Off-pump coronary artery grafting in patients necessitating multiple distal anastomoses

Off-pump surgery has become a valuable alternative if a small number of distal anastomoses is required. The aim of the present study was to test the hypothesis that outcome is not altered in multiple distal anastomoses.

During a 4 year period, 350 patients were operated off-pump. 187 patients received one or two distal anastomoses (group A), and 163 patients received more than two distal anastomoses (group B). Pre-operative characteristics, intra-operative details and postoperative outcome were reviewed.

In group A, 1.8 +/- 0.4 distal anastomoses were performed, versus 3.2 +/- 0.5 in group B (P < 0.001). There were more sequential distal anastomoses in group B (1.09 in group A versus 1.38 in group B) with a wider use of right internal thoracic and radial arteries. There were more anastomoses performed on the lateral (89% vs. 45%) and on the inferior wall (65% vs. 16%) in group B, compared with group A. The operation time was significantly longer (206 +/- 75 minutes versus 158 +/- 33 minutes) and the operative blood loss significantly higher (748 +/- 516 ml versus 509 +/- 361 ml) in group B. Total blood loss, transfusion requirements, neurological disfunction, hospital stay, troponine I level, postoperative infarction and 30 days mortality did not differ significantly between groups. There were 11 conversions (3.1%), 3 patients in group A and 8 patients in group B (NS). Most conversion occurred imperative while performing an anastomosis on the anterior wall.

Beating heart surgery with multiple distal anastomoses, can be performed without increased myocardial damage, postoperative morbidity or hospital mortality. Lateral wall grafting could not be identified as a trigger for conversion.