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Myocardial revascularization using the "no-touch" technique, with mild systemic hypothermia, in patients with a
C A Dietl1, N P Madigan, C A Laubach
1Department of Cardiology, Geisinger Medical Center, Danville PA 17822-1343, USA.
Insights
The "no-touch" technique for coronary artery bypass grafting is safe for patients with calcified aortas, avoiding clamp injury and atheroembolism. This method uses pedicled arterial grafts effectively for myocardial revascularization.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
Background:
- Standard coronary artery bypass grafting (CABG) requires aortic manipulation, posing risks like clamp injury or atheroembolism in patients with calcified aortas.
- A calcified ascending aorta presents unique challenges during CABG, necessitating modified surgical approaches.
Purpose of the Study:
- To evaluate the safety and efficacy of the "no-touch" technique for myocardial revascularization in patients with heavily calcified ascending aortas.
- To assess the feasibility of avoiding aortic clamping and cardioplegia in this high-risk patient group.
Main Methods:
- The "no-touch" technique was employed in 18 patients with calcified aortas undergoing myocardial revascularization.
- This technique avoids aortic clamping and cardioplegia, utilizing pedicled arterial grafts for distal anastomoses.
- Cardiopulmonary bypass with mild hypothermia was used in most patients; two underwent off-pump procedures.
Main Results:
- No postoperative cerebrovascular accidents occurred in the study cohort.
- Overall mortality was 16.7% (3 deaths) due to causes including pneumonia, congestive heart failure, and low cardiac output.
- Fifty-two distal anastomoses were performed using 37 pedicled and 15 free arterial grafts.
Conclusions:
- The "no-touch" technique is a safe and effective alternative for myocardial revascularization in patients with calcified aortas, mitigating risks of clamp injury and atheroembolism.
- The use of pedicled arterial grafts is well-tolerated and successful in this patient population.
- Deep hypothermia is not essential when employing the "no-touch" technique.
Abstract:
Modifications in the standard technique for coronary artery bypass grafting are recommended in presence of a calcified ascending aorta, to avoid clamp injury or atheroembolism. Between January 1991 and August 1994, we used a "no-touch" technique in 18 patients undergoing myocardial revascularization, who had a heavily calcified and atherosclerotic ascending aorta. Their mean age was 76.1 years (range 63 to 82 years). Cardiopulmonary bypass with mild systemic hypothermia (32 degrees C) was employed in 16 patients; 2 other patients were operated upon without cardiopulmonary bypass. The "no-touch" technique avoids all types of clamps in the aorta. No cardioplegia was given, and no grafts were anastomosed to the aorta. Fifty-two distal anastomoses (mean: 2.9 per patient) were performed, using 37 pedicled arterial grafts (22 internal mammary and 15 gastroepiploic arteries), and 15 free grafts, which were anastomosed proximally to the internal mammary artery. There were no postoperative cerebrovascular accidents. Three patients died (16.7% overall mortality): 1 died of pneumonia, one patient with a large left ventricular aneurysm died in congestive heart failure, and one patient with associated aortic insufficiency died in low cardiac output. Our experience suggests that using pedicled arterial grafts for myocardial revascularization is safe and effective to avoid clamp injury or atheroembolism in patients with a calcified aorta. Deep hypothermia is not necessary when using the "no-touch" technique.