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Off-pump revascularization of the circumflex artery: technical aspect and short-term results
1Department of Surgery, Montreal Heart Institute, Quebec, Canada. cartierr@icm.umontreal.ca
Insights
Beating heart surgery successfully revascularized over 90% of patients with multivessel disease, including complex circumflex artery cases, achieving complete revascularization with low morbidity and mortality.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Cardiac Surgery
- Interventional Cardiology
Background:
- Beating heart surgery is established for anterior and inferior territory revascularization.
- Circumflex artery revascularization presents unique surgical challenges.
- A novel apparatus and technique expanded beating heart surgery applicability.
Purpose of the Study:
- To evaluate the feasibility and outcomes of beating heart surgery for multivessel coronary artery disease.
- To assess the efficacy of a specific technique for circumflex artery revascularization.
- To determine the safety and early results of this extended application of off-pump surgery.
Main Methods:
- Prospective study of 140 patients undergoing beating heart surgery (Oct 1996-Nov 1997).
- Focus on 111 patients requiring circumflex artery territory revascularization.
- Detailed analysis of surgical technique, patient demographics, and perioperative data.
Main Results:
- Complete revascularization achieved in 95% of patients.
- Average of 3.1 grafts per patient performed.
- Low rates of perioperative complications: 0.7% operative mortality, 2.7% myocardial infarction, and 1 conversion to cardiopulmonary bypass.
- Excellent early angiographic results: 100% graft patency and 95% freedom from significant stenosis.
Conclusions:
- Complete coronary artery revascularization is feasible on the beating heart without cardiopulmonary bypass.
- The technique offers low morbidity and mortality with excellent early angiographic outcomes.
- Further long-term follow-up is necessary to confirm sustained benefits.
Background:
Beating heart surgery is a technique currently used for revascularization of the anterior and inferior territory. However, revascularization of the circumflex artery is more problematic. With a specific apparatus and surgical technique, we have extended the use of beating heart surgery to more than 90% of patients with multivessel disease, including those necessitating circumflex artery revascularization.
Methods:
Between October 1996 and November 1997, 140 patients underwent beating heart surgery by the same surgeon (R.C.). Among these patients, 111 required reconstruction of the circumflex artery territory and were followed up prospectively. They represent the cohort of patients presented in this study. There were 90 men and 21 women averaging 64+/-9.9 years of age. Mean left ventricular ejection fraction was 55%+/-13.7%, and a significant left main coronary artery disease was present in 27% of the patients. Five patients had prior coronary revascularization.
Results:
An average of 3.1+/-0.1 grafts/patient were performed. Complete revascularization was achieved in 95%. Only 1 patient needed conversion to cardiopulmonary bypass because of spontaneous ascending aortic dissection. Perioperative and postoperative bleeding were 446+/-245 mL and 644+/-442 mL, respectively. Homologous transfusions were required in 40% of the patients. Myocardial infarction occurred in 2.7% and operative mortality in 0.7% (1 patient). Average hospital stay was 6.6+/-3.1 days, and no patient exhibited early recurrence of angina. Early coronary angiograms (first 8 patients) demonstrated a 100% patency with 95% freedom from significant stenosis.
Conclusions:
Complete coronary artery revascularization is feasible on the beating heart without the assistance of cardiopulmonary bypass with a low morbidity and mortality and excellent early angiographic results. Long-term follow-ups are needed to substantiate the potential long-term benefits of this technique.