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Off-pump redo coronary artery bypass grafting: technical aspects and early results
F Alamanni1, G Pompilio, G Polvani
1Department of Cardiovascular Surgery, University of Milan, Italy.
Insights
Off-pump redo coronary artery bypass grafting (CABG) is a safe and effective alternative to on-pump procedures. This technique allows for complete revascularization with a low incidence of perioperative complications.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery
- Minimally Invasive Cardiac Surgery
Background:
- Redo coronary artery bypass grafting (CABG) is a high-risk procedure with increased perioperative complications.
- Off-pump techniques theoretically reduce surgical trauma and improve early outcomes.
Purpose of the Study:
- To evaluate the safety and efficacy of off-pump redo CABG.
- To assess the feasibility of complete revascularization using off-pump techniques in redo CABG.
Main Methods:
- A retrospective analysis of 123 redo CABG procedures performed between January 1995 and May 2001.
- 53 (44%) of these procedures were performed off-pump, with a significant increase in their utilization in the later period (90% in 2000-2001).
- Advanced surgical techniques including deep traction stitches, wall stabilizers, coronary intraluminal shunts, and trans-esophageal echocardiographic monitoring were employed.
Main Results:
- No in-hospital deaths were recorded.
- Low incidence of perioperative myocardial infarction (1.9%) and stroke (1.9%).
- 9 atrial fibrillations (17%) and 13 (24.5%) patients required blood transfusion; no re-explorations for bleeding were necessary. Mean postoperative stay was 7.5 days.
Conclusions:
- Off-pump redo CABG is a safe and effective alternative to on-pump procedures.
- Off-pump technique is now the preferred method for redo CABG in this institution.
- Complete revascularization is achievable with a low complication rate.
Background:
Redo coronary artery bypass grafting (CABG) represents an high-risk surgical procedure, because of an increased incidence of perioperative death, myocardial infarction and stroke. Theoretically, the avoidance of cardiopulmonary bypass may reduce surgical traumatism and ameliorate early results.
Materials And Methods:
From January 1995 to May 2001, we performed 123 redo CABGs, of which 53 (44%) off-pump. Off-pump procedure represented respectively 90% of redo CABG in the period 2000-2001 versus 30% in the 1995-1999 period. The mean age was 66.4 years, males were 39 (73%). The mean 2D-echo ejection fraction was 56% and in 9 cases (17%) was less than 40%. Three operations (5.6%) were performed on an urgent base. The access was median sternotomy in all cases. The mean number of grafts per patient was 1.9 (1.7 in the period 1995-99 vs. 2.3 in the period 2000-01, p=0.01). In 20 cases (38%) we grafted the circumflex artery branches (19% in the period 1995-99 vs. 55.5% in the period 2000-01, p=0.015). Improvements in surgical techniques were achieved over time. The current operative strategy includes the use of deep traction stitches in the posterior pericardium and wall stabilizers to expose target vessels, coronary intraluminal shunts during construction of the anastomoses and continuous trans-esophageal echocardiographic monitoring. Urgent conversion to on-pump procedure was not required in any case.
Results:
We recorded no in-hospital death, one perioperative myocardial infarction (1.9%), one fifth postoperative day-stroke (1.9%) and 9 atrial fibrillations (17%). Mediastinal re-exploration for bleeding was performed in no one patient; 13 patients (24.5%) required postoperative blood transfusion. The mean length of postoperative stay was 7.5 days, ranging from 6 to 18 days.
Conclusions:
In our experience off-pump redo CABG is a safe and effective alternative to on-pump procedure and now off-pump is our first choice-technique in redo CABG. A complete revascularization is technically feasible with a low incidence of perioperative complications.