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Initial experience with beating heart surgery: comparison with fast-track methods
R A Ott1, D E Gutfinger, R Steedman
1Department of Surgery, Anaheim Memorial Medical Center, California, USA.
Insights
Conventional cardiopulmonary bypass (CPB) in coronary artery bypass grafting (CABG) offers extensive revascularization. Off-pump techniques suit specific patient groups, but minimizing CPB exposure is key to reducing risk.
Area of Science:
- Cardiac Surgery
- Cardiovascular Surgery
- Minimally Invasive Cardiac Surgery
Background:
- Cardiopulmonary bypass (CPB) in coronary artery bypass grafting (CABG) is associated with increased postoperative complications in high-risk individuals.
- Exploring alternative surgical strategies to mitigate risks associated with CPB is crucial for improving patient outcomes.
Purpose of the Study:
- To retrospectively compare outcomes of conventional CABG with a fast-track recovery method against off-pump beating heart surgery techniques.
- To evaluate the efficacy of minimally invasive direct coronary artery bypass (MIDCAB) and off-pump multivessel bypass in different patient cohorts.
Main Methods:
- Retrospective review of 158 consecutive CABG patients.
- Group A: Conventional CABG with CPB and fast-track recovery (n=104).
- Group B: Minimally invasive direct coronary artery bypass (MIDCAB) off-pump (n=29).
- Group C: Off-pump multivessel CABG with median sternotomy (n=25).
Main Results:
- Fast-track CPB group (A) showed minimal complications and rapid recovery with extensive revascularization.
- Off-pump multivessel group (C) had higher comorbidity, fewer grafts, but similar recovery to Group A.
- MIDCAB group (B) had no apparent recovery advantage despite being younger and elective.
- Overall mortality was 1.8%; conversion rates for off-pump to CPB were 10.3% (B) and 16% (C).
- Postoperative hospital stay: Group A (4.8 days), Group B (3.9 days), Group C (5.2 days).
Conclusions:
- Reducing CPB exposure, not necessarily eliminating it, is key to minimizing operative risk.
- Off-pump multivessel bypass is suitable for high-risk patients needing ≤3 grafts; MIDCAB for single-vessel bypass unsuitable for percutaneous intervention.
- Patients requiring >3 grafts benefit most from conventional CABG with CPB.
Abstract:
Cardiopulmonary bypass (CPB) in coronary artery bypass grafting (CABG) may increase postoperative complications in high-risk patients. The goal of this study is to retrospectively review a series of consecutive patients undergoing conventional CABG using a fast-track recovery method and to compare this series with the initial series of patients undergoing beating heart surgery using either the single-vessel minimally invasive approach or the off-pump multivessel bypass technique with a median sternotomy. One hundred fifty-eight consecutive patients underwent CABG. One hundred four patients underwent conventional CABG using CPB with a short-pump fast-track recovery method (Group A). Twenty-nine patients underwent a single-vessel bypass via a left anterior thoracotomy off pump [Group B, minimally invasive direct coronary artery bypass (MIDCAB)]. Twenty-five patients underwent multivessel CABG with a median sternotomy off pump (Group C). Short-pump fast-track (Group A) patients exhibited minimal complications and expedient recovery and received extensive revascularization. Off-pump multivessel patients (Group C) received fewer bypass grafts, had more preoperative comorbidity, and recovered as quickly as lower-risk fast-track short-pump patients (Group A). Single-vessel off-pump patients (Group B, MIDCAB) were younger elective patients and demonstrated no recovery advantage. The overall mortality was 1.8 per cent. The conversion rates from beating heart surgery to CPB for groups B and C were 10.3 and 16 per cent, respectively. The postoperative hospital length of stay for groups A, B, and C were 4.8+/-2.4, 3.9+/-1.8, and 5.2+/-2.3 days, respectively. Eliminating CPB is not as important as reducing exposure for minimizing operative risk. Beating heart surgery is an adjunct to conventional CABG with CPB. The off-pump multivessel bypass technique is best suited for high-risk patients requiring three grafts or fewer, whereas MIDCAB is best suited for single-vessel bypass that cannot be managed using interventional percutaneous techniques; however, the recovery advantage with MIDCAB is not apparent. Patients requiring more than three bypass grafts should undergo conventional CABG with CPB.