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Awake coronary artery bypass grafting: utopia or reality?
Tayfun Aybek, MD, Paul Kessler, MD, PhD, Selami Dogan, MD, Gerd Neidhart, MD, Mohammad Fawad Khan, MD, Gerhard Wimmer-Greinecker, MD, PhD, and Anton Moritz, MD, PhD Departments of Thoracic and Cardiovascular Surgery, and Anesthesiology, Intensive Care, and Pain Therapy, Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
Background. Off-pump coronary artery bypass grafting (OPCAB) was implemented to reduce trauma during surgical coronary revascularization. High thoracic epidural anesthesia further reduced intraoperative stress and postoperative pain. This technique also supports awake coronary artery bypass (ACAB), completely avoiding the drawbacks of mechanical ventilation and general anesthesia in high-risk patients. We compared our first results of the ACAB procedure with the conventional OPCAB operation. Methods. Thirty-five patients underwent ACAB (group A) with left internal mammary artery to left anterior descending coronary artery grafting using a partial lower ministernotomy (n ⴝ 25) or double bypass grafting (n ⴝ 9) and even triple vessel coronary artery revascularization (n ⴝ 1) through complete median sternotomy. Thirty-four patients (group B), matched for age, sex, and comorbidity with group A, underwent either partial lower ministernotomy (n ⴝ 24) or OPCAB by complete sternotomy (n ⴝ 10). We recorded clinical outcomes and postoperative visual analog scale pain scores.
Results. In group A, 32 patients remained awake throughout the entire procedure. Three patients required secondary intubation because of incomplete analgesia (n ⴝ 1) or pneumothorax (n ⴝ 2). Patients in group A had a recovery room stay of 6.0 ⴞ 3.2 hours. In group B, mechanical ventilation was implemented for 4.8 ⴞ 3.1 hours and intensive care unit stay lasted 12 ⴞ 6.8 hours. Group A had no in-hospital deaths, compared with 1 death in the conventional OPCAB group. Each group had 1 patient with graft stenosis detected on the predischarge angiogram. Early postoperative pain was significantly less in group A than in group B (visual analog scale of 32 ⴞ 8 compared with 58 ⴞ 11, p < 0.0001). Conclusions. The present data demonstrate the feasibility and safety of surgical coronary revascularization without general anesthesia. Continuation of thoracic epidural analgesia provides better pain control and faster mobilization after such procedures. Surprisingly, the ACAB procedure was well accepted by the patients. (Ann Thorac Surg 2003;75:1165–70) © 2003 by The Society of Thoracic Surgeons
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geons to carry out coronary artery bypass surgery in the awake patient. Awake coronary artery bypass (ACAB) through a left anterior small thoracotomy was first reported by Karagoz and colleagues [16]. To evaluate clinical outcome of the new technique, we compared standard OPCAB and minimally invasive direct coronary artery bypass grafting (MIDCABG) procedures with ACAB.
inimally invasive cardiac surgery has several advantages: First, operations without cardiopulmonary bypass reduce inflammatory whole body response and potential emboli generation [1]. Second, such procedures minimize incisions and surgical trauma [2–7]. Minimally invasive surgery may obviate the need for general anesthesia and its potential disadvantages [8 –10]. Thoracic epidural anesthesia (TEA) provides excellent perioperative pain management and favorable conditions for off-pump coronary artery bypass surgery by dilating the coronary arteries and the internal thoracic artery (ITA) and by reducing heart rate and arrhythmias during manipulation of the heart [11, 12]. Thoracic epidural anesthesia improves postoperative outcome and accelerates recovery [13–15]. Combining off-pump coronary artery bypass grafting (OPCAB) with TEA seems advantageous, as the combination would enable sur-
Accepted for publication Oct 24, 2002. Address reprint requests to Dr Aybek, Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University Frankfurt, Theodor Stern Kai 7, 60590 Frankfurt, Germany; e-mail: [email protected].
© 2003 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Patients and Methods Between March 2001 and August 2002, 35 CABG procedures were performed in conscious patients using TEA in our department (group A). Twenty-five patients underwent MIDCABG through a partial lower ministernotomy. Off-pump coronary artery bypass grafting was performed in 10 patients of group A. Patient selection criteria included restriction to significant (⬎ 70%) stenoses of the left anterior descending coronary artery (LAD), This article has been selected for the open discussion forum on the CTSNet Web site: http://www.ctsnet.org/discuss 0003-4975/03/$30.00 PII S0003-4975(02)04710-0
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Table 1. Patient Demographics and Preoperative Data Group A
Group B
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Patient Demographics
MIDCABG (n ⫽ 25)
OPCAB (n ⫽ 10)
MIDCABG (n ⫽ 24)
OPCAB (n ⫽ 10)
Age, y Sex ratio, F:M BSA, m2 CCS preoperative, score Left ventricle ejection fraction Previous myocardial infarction, n Emergency cases, n Chronic obstructive lung disease, n Renal disease, n Dialysis, n Peripheral vascular disease, n Diabetes mellitus, n Risk score, Euro High-risk patients, n
66 ⫾ 8 6:19 1.88 ⫾ 0.1 2.8 ⫾ 0.6 0.61 ⫾ 0.11 6 ... 6 4 1 5 4 3.5 ⫾ 1.7 6
65 ⫾ 12 2:8 1.84 ⫾ 0.1 3.1 ⫾ 0.8 0.63 ⫾ 0.13 2 ... 2 3 1 3 3 2.6 ⫾ 2.3 3
63 ⫾ 11 7:17 1.86 ⫾ 0.1 3.0 ⫾ 0.7 0.63 ⫾ 0.6 6 4 5 3 ... 2 2 2.9 ⫾ 1.8 5
69 ⫾ 9 2:8 1.89 ⫾ 0.1 3.2 ⫾ 0.7 0.58 ⫾ 0.11 2 1 5 5 2 4 3 3.4 ⫾ 1.7 5
a
Group A versus group B for MIDCAB.
