Off-Pump Coronary Artery Bypass Grafting Improves Early Clinical Outcomes Including Operative Mortality.

BACKGROUND: Whether coronary artery bypass grafting (CABG) should be performed on- or off-pump remains a matter of debate. We aim to present our experience with off-pump CABG. Early clinical outcome and adverse events were analyzed over the time course of the study. Methods: A total of 4310 patients undergoing isolated off- pump CABG from January 2002 until December 2016 at the Malabar Institute of Medical Sciences in India were included. Preoperative, intraoperative, and postoperative, as well as follow-up data were prospectively collected. To analyze the differences of patient characteristics and outcomes over time, five-year periods were created (early: 2002-2006; middle: 2007-2011; late: 2012-2016). Traditional techniques of quality control monitoring were applied. Results: The mean age of our patients was 59 ± 9 years, and 13% (533) were female. Postoperative mortality was observed in 0.7% (25), acute renal failure and stroke in 0.2% (8) each, and mediastinitis in 1.2% (53) of the patients. Despite the progressive worsening of the patient risk profile, significant improvement in mortality was observed over time, while stroke, acute renal failure, and mediastinitis remained similar. Continuous quality control monitoring revealed that the system was within the control boundaries for the entire period of the study. The current probability of 30-day mortality or conversion to on-pump CABG is about 0.5%. Conclusion: Off-pump CABG is safe and effective for patients undergoing CABG. It can provide superior results compared to on-pump CABG, particularly when performed by a dedicated off-pump surgeon.

Mammary artery patch reconstruction of left anterior descending coronary artery.

Most patients with diffuse coronary disease require endarterectomy for revascularization. In view of the high morbidity and mortality associated with coronary endarterectomy, patch angioplasty and reconstruction of the coronary artery was developed. We retrospectively evaluated 104 patients who underwent mammary artery patch angioplasty of the left anterior descending coronary artery. The procedure consisted of laying open the entire diseased segment of the coronary artery and patching it with an in-situ left internal mammary artery onlay patch, without endarterectomy, in an off-pump procedure. One (0.9%) patient died, 2 (1.8%) suffered perioperative myocardial infarction, and an intraaortic balloon pump was used in 2. The mean blood loss was 224 mL. Intensive care unit stay was 2.5 days, and hospital stay was 7.8 days. At 1-year follow-up, most patients were in New York Heart Association functional class I. Follow-up angiography was carried out in 16 patients and showed good patency of all anastomoses. Arterial patch reconstruction of the left anterior descending coronary artery can be performed safely and effectively in an off-pump procedure, with excellent early and intermediate results.

Vettath's technique of long mammary patch reconstruction of a diffusely diseased left anterior descending coronary artery without endarterectomy on the beating heart.

Surgery for diffuse coronary artery disease requires coronary reconstruction with or without endarterectomy. Considering the immediate and late postoperative problems of coronary endarterectomy, many surgeons now prefer coronary reconstruction without endarterectomy. Patch reconstruction of the diseased coronary artery with either the internal mammary artery or another conduit is an attractive option. This article describes the technique of long mammary patch reconstruction of the left anterior descending coronary artery without endarterectomy as an off-pump procedure.

Vettath's blower and blower/mister - a simple device for OPCAB surgery.

Since the advent of off-pump coronary artery bypass surgery, a blower/mister has been routinely used in cardiac operation theatres. In our setup, in an attempt to reduce the cost of coronary artery bypass grafting by performing off-pump coronary artery bypass, reusable materials have been routinely used.

Traumatic suprahepatic inferior vena cava injury: surgical management.

SUMMARY: : Suprahepatic inferior vena caval (IVC) injuries are rare but carry nearly a 100% mortality rate. The main problem with its surgical management is the technical difficulty in draining the IVC during cardiopulmonary bypass. In this report, an efficient method of IVC drainage for repair of the IVC on cardiopulmonary bypass is described.

