Recent Advances in Multivessel Coronary Grafting Without Cardiopulmonary Bypass

(#1998-33589 ... May 20, 1998)

Antonio Maria Calafiore, MD, Gabriele Di Giammarco, MD, Giovanni Teodori, MD, Valerio Mazzei, MD, and Giuseppe Vitolla, MD

Department of Cardiac Surgery, "G.D'Annunzio" University, "San Camillo de' Lellis" Hospital, Chieti, Italy

ABSTRACT

Background: Coronary artery bypass grafting (CABG) without the heart lung machine has been possible for easily accessible targets such as the anterior descending or proximal right coronary. Until now technical difficulty in reaching lateral and inferior wall targets imposed significant barriers to multivessel off-pump grafting. To expand the potential for off-pump CABG the authors have devised new exposure and stabilization techniques suitable for all target vessels. In this report we relate our experience with these new techniques and demonstrate that multivessel coronary bypass can be safely performed without cardiopulmonary bypass (CPB).

Methods: From February 8, 1993 to December 16, 1997 a total of 280 patients underwent myocardial revascularization on the beating heart via median sternotomy. Until May 20, 1997 only patients with high preoperative risk factors for CPB were considered for this approach (Group A; N = 122). After this date any patients with favorable anatomy were included (Group B; N = 158) and were subsequently compared with patients operated on using CPB during the same time interval (Group C; N = 114). In Group B patients lateral and/or inferior wall targets were exposed by means of 4 cloth slings (2 through the transverse sinus and 2 behind the inferior vena cava) and by positioning the patients in Trendelenburg with rightward rotation of the table. Regional stabilization of the target artery was obtained with a commercial stabilizing foot plate.

Results: Thirty day hospital mortality was only 2 patients (1.6%) in Group A, 3 patients (1.9%) in Group B, and 3 patients (2.6%) in Group C (NS). Postoperative complications were low in both Group A and B. When Group B was compared with a similar cohort in whom CPB was used (Group C), there were statistically significant improvements in ICU and hospital stay demonstrated when CPB was not used (16.8±10.7 vs 26.3±38.6 hours respectively; p = 0.007, and 4.1±1.5 vs 5.5±2.4 days respectively, p<0.001). Angiographic followup was available for 78 patients in Groups A and B with a global patency rate (all grafts) of 98.6%, including a patency rate of 96.7% for 60 grafts to obtuse marginal branches of the circumflex).

Conclusions: Multivessel CABG without CPB is possible with results similar to those obtained with pump-oxygenator support using simple exposure and stabilization techniques.

AUTHOR/ARTICLE INFORMATION

Presented At: NewEra Cardiac Care, January 9-10, 1998, Rancho Mirage California, USA

Reprint requests to: Dr. Antonio Maria Calafiore, Department of Cardiac Surgery , "G.D'Annunzio" University, "San Camillo de' Lellis" Hospital, Via C. Forlanini 50, 66100 Chieti, Italy; Phone: 39 871 358653; Fax: 39 871 402239; Email: Calafiore@unich.it

Submitted on: December 17, 1997

Keywords: Beating heart, off-pump, coronary artery byass grafting (CABG), multivessel grafting.