b
pa
pb
NS NS NS NS NS
NS NS NS NS NS
NS NS
NS NS
Group A versus group B for OPCAB.
Values are mean ⫾ SD unless otherwise indicated. Patients with Euro scores 0 to 2 are considered to be low risk, scores 3 to 5 medium risk, and scores ⬎ 5 high risk. BSA ⫽ body surface area; CCS ⫽ Canadian Cardiovascular Society; OPCAB ⫽ off-pump coronary artery bypass grafting.
MIDCABG ⫽ minimally invasive direct coronary artery bypass grafting;
diagonal branches, or the right coronary artery, as well as a cooperative patient. Presence of comorbidity did not affect patient selection, with the exception of impaired lung function (forced expiratory volume in 1 second ⬍ 50%). In group B (n ⫽ 34) MIDCABG was performed in 24 patients through partial lower sternotomy and 10 patients had various OPCAB procedures through complete median sternotomy. All patients in group B had conventional general anesthesia and early extubation after the operation. Demographic data and preoperative status of all patients are provided in Table 1. Eighteen patients in group A had significant comorbidity such as obstructive lung disease, peripheral vascular disease, renal failure, or diabetes. To assess preoperative risk for death, Euro scoring [17] was calculated for all patients. Euro scores of 0 to 2 were considered to indicate low risk, scores of 3 to 5 were considered to indicate medium risk, and scores of more than 5 were considered to indicate high risk (Table 1). To ensure equivalency between both groups, patients had to be appropriate candidates for either procedure to be included in this prospective study. Individuals were selected for each group by the surgeon, in consultation with the patient. Written informed consent was obtained from all patients. The study was approved by the local ethics committee. Activities of daily living were assessed to evaluate the patients’ grade of mobilization on the day of surgery [18]. Postoperative pain perception was assessed by the patients themselves using visual analog scale (VAS) on the second and third day after the operation [19]. All data were reviewed prospectively. Data are ex-
pressed as mean ⫾ standard deviation. Continuous clinical data were compared by t test and categorical variables were compared using the Mann-Whitney U test. The tests were carried out using the Stat View statistical software package 5.0.1 (Abacus Concepts, Inc, Cary, NC).
Anesthesia for Awake Coronary Artery Bypass High TEA was used in group A only. The objective of this approach was to achieve somatosensory and motor block at the T1 to T8 level. The maximum permissible block level was C6, which was monitored by the development of Horner’s syndrome. One of the major objectives was to achieve motor block of the intercostal muscles while preserving diaphragmatic respiration. Antiplatelet therapy was stopped 5 days before surgery in all cases. One day before elective surgery a thoracic epidural catheter (20 G; B. Braun Melsungen AG, Melsungen, Germany) was inserted at the T2-T3 level. On the day of surgery patients were premedicated orally with 7.5 mg midazolam (Hoffmann-LA Roche AG, GrenzachWyhlen, Germany). In the operating room patients received an infusion of ropivacaine 0.5% (Astra Zeneca, Wedel, Germany) with sufentanil 1.66 g/mL (Janssen Cilag, Neuss, Germany) into the epidural space. Sensory level was tested every 5 minutes. Thus sensory block was achieved between the neck and the abdomen, including both arms. Patients breathed O2 at 5 L/min through a facemask. Monitoring included arterial and central venous blood pressure, electrocardiogram (ECG) (II, aVF, V5), pulse oximetry, and end-tidal CO2 (Hellige Marquette Solar 8000 Patient Monitor, Marquette Medical Systems, Milwaukee, WI). Patients received no sedative medication or intravenous analgesic agents during the
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Table 2. Perioperative Data
Operative Data Procedure time, min Number of anastomosis, n Conversion to intubation, n Extubation in operating room, n Ventilation time, min Chest tube drainage, mL Recovery room stay, hours ICU stay, hours Hospital stay, days Pain VAS score, 0 –100 Need for analgesia within 3 days Dipidolor (mg) Diclofenac (mg) ADL (day of surgery) a
Group A versus group B for MIDCAB.