Off-pump excision of left atrial appendage aneurysm: a case report.

Isolated congenital intrapericardial aneurysm of the left atrium (LA) or the left atrial appendage (LAA) is a rare anomaly [Zhao 1999]. The patient usually presents with features of systemic embolization, serious arrhythmia, and severe congestive cardiac failure as a complication, which can be fatal. Once the condition is diagnosed, surgery is indicated [Zhao 1999]. We report a case of congenital left atrial appendage aneurysm in a woman who underwent excision of the same.

Vettath's anastamotic obturator--our experience of 269 proximal anastomoses.

BACKGROUND: Coronary artery bypass grafting (CABG) has come full circle-it started as an off-pump affair, then became an on pump one and now we are trying to keep off the pump again. One of the main reasons for this has been the neurological sequelae subsequent to CABG. But neurological problems kept causing concern even in off-pump CABGs (OPCAB). Side clamping the aorta was thought to be the major factor and thus came the concept of 'no touch proximal anastomoses' onto the aorta (1). Though a variety of proximal anastamotic devices are available in the market, high cost is a matter of real concern in third world countries like India. Hence, this endeavor of ours to fabricate an anastamotic device of our own-'the Vettath's anastamotic obturator' (VAO) for proximal anastomoses of saphenous vein grafts (SVG) onto the aorta. VAO is a stainless steel rod with three grooves and a guard at the end, which sinks into the aorta, through a punch hole, cordoned off by two wide purse string sutures. METHODS: After trials on perfused animal heart models, we started using this device on humans. We have performed 269 proximal anastomoses using the VAO in 177 of our OPCAB patients in the past 1 year (till July 2003). Ninety-five of them had single top ends, 72 had 2 top ends and 10 had 3 top ends onto the aorta. We have used this on disease free islands on four patients with palpable aortic plaques. Initially all anastomoses were of the proximal first type (to ensure that the flow was adequate). Now-a-days, with confidence, distal first anastomoses are being performed. RESULTS: We had no operative mortality in this group. None of our patients needed IABP support. One patient reported back with angina, after 3 months-he was studied and his grafts were found to be patent. All patients, except three, are being followed up till date and they are leading active symptom free and event free lives. DISCUSSION: It is logical to think that avoidance of side clamp on the aorta reduces the risk of neurologic complications. Vettath's anastamotic obturator is an indigenous, cheap and reusable alternative to the other costlier devices, which serve the same purpose. Though there is a small learning curve, results are gratifying and complications are few.

Vettath's anastomotic obturator: a simple proximal anastomotic device.

BACKGROUND: Off-pump coronary artery bypass grafting has been shown to improve the postoperative course of patients undergoing coronary artery bypass grafting (CABG) surgery, but the need for side-clamping the aorta to perform the proximal anastomosis is still a risk factor for causing neurologic injury postoperatively. Hence, our endeavor to fabricate an obturator to perform the proximal anastomosis without side-clamping the aorta is described. METHODS: From July 2002 to February 2003, we performed more than 150 CABG surgeries in our new cardiac center, and 92 patients had proximal saphenous vein graft anastomoses performed with Vettath's anastomotic obturator (VAO). RESULTS: A total of 147 CABG surgeries (98%) were performed on the beating heart, of which 135 (90%) were done off-pump. Early in our experience, the top ends were performed with side-clamping until we introduced our new VAO after trials on a perfused animal heart model. Ninety-two patients had proximal anastomoses carried out with the VAO, and 97 proximal anastomoses were performed on the aorta, because 5 of the patients had 2 proximal anastomoses. We had only one patient in our series who came back with angina after 3 months. Results of repeat coronary angiography with this patient showed a patent proximal anastomosis and no graft problems. CONCLUSION: Our initial results with the VAO have been excellent. We have been able to use it in all of our proximal anastomoses of late. With regular practice, this procedure can be performed with ease and can definitely avoid the neurologic deficits caused by side-clamping the aorta.