis and logistic regression. RESULTS: The number of distal anastomoses was lower in women than in men (2.8 vs. 3.0; p = 0.001). In-hospital mortality was 2.0% in women and 0.8% in men (p = 0.01) and female gender was one of the eight risk factors for in-hospital mortality identified by univariate analysis. Using a logistic regression model, only age (OR: 1.7; 95% CI 1.01-1.14; p = 0.02) and logistic EuroSCORE (OR: 1.07; 95% CI 1.03-1.10; p < 0.001) were independently associated with in-hospital mortality. Logistic EuroSCORE was the only independent risk factor for major morbidity (OR: 1.07 95% CI 1.04-1.10; p < 0.001). CONCLUSION: Women who undergo coronary artery bypass grafting have an unfavorable clinical profile compared to men, resulting in higher unadjusted in-hospital mortality. However, in an unselected patient population undergoing off-pump CABG, female gender was not found to be an independent risk factor for mortality or major morbidity.

Sixteen-slice multidetector computed tomography for graft patency evaluation after coronary artery bypass surgery.

OBJECTIVE: To investigate the ability of 16-slice multidetector computed tomography (MDCT) to assess coronary artery bypass graft patency and to detect bypass stenosis by comparison with coronary angiography. METHODS: Thirty patients underwent both conventional coronary bypass angiography and retrospective ECG gated 16-slice multidetector computed tomography after surgery using 0.4 seconds rotation time and 1.25 mm slice thickness. RESULTS: Among a total of 107 bypass grafts, 101 grafts (94.4%) were evaluable by MDCT. Thirteen patients were taking oral beta blockers. Mean heart rate was 73.6 (52-105). Of the 40 internal mammary arteries and two radial arteries examined, only one was occluded by coronary bypass angiography and MDCT, resulting in a sensitivity of 100% and a specificity of 100%. MDCT correctly diagnosed all patent venous grafts and missed two of the 14 venous grafts shown occluded by conventional angiography resulting in a sensitivity of 85.7% and specificity of 100%. When occluded grafts were excluded, MDCT did not detect two out of two anastomotic arterial graft stenosis >50% and resulted in one false positive result for a sensitivity and specificity of 0% and 97.4%, respectively. MDCT correctly diagnosed one out of three venous stenosis >50% and falsely diagnosed one venous graft stenosis >50% yielding a 33.3% and 97.6% sensitivity and specificity, respectively. CONCLUSION: Sixteen-slice MDCT allows for noninvasive evaluation of coronary bypass grafts patency with high diagnostic accuracy. Assessment of distal anastomotic stenosis was deficient, particularly for arterial grafts, still limited by low resolution or artifacts. Improved accuracy may be obtained by more aggressive heart rate reduction.

Less invasive coronary artery bypass surgery: early results in 1083 patients operated off-pump.

OBJECTIVE: To analyze the early results of coronary surgery without cardiopulmonary bypass using the EuroSCORE risk model. METHODS: Out of a series of 1104 consecutive patients undergoing CABG during a 20-month period and whose data were prospectively collected, 1083 patients (98.1%) were operated without cardiopulmonary bypass (CPB) and represent the patient population. Mean age was 65.6 +/- 9.9 years (31-90), 23.1% were female, 77.9% hypertensive, 38.0% diabetic, 22.8% had peripheral vascular disease, 73.0% triple-vessel disease, 54.7% previous myocardial infarction and 67.0% were in CCS class III or IV. Three hundred and forty-one patients (31.5%) were operated on urgently. Surgery was performed with the aid of cardiac stabilizers and intracoronary shunts. RESULTS: The mean number of distal anastomoses was 2.9; the left internal mammary artery was used in 99% of patients. In 10 patients (0.9%), conversion to CPB was required, without mortality or morbidity. Sixteen patients (1.5%) had myocardial infarction; mean troponin T and CK-MB at 24 h were 0.20 +/- 0.43 ng/ml and 28.2 +/- 49.9 U/l respectively. Twenty patients (1.8%) had neurologic deficit, 10 (0.9%) required hemofiltration or dialysis, 229 (21%) received blood transfusions and 135 (14.2%) had atrial fibrillation. Median intubation time was 9 h, and median ICU stay was one day. Median hospital stay was 5 days. Twelve patients died in hospital (1.1%). Thirty-day observed mortality and EuroSCORE-predicted mortality were 1.3% and 4.0% respectively (p < 0.01). CONCLUSION: Off-pump CAB surgery has become our preferred method in almost all patients undergoing coronary surgery, without compromising completeness of revascularization. Observed mortality was significantly lower than that predicted by EuroSCORE and the incidence of complications was reasonably low considering the population's risk factors.

