Use of Impella CP Device in Off-Pump Coronary Artery Bypass Graft Surgery.

Off-pump coronary artery bypass grafting (OPCABG) may be performed on patients with high surgical risk who are poor candidates for traditional mechanical circulatory support. Hemodynamic support with micro-axial mechanical circulatory devices has been performed with limited but promising results.We report a case of a 66-year-old male with multiple comorbidities and low cardiac output undergoing OPCABG. Impella CP device was deployed for "in-pump" support during surgical coronary revascularization resulting in intraoperative stability and uncomplicated post-operative recovery.Previous reports have described the use of the Impella Recover LP 5.0 device for use during OPCABG. We describe the successful and safe perioperative use of the Impella CP device. Despite lower flow rates, adequate support was achieved and the transfemoral cannulation and smaller outer diameter than the Impella 5.0 device may decrease the risk of complications and expedite recovery. Further research will be necessary to determine the optimal perioperative hemodynamic support strategy to offer hemodynamically unstable, high, and prohibitive risk patients.

Device Use for Proximal Anastomosis on Ascending Aorta in Off-Pump Coronary Artery Bypass Grafting.

BACKGROUND: We recently reported early postoperative results comparing the use of an anastomosis-assist device with a side-biting clamp for ascending aorta during coronary artery bypass grafting (CABG). Transient neurological complications occurred less often with the device. Here, we evaluated the perioperative safety of the device compared with the aorta no-touch technique (no-touch). METHODS: We evaluated patients listed in the Japan Adult Cardiovascular Surgery Database who received isolated off-pump CABG with either the device or the no-touch approach from 2014 to 2016. We performed a one-to-one matched analysis based on a propensity score modeled from patient demographics, comorbidities, cardiac conditions, and procedural characteristics. We compared early outcomes in both groups using Pearson's chi-square or Wilcoxon rank sum test as appropriate; P less than .05 was statistically significant. RESULTS: Among 9546 device and 6890 no-touch patients, we found 5012 patient matches for each group. The device operation time was significantly longer (293 versus 281 minutes; P < .001) and homologous transfusion was significantly greater (56.9% versus 51.0%; P < .001) than with no-touch. Thirty-day operative mortality (1.5% versus 1.7%; P = .34), morbidity and mortality (6.8% versus 7.5%; P = .17), and stroke (0.9% versus 1.1%; P = .36) were similar in both groups. New-onset atrial fibrillation (11.9% versus 10.3%; P = .01) occurred significantly more often with the device. Newly initiated dialysis (1.4% versus 1.9%; P = .051) was more frequent with no-touch whereas reoperation for graft occlusion was more frequent with the device (1.0% versus 0.6%; P = .06) but was not significant for either outcome. CONCLUSIONS: The clinical safety of use of the device in CABG was comparable to no-touch for mortality and morbidity. Hemostasis may be a key issue for accomplishing higher-level quality control when devices are used in proximal anastomosis of CABG.

Massive air embolism during off-pump CABG: A case report.

Off-pump coronary artery bypass grafting (OPCAB), although devoid of the morbidity associated with cardiopulmonary bypass (CPB), has its own technical difficulties. Achieving optimum tissue stabilization on a beating heart along with hemodynamic fragility due to extreme positioning also complicates the anesthetic management. In addition, it is difficult to obtain a clear surgical field in the presence of arteriotomy. The use of catheter-directed high-flow gas blower (mister blower) helps achieve a clear surgical field to a great extent. However, there have been reported cases of arterial and pulmonary embolism caused by these high-flow gas blowers. The present case reports a case of massive venous air embolism caused by the use of mister blower.

A New MultiSuction Heart Positioner for Minimally Invasive Coronary Artery Bypass Grafting.

Proper positioning of the heart through a small left thoracotomy is the main challenge during off-pump minimally invasive cardiac coronary artery bypass grafting. Here we report a novel technique for target vessel exposure using the Tentacles NEO (Sumitomo Bakelite, Co Ltd, Tokyo, Japan) multisuction heart positioner, a device with 3 independent small suction cups that can be applied to various surfaces of the heart and pulled toward any direction using attached traction cords. The armless design of the device enables the use of flexible exposure techniques and contributes to the safety and feasibility of minimally invasive coronary artery bypass grafting.

Benefit of Robotic Beating-Heart Totally Endoscopic Coronary Artery Bypass in Octogenarians.

