Aiming towards complete myocardial revascularization without cardiopulmonary bypass: a systematic approach

Coronary artery bypass grafting (CABG) has become the surgical procedure of choice for symptomatic coronary artery disease. However, the use of traditional cardiopulmonary bypass (CPB) techniques represents an invasive therapeutic system with immediate and long-term complications. Off-pump myocardial revascularization has emerged as an attractive alternative that offers improvements in early outcomes and avoidance of the recognized adverse affects of CPB. A major criticism of this procedure has been a perceived inability to accomplish complete revascularization of the heart. In this report, we describe a surgical technique we have used in a series of patients that has allowed complete myocardial revascularization.

Combinations of intraoperative techniques were employed, including (1) right pleural-pericardial window, (2) deep pericardial sutures, (3) right heart displacement, (4) intermittent hypotensive anesthesia, (5) multimodality brain monitoring, and (6) coronary shunting. Following surgery, coronary artery grafts performed were statistically compared to each coronary artery's vascular territory to show that all territories were equally treatable with the combination of techniques.

There were 734 coronary artery grafts performed in 200 consecutive patients (mean of 3.7 grafts/patient), and 533 compromised vascular territories were revascularized (mean of 1.38 grafts for each diseased vessel). Eight patients had one-vessel disease, 51 had two-vessel disease and 141 had three-vessel disease. The left anterior descending coronary artery (LAD) was compromised in 192 patients, the circumflex in 171 and the right coronary artery in 170 patients. The overall 30-day estimated hospital mortality was 5.5%; the observed was 4.0% (8 of 200). Postoperative complications included pulmonary insufficiency in 6 patients (3.0%), reoperation for bleeding in 3 patients (1.5%), cerebrovascular accident in 3 patients (1.5%), renal dysfunction in 2 patients (1.0%), perioperative myocardial infarction in 8 patients (4.0%), cardiac arrest in 2 patients (1.0%), low cardiac output in 5 patients (2.5%), and deep sternal infection in 2 patients (1.0%).

Use of intermittent hypotensive anesthesia in conjunction with multimodality brain monitoring, right heart displacement, deep pericardial sutures, coronary shunting and epicardial compression stabilization facilitates complete revascularization of the myocardium.