Coronary surgery: which method to use?

OBJECTIVE: To compare 4 methods of myocardial protection in GABG in terms of markers of myocardial ischemia, mortality, morbidity and mid-term results. MATERIAL & METHODS: Retrospective study of 241 consecutive patients undergoing isolated > 1 CABG using one of 4 methods: off-pump (OFF, n = 108), cardiopulmonary bypass (CPB) and cardioplegia (CARD, n = 66), CPB and beating heart (BEAT, n = 47), or CPB and ventricular fibrillation (FIBR, n = 20). Mean age was 65.7 +/- 9.3 years and mean EuroSCORE was 3.2 +/- 2.3. The groups were similar in terms of age, gender distribution, body mass index, incidence of smoking, hypertension, renal insufficiency, CCS class, ventricular function and mean EuroSCORE. Serial blood samples were collected for CK-MB and troponin T, preoperatively and 1, 6, 12 and 24 hours after the procedure. RESULTS: Mean number of distal anastomoses was 3.27 BEAT, 2.98 CARD, 2.90 FIBR and 2.55 OFF (p < 0.05 OFF vs. the other 3 groups). Six patients died in hospital (2.5%), 2/47 BEAT (4.2%), 1/66 CARD (1.5%), 1/20 FIBR (5.0%), 2/108 (1.9% OFF) (p = 0.1). The incidence of atrial fibrillation, stroke/TIA and blood transfusion and length of stay were similar between groups (p = 0.1) but there was a tendency for increased incidence of Q-wave MI (p = 0.08) in OFF and combined adverse events in FIBR (p = 0.07). At 12 hours postoperatively, CK-MB and troponin T were significantly higher in FIBR than in CARD or OFF (p < 0.05) and at 24 hours, troponin T remained higher in FIBR than in all other groups (p < 0.05). After a mean follow-up of 19 months, no significant difference was observed between groups in mortality or relief of angina. CONCLUSION: We were unable to demonstrate the superiority of any one revascularization method over another in terms of mortality, morbidity or length of stay. As shown by lower levels of myocardial markers of ischemia, better myocardial protection was obtained with OFF, BEAT and CARD compared to FIBR. Mid-term survival and relief of angina were similar between groups.

Coronary surgery in patients with porcelain aorta.

Four patients with unstable angina due to left main or three-vessel disease scheduled for coronary artery bypass grafting were found intra-operatively to have porcelain ascending aorta, defined as massive calcification of the ascending aorta from the aortic valve to the transverse arch, precluding ascending aorta cannulation or clamping. A no-touch operative technique was applied using the two internal mammary arteries in three cases, with complementary Y-grafting when necessary. Three cases underwent off-pump myocardial revascularization. The fourth case was revascularized with pump-assisted beating heart and proximal saphenous graft anastomosis with an automatic connector. There was no mortality or neurologic morbidity and all patients were discharged home before post-operative day 8.

Cardiac surgery and morbid obesity.

OBJECTIVE: Obesity is considered a risk factor for the occurrence of complications after cardiac surgery. The objective of this study was to analyze mortality and morbidity in patients with morbid obesity following heart surgery. DESIGN: Retrospective study in a tertiary care setting. METHODS: Out of 1815 adult patients undergoing cardiac surgery, 50 consecutive patients (3%) with morbid obesity (defined by a body mass index (BMI) > 35 kg/m2) operated on between 7/98 and 3/01 were studied. Mean age was 61.9 +/- 10.4 years, mean BMI was 38.0 +/- 2.7 kg/m2 and mean Parsonnet score was 14.3. Thirty patients had CABG, 14 underwent valve surgery and 6 had combined valve and CABG. RESULTS: Three patients died in the first 30 days (hospital mortality = 6%). Four patients had myocardial infarction (8%), 4 patients had stroke (8%) and 13 required blood transfusion (29%). There were no deep sternal wound infections or reoperations but 9 patients (15%) presented superficial wound infections. Mean ICU and hospital stay were 2.2 +/- 2.2 and 6.8 +/- 4.1 days respectively. With a mean follow up of 13.9 +/- 8.9 months, 4 patients died; 38 (93%) out of the 41 patients reviewed are in NYHA class I or II and 27 (65%) have unrestricted physical activity. CONCLUSIONS: Cardiac surgery in patients with morbid obesity carries a higher morbidity and mortality risk. Short- and medium-term results were satisfactory with improvement in quality of life in two-thirds of the patients.