OBJECTIVE: An important advantage of robotic beating-heart totally endoscopic coronary artery bypass (TECAB) is early functional recovery, in which fragile patients like octogenarians (age >80 years) benefit most. The aim of this study was to investigate the safety and feasibility of TECAB in octogenarians. METHODS: We retrospectively reviewed patients undergoing TECAB from July 2013 to September 2017 at our institution. Perioperative outcomes of octogenarian patients and that of younger patients were compared. RESULTS: Of 308 patients who underwent TECAB, 28 patients (9.1%) were octogenarians (mean age 83.8 ± 3.0 years). Octogenarians had a higher rate of hypertension and atrial fibrillation compared to younger patients. TECAB was successfully performed without conversion to any larger incisions in octogenarians. Mean operative time (299 ± 83 minutes vs 281 ± 89 minutes, P = 0.309) and the rate of multivessel bypass (60.7% vs 58.2%, P = 0.798) were similar between octogenarians and younger patients. New atrial fibrillation was observed more frequently in octogenarians compared to younger patients (35.7% vs 18.6%, P = 0.031). Mean length of hospital stay was similar between the 2 groups (octogenarians: 3.9 ± 1.8 days vs younger patients: 3.5 ± 3.0 days, P = 0.475). Twenty-two octogenarians (78.6%) were discharged directly to home. In-hospital mortality was zero in octogenarians. CONCLUSIONS: Robotic beating-heart TECAB had favorable results in octogenarians with acceptable morbidity and mortality and excellent short length of stay similar to younger patients.

The Utility of a 3D Endoscope and Robot-Assisted System for MIDCAB.

BACKGROUND: Minimally invasive direct coronary artery bypass (MIDCAB) has been revived with new techniques and hybrid procedures for MIDCAB and percutaneous coronary intervention (PCI). We reviewed the midterm results of MIDCAB with a three-dimensional (3D) endoscope in our institution. METHODS: Of the 359 patients who underwent off-pump coronary artery bypass grafting (CABG) from December 2013 to March 2017, 54 had MIDCAB with the left internal thoracic artery (LITA) to left anterior descending (LAD) artery through a small left thoracotomy with a 3D endoscope. The same intercostal space was used for the main surgical incision and the insertion site of the 3D endoscope. In all, 22 patients had hybrid coronary revascularization (HCR), combined PCI and MIDCAB. RESULTS: There was no operative death. One patient had cerebral infarction without disability. No cases showed significant increases in CKMB. In all, 34 patients commenced ambulation on postoperative day 1. The postoperative hospital stay was 9.1 ± 5.0 days. In total, 37 patients had coronary computed tomography (CT), and their patency of LITA was 100%. In HCR, there was no mortality and major adverse cardiovascular event (MACE). Target lesion revascularization among 12 months was 1.6%. CONCLUSION: The midterm results of MIDCAB with 3D endoscope-assisted LITA harvesting were satisfactory. MIDCAB, including HCR, is a good alternative for selected high-risk patients.

Applying a clampless haemostatic device for left ventricular assist device outflow graft anastomosis.

Performing a left ventricular assist device outflow graft anastomosis in redo cases with a short ascending aorta and open vein grafts requires side clamping of the aorta and may necessitate temporary clamping of the vein grafts to optimize the surgical field. We aim to describe the technique and report our experience with applying the HeartString® device for the anastomosis of the left ventricular assist device outflow graft in 2 male patients with ischaemic cardiomyopathy following coronary artery bypass surgery. The feasibility of using the HeartString device has been shown and no procedure-related complication was documented.

Propensity-matched analysis of a side-clamp versus an anastomosis assist device in cases of isolated coronary artery bypass grafting.

OBJECTIVES: The use of an anastomosis assist device during coronary artery bypass grafting (CABG) is considered less invasive for the ascending aorta than the use of a side-biting clamp (Side-clamp) and to possibly be associated with a lower incidence of postoperative stroke. However, this benefit has not yet been clearly demonstrated. This study was to evaluate whether the use of an anastomosis assist device will minimize the postoperative stroke and other complications in patients undergoing off-pump CABG in comparison with the use of the Side-clamp. METHODS: Patients undergoing isolated off-pump CABG were retrospectively reviewed using the Japan Adult Cardiovascular Surgery Database (2013-2016). We performed a one-to-one matched analysis based on the estimated propensity scores of those who underwent off-pump CABG with an anastomosis assist device (Device group, n = 14 213) or a side-biting clamp (Side-clamp group, n = 7374) and obtained 2 cohorts (n = 7348 each). We compared the early outcomes and the details of postoperative complications using the Pearson's χ2 test. P-values of <0.05 were considered to indicate statistical significance. RESULTS: No significant differences were observed in the rates of 30-day mortality (Side-clamp versus Device: 0.8% vs 0.8%, P = 0.93) or stroke (1.4% vs 1.4%, P = 0.46). Transient ischaemic attack/reversible ischaemic neurological deficit/delirium occurred more frequently in the Side-clamp group (1.3% vs 0.9%, P = 0.020), whereas new-onset atrial fibrillation (11.0% vs 12.8%, P < 0.001) and prolonged ventilation (2.0% vs 2.9%, P < 0.001) occurred more frequently in the Device group. There was no difference in the length of intensive care unit stay. CONCLUSIONS: The use of an anastomosis assist device partially provided better results with regard to the transient neurological complications; however, no overall benefit was observed in this study.

