Anaortic techniques reduce neurological morbidity after off-pump coronary artery bypass surgery

Stroke remains one of the most devastating complications of cardiac surgery. Advocates of off-pump coronary revascularisation (OPCAB) maintain that post-operative neurologic morbidity is reduced by avoiding aortic cannulation and cross-clamping, and by eliminating the systemic effects of cardiopulmonary bypass. We sought to determine whether completing off-pump coronary surgery without any aortic manipulation ("anaortic" technique) afforded any additional neurological protection, as compared to off-pump grafting in which the aorta was utilised for graft inflow.

A comprehensive review of prospectively collected data was undertaken of all patients undergoing OPCAB in our institution between January 2002 and December 2006. Cases requiring intra-operative conversion to cardiopulmonary bypass were excluded from further analysis. Patients having OPCAB surgery with aortic manipulation were compared to those having OPCAB surgery without aortic manipulation. Multiple logistic regression was used to identify possible predictors of post-operative neurologic morbidity, with particular focus on the role of aortic manipulation.

During the period of review, 1758 patients underwent OPCAB, of which 1201 (68.3%) were completed without aortic manipulation, constituting the "anaortic" cohort. This group was compared with the remaining 557 patients, which included fashioning at least one aorto-conduit anastomosis, utilising either a side-biting aortic clamp or a no-clamp proximal anastomotic device. The two groups of patients were well-matched with respect to risk factors for adverse neurologic outcomes. Nine patients sustained focal neurological deficits (transient or permanent) in the peri-operative period, constituting a stroke rate of 0.51% for the entire series. The incidence of peri-operative neurological deficit in the anaortic group was 0.25% compared with 1.1% in the aortic manipulation group (odds ratio (OR) 0.23, 95% confidence interval (CI) 0.06-0.92, p=0.037). Advanced age was also associated with peri-operative neurological injury (OR 1.1, 95% CI 1.01-1.20, p=0.017).

Off-pump coronary artery surgery is associated with a low incidence of peri-operative stroke. Completing the surgical procedure without manipulating the ascending aorta in any way ("anaortic" technique) offers additional neurological protection and should be the goal in all suitable off-pump coronary cases.