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Conversion to cardiopulmonary bypass in off-pump coronary artery bypass grafting: its effect on outcome
P Soltoski1, T Salerno, L Levinsky
1The Center of Less Invasive Cardiac Surgery, Department of Cardiothoracic Surgery, CGF and The State University of New York at Buffalo, New York, USA.
Insights
Conversion to cardiopulmonary bypass (CPB) during off-pump coronary artery bypass grafting (CABG) using the less invasive surgical approach (LISA) was assessed. While conversion is generally well-tolerated, it is less so when graft malfunction occurs with hemodynamic instability.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Cardiac Surgery
Background:
- The less invasive surgical approach (LISA) offers complete myocardial revascularization without cardiopulmonary bypass (CPB).
- Previous studies demonstrated reduced mortality and complications with off-CPB coronary artery bypass grafting (CABG) using LISA.
Purpose of the Study:
- To assess the surgical outcomes of patients converted to CPB during myocardial revascularization using LISA.
- To evaluate the factors influencing conversion to CPB in off-CPB CABG procedures.
Main Methods:
- Retrospective analysis of 1210 isolated CABG patients from January to December 1997.
- Categorization of conversions into Class I (inability to complete revascularization), Class II (hemodynamic instability), and Class III (graft malfunction).
- Comparison of conversion rates between surgeons primarily using LISA and those selecting off-CPB cases.
Main Results:
- Of 378 off-CPB cases, 48 (12.7%) were converted to CPB.
- Conversion rates were reduced to 11% with the comprehensive LISA technique and modern technology.
- Four deaths occurred, all with perioperative infarctions requiring intra-aortic balloon pump (IABP).
- Conversion was well-tolerated unless due to graft malfunction combined with hemodynamic instability or collapse.
Conclusions:
- Conversion to CPB during off-CPB CABG is generally well-tolerated.
- The LISA technique, when combined with modern technology, can reduce conversion rates.
- Conversion for graft malfunction with hemodynamic instability poses the highest risk.
Abstract:
The surgical outcome of patients requiring conversion to cardiopulmonary bypass (CPB) during myocardial revascularization using the less invasive surgical approach (LISA) was assessed. The LISA was recently introduced as a technique for complete myocardial revascularization without CPB. It combines avoidance of CPB with the versatility of a median sternotomy for access to all coronary vessels. We have previously demonstrated reduced risk-adjusted mortality and complications in off-CPB coronary artery bypass grafting (CABG) using LISA compared to standard myocardial revascularization. From January to December 1997, 1210 patients underwent isolated CABG at our institution. Of these patients, 832 (63%) were scheduled as on-CPB cases and 378 (37%) as off-CPB. Of the off-CPB patients, 48 were converted to CPB. Team A surgeons used LISA as their primary strategy for CABG whereas team B surgeons used off-CPB CABG in selected patients. Conversions were divided in three classes: Class I patients were converted when the surgeon considered complete revascularization impossible off-CPB; Class II patients were converted due to hemodynamic instability during the procedure; and Class III patients were converted due to graft malfunction, determined by flow measurements or clinical evidence. There were four deaths. All had perioperative infarctions and required intra-aortic balloon pump (IABP). Conversion to CPB occurred in up to 25% of patients scheduled for off-CPB CABG. When off-CPB cases are done using the comprehensive LISA technique and modern technology, conversion rates may be reduced to 11%. Conversion is in general well tolerated except when it is instituted for graft malfunction combined with hemodynamic instability or collapse.