Beating-heart registration for organ-mounted robots.

BACKGROUND: Organ-mounted robots address the problem of beating-heart surgery by adhering to the heart, passively providing a platform that approaches zero relative motion. Because of the quasi-periodic deformation of the heart due to heartbeat and respiration, registration must address not only spatial registration but also temporal registration. METHODS: Motion data were collected in the porcine model in vivo (N = 6). Fourier series models of heart motion were developed. By comparing registrations generated using an iterative closest-point approach at different phases of respiration, the phase corresponding to minimum registration distance is identified. RESULTS: The spatiotemporal registration technique presented here reduces registration error by an average of 4.2 mm over the 6 trials, in comparison with a more simplistic static registration that merely averages out the physiological motion. CONCLUSIONS: An empirical metric for spatiotemporal registration of organ-mounted robots is defined and demonstrated using data from animal models in vivo.

Endotracheal bioimpedance cardiography improves immediate postoperative outcome: a case-control study in off-pump coronary surgery.

The feasibility and clinical utility of the endotracheal cardiac output monitor (ECOM) to optimize intraoperative hemodynamics and improve short-term outcome in off-pump coronary artery bypass grafting (OPCAB) is unknown. We aimed to compare ECOM with a standard of care in that specific surgical setting. Twenty consecutive adult ECOM-monitored patients undergoing OPCAB were prospectively included (ECOM group) and retrospectively compared to 42 patients scheduled for similar surgery without ECOM monitoring (Control group). The primary endpoint was the global rate of postoperative admission to the intensive care unit (ICU). Secondary endpoints were the time to extubation, the length of stay in ICU and in hospital, the postoperative levels of lactate and troponin and the feasibility of ECOM. The rate of postoperative admission to the ICU was 38/42 (90%) in the Control group versus 11/20 (55%) in the ECOM group, P = 0.008. None unexpected admission for hemodynamic instability was observed in the ECOM group. The time to extubation, the length of stay in ICU, and both troponin level at admission and lactate level at H6 were all significantly decreased in the ECOM group. On a scale ranging from 0 to 5, convenience and satisfaction regarding ECOM were 4.30 ± 1.17 and 3.45 ± 0.68, respectively. The systematic use of ECOM is associated with a significant reduction in the rate of admission to the ICU and an improvement in immediate outcome in OPCAB.

Anaortic off-pump versus clampless off-pump using the PAS-Port device versus conventional coronary artery bypass grafting: mid-term results from a matched propensity score analysis of 5422 unselected patients.

OBJECTIVES: Meta-analyses from observational and randomized studies have demonstrated benefits of off-pump surgery for hard and surrogate endpoints. In some of them, increased re-revascularization was noted in the off-pump groups, which could impact their long-term survival. Therefore, we analyzed the course of all patients undergoing isolated coronary surgery regarding the major cardiac and cerebrovascular event (MACCE) criteria. METHODS: A prospective register was taken from a high-volume off-pump center recording all anaortic off-pump (ANA), clampless off-pump (PAS-Port) and conventional (CONV) coronary artery bypass operations between July 2009 and June 2015. Propensity Score Matching was performed based on 28 preoperative risk variables. RESULTS: We identified 935 triplets (N = 2805). Compared with CONV, in-hospital mortality of both the ANA group (OR for ANA [95% CI] 0.25 [0.06; 0.83], P = 0.021), and the PAS-Port group was lower (OR for PAS-Port [95% CI] 0.50 [0.17; 1.32], P = 0.17). In the mid-term follow-up there were no significant differences between the groups regarding mortality (HR for ANA [95%-CI] 0.83 [0.55-1.26], P = 0.38; HR for PAS-Port [95%-CI] 1.06 [0.70-1.59], P = 0.79), incidence of stroke (HR for ANA 0.81 [0.43-1.53], P = 0.52; HR for PAS-Port 0.78 [0.41-1.50], P = 0.46), myocardial infarction (HR for ANA 0.53 [0.22-1.31], P = 0.17; HR for PAS-Port 0.78 [0.37-1.66], P = 0.52) or re-revascularization rate (HR for ANA 0.99 [0.67-1.44], P = 0.94; HR for PAS-Port 0.95 [0.65-1.38], P = 0.77). CONCLUSIONS: Both off-pump clampless techniques were associated with lower in-hospital mortality compared with conventional CABG. The mid-term course showed no difference with regard to the MACCE criteria between anaortic off-pump, clampless off-pump using PAS-Port and conventional CABG.

Novel Dry-Lab Training Method for Totally Endoscopic Coronary Anastomosis: A Pilot Study.

OBJECTIVE: We describe our original dry-lab training system for nonrobotic and beating heart endoscopic coronary artery anastomosis. METHODS: All the materials used for this training were commercially available. We selected a boxed machine, which can produce pulsatile movements of artificial vessels, and on its roof, we installed a two-dimensional home video camera and a monitor. A multiple-holed plate was placed in front of the machine, and through these holes, a trainee inserted endoscopic surgical instruments and anastomosed the artificial vessels by running fashion while watching the monitor. This training program has four stages. During the first stage, a trainee has to demonstrate mastery in conducting a conventional off-pump coronary artery anastomosis without assistance. The second stage is the "nonbeating" version, and the third stage is the "beating" version with the model mentioned previously. After a trainee gets accustomed to the third stage, the original artificial vessel is replaced with an extremely fragile one, and this is the fourth stage. Our trainee conducted one hundred fourth-stage anastomoses and each procedure was recorded with the video camera. We analyzed several factors from the videos and evaluated the efficacy of the training method. We compared the outcomes of the first 50 consecutive anastomoses with the following 50 ones and described the learning curves. RESULTS: The comparison showed a significant decrease in anastomotic time and vessel injury. We considered the quality of anastomosis acceptable after 47 anastomoses, and anastomotic time fell below 15 minutes at the 81st training at the fourth stage. CONCLUSIONS: Our dry-lab system might be an effective training method for endoscopic coronary anastomosis.

Clampless versus clamped coronary bypass grafting: does it make a difference?

PURPOSE OF REVIEW: The techniques of coronary artery bypass grafting (CABG) have evolved remarkably over the last two decades since the introduction of off-pump coronary artery bypass (OPCAB). This article focuses on the clinical outcomes of 'clampless' CABG strategies, that include OPCAB with a partial clamp, OPCAB with a proximal suture device, and aorta no-touch OPCAB. RECENT FINDINGS: Observational studies have shown the superiority of OPCAB for preventing strokes and pulmonary complications. Conversely, recent large-scale randomized controlled trials (RCTs) have been unable to demonstrate the benefits of OPCAB. Because of these differing results across numerous studies, the debate about the overall superiority of OPCAB versus on-pump CABG remains controversial. However, the literature regarding the OPCAB technique with minimized manipulation of the aorta suggests this has likely benefits, especially for high-risk patients. SUMMARY: Previous large RCTs did not focus on specific approaches of OPCAB or the importance of the experience of surgeons and institutions, and so further studies are needed. Observational studies and meta-analyses have indicated that improved outcomes can be achieved by applying specific OPCAB approaches according to each patient's characteristics.

A Safe Technique for Using an Enclose II Anastomosis Assist Device During Off-Pump Coronary Bypass.

Several proximal anastomosis devices have been developed to facilitate the creation of a clampless, hand-sewn coronary artery bypass-to-ascending aorta anastomosis. An Enclose II anastomosis assist device (Novare Surgical Systems, Cupertino, CA) is a device commonly used for this purpose. We demonstrate a new, easy, and safe technique for cutting the aortic wall and making a punch hole over the aorta.

[New Intracoronary Shunt Cannula in Off-pump Coronary Artery Bypass Grafting].

In off-pump coronary artery bypass grafting(OPCAB), a bloodless operative field has great influence on the quality of anastomosis. In addition, maintenance of distal coronary flow during anastomosis stabilizes hemodynamics. We introduced a new intracoronary shunt cannula, Mini Shunt Pro (MSP). MSP adopts the step-tip, which allows easy insertion and reduces the risk of intimal injury. The distal and proximal sides of the tips of MSP are 0.25 mm different in diameter, which improves its fitness to the coronary artery and enhances a bloodless operative field. This new shunt cannula is considered to be safe and useful for high-quality anastomosis in OPCAB.

Minimally invasive direct coronary artery bypass grafting with an improved rib spreader and a new-shaped cardiac stabilizer: results of 200 consecutive cases in a single institution.

BACKGROUND: Performing minimally invasive direct coronary artery bypass (MIDCAB) grafting via small chest incisions on a beating heart is challenging. We report our experiences of MIDCAB with the utilization of both an improved rib spreader to harvest the left internal mammary artery (LIMA) and a new-shaped cardiac stabilizer to facilitate LIMA-left anterior descending (LAD) coronary anastomosis. METHODS: Between May 2012 and June 2104, a total of 200 patients who were consecutively operated on in this period were enrolled in this study. Data reported included demographic information, preoperative clinical and cardiac status, LIMA harvest time, postoperative in-hospital outcomes, and 30-day mortality. RESULTS: The average LIMA harvest time was 43 min. The mean age was 62.59 ± 10.19 years, and 45 of the 200 were females. The 30-day mortality was 0.5% (one patient) due to perioperative myocardial infarction. Duration of mechanical ventilation and length of stay in intensive care unit was 9.27 ± 7.65 and 24.27 ± 17.85 h, respectively. The unit of packed RBC transfusion was 0.79 ± 1.58. Postoperative atrial fibrillation was observed in 14 (7%) patients. There was no postoperative stroke, renal failure, or incision complication. CONCLUSION: Performing MIDCAB with the improved retractor and stabilizer utilized in this study showed favorable outcomes in terms of harvesting the LIMA, postoperative morbidities, and 30-day mortality.

Cerebrovascular Events After No-Touch Off-Pump Coronary Artery Bypass Grafting, Conventional Side-Clamp Off-Pump Coronary Artery Bypass, and Proximal Anastomotic Devices: A Meta-Analysis.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) has been shown to reduce the risk of neurologic complications as compared to coronary artery bypass grafting performed with cardiopulmonary bypass. Side-clamping of the aorta while constructing proximal anastomoses, however, still carries substantial risk of cerebral embolization. We aimed to perform a comprehensive meta-analysis of studies assessing 2 clampless techniques: aortic "no-touch" and proximal anastomosis devices (PAD) for OPCAB. METHODS AND RESULTS: PubMed, CINAHL, CENTRAL, and Google Scholar databases were screened for randomized controlled trials and observational studies comparing "no-touch" and/or PAD with side-clamp OPCAB and reporting short-term (≤30 days) outcomes: cerebrovascular accident and all-cause mortality. A total of 18 studies (3 randomized controlled trials) enrolling 25 163 patients were included. Aortic "no-touch" was associated with statistically lower risk of cerebrovascular accident as compared to side-clamp OPCAB: risk ratio 95% CI: 0.41 (0.27-0.61); P<0.01; I(2)=0%. Event rates were 0.36% and 1.28% for "no-touch" and side-clamp OPCAB, respectively. No difference was seen between PAD and side-clamp OPCAB: 0.71 (0.33-1.55); P=0.39; I(2)=39%. A trend towards increased 30-day all-cause mortality with PAD and no difference with "no-touch" were observed when compared to side-clamp OPCAB. In a subset analysis, "no-touch" consistently reduced the risk of cerebrovascular accident regardless of patients' baseline risk characteristics. A benefit with PAD was observed in low-risk patients. CONCLUSIONS: Aortic "no-touch" technique was associated with nearly 60% lower risk of postoperative cerebrovascular events as compared to conventional side-clamp OPCAB with effect consistent across patients at different risk.

Novel Anastomotic Device for Distal Coronary Anastomosis: Preclinical Results From Swine Off-Pump Coronary Artery Bypass Model.

PURPOSE: We evaluated the safety and feasibility of a new anastomotic device that simplifies coronary distal anastomosis during minimally invasive and robotically assisted coronary artery bypass graft surgery (CABG). DESCRIPTION: Fourteen miniature pigs underwent off-pump CABG using bilateral internal thoracic arteries (ITA), namely, left ITA to left anterior descending artery and right ITA to right coronary artery. The device was used for distal anastomosis in a device group (n = 11), and conventional 7-0 polypropylene suture in a control group (n = 3). Graft flow was measured intraoperatively. One-month, 3-month, and 6-month postoperative angiography evaluations were done. Histopathologic examination of the anastomosis was also done. EVALUATION: Baseline and intraoperative characteristics were similar in the two groups. There was no difference of anastomotic time between groups (p = 0.59). Graft flows were also similar (p = 0.55), with good diastolic pattern in both groups. Angiography demonstrated FitzGibbon A patency in all anastomoses of both groups at each evaluation period. Histopathologic examination showed nonspecific inflammatory changes in the device group. CONCLUSIONS: The safety and feasibility of this anastomotic device for distal coronary anastomosis were shown in the swine model.