b
Group B OPCAB (n ⫽ 10)
MIDCABG (n ⫽ 24)
OPCABG (n ⫽ 10)
78 ⫾ 16 1 3 3 ... 150 ⫾ 79 4.1 ⫾ 3 ... 6.6 ⫾ 1.3 30 ⫾ 7
117 ⫾ 34 2.8 ⫾ 0.6 ... ... ... 287 ⫾ 99 7.6 ⫾ 3.2 ... 8.4 ⫾ 1.9 34 ⫾ 8
88 ⫾ 26 1 ... 6 4.3 ⫾ 2.5 212 ⫾ 171 ... 8.3 ⫾ 5.2 7.1 ⫾ 1.0 56 ⫾ 7
123 ⫾ 23 2.7 ⫾ 1.4 ... 2 5.8 ⫾ 4.1 368 ⫾ 87 ... 19.4 ⫾ 2.4 9.5 ⫾ 4.5 65 ⫾ 6
1.1 ⫾ 2.7 44 ⫾ 40 17/(25)
1.7 ⫾ 3.3 59 ⫾ 54 6/(10)
7.9 ⫾ 4.3 140 ⫾ 42 3/(24)
8.8 ⫾ 3.1 180 ⫾ 48 1/(10)
pa
pb
NS NS
NS NS
NS
NS
NS ⬍ 0.0001
NS ⬍ 0.0001
⬍ 0.0001 ⬍ 0.0001 ⬍ 0.0001
⬍ 0.0001 ⬍ 0.0001 ⬍ 0.0001
Group A versus group B for OPCAB.
Values are mean ⫾ SD unless otherwise indicated. ADL ⫽ activities of daily living; ICU ⫽ intensive care unit; MIDCAB ⫽ minimally invasive direct coronary artery bypass grafting; off-pump coronary artery bypass grafting; VAS ⫽ visual analog scale.
procedure. After wound closure, the anesthetic regimen was changed to ropivacaine 0.16% and sufentanil 1 g/mL at 2 to 5 mL/h to provide postoperative analgesia. The thoracic epidural catheter was used for postoperative pain management for as long as 3 days. Group B received general anesthesia with intravenous propofol (Astra Zeneca, Wedel, Germany), sufentanil (Janssen Cilag), and cisatracurium (GlaxoSmithKline, Munich, Germany). Patients underwent standard monitoring perioperatively and were extubated in the early postoperative period. Criteria for extubation were a normothermic patient, stable hemodynamic and respiratory conditions, and an unremarkable neurologic examination. Pain relief was provided with intravenous Dipidolor (Janssen Cilag) or diclofenac suppositories (Novartis Pharma, Nu¨ rnberg, Germany). The amount of analgesic medication in both groups is listed in Table 2.
OPCAB ⫽
Operative Technique for Group B Group B patients were anesthetized using standard narcotic medications (see above) and were intubated conventionally. The chest was opened by either complete sternotomy for double or triple CABG or partial lower ministernotomy for single CABG. Internal thoracic artery takedown was then conducted under direct vision. The same surgical techniques were used for the anastomoses as in group A.
Operative Technique for Awake Coronary Artery Bypass The patients were conscious and fully alert throughout the procedure (Fig 1). The chest was opened either by complete sternotomy for double or triple CABG and by partial lower ministernotomy for single CABG. Careful dissection of the ITA was necessary to avoid pneumothorax in the spontaneously breathing patient. For multivessel CABG an additional radial artery graft was dissected after application of local anesthesia. After creating a pericardial cradle, the surgeon exposed the target vessels and used traction sutures for mechanical stabilization of the target vessels. Anastomoses were performed in standard beating-heart bypass technique using proximal control of the target vessel and a blower mister to clear the anastomotic site.
Fig 1. Coronary artery bypass grafting through a lower ministernotomy while the patient is awake.
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Group A MIDCABG (n ⫽ 25)
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group B). (The normal level for serum creatinine is ⬍ 1.0 mg/dL.)
Clinical Outcome Variables CARDIOVASCULAR Fig 2. Intraoperative hemodynamics in group A. ⴛ, SAP ⫽ systolic arterial pressure (mm Hg); E, Sao2 ⫽ oxygen saturation (%); , HR ⫽ heart rate (beats per minute); ●, CVP ⫽ central venous pressure (mm Hg). Time points: 1 ⫽ induction of epidural anesthesia; 2 ⫽ sternotomy; 3 ⫽ anastomosis; 4 ⫽ sternal closure; 5 ⫽ 1 hour after the operation. (Mean value ⫾ standard deviations.)
Results Perioperative Data In group A, 25 patients underwent single-vessel CABG, 9 patients had double-vessel CABG, and 1 patient had triple-vessel CABG. Three patients in this series required secondary intubation after completion of ITA harvesting because of incomplete analgesia of the upper chest (n ⫽ 1) or pneumothorax (n ⫽ 2) with consecutive coughing and chest discomfort. These patients underwent postoperative extubation in the operating room. Mean length of skin incision was 7.4 ⫾ 0.8 cm in group A (MIDCABG subgroup, n ⫽ 25) versus 7.5 ⫾ 0.6 cm in group B (MIDCABG subgroup, n ⫽ 24). Operative time in group A for MIDCABG procedures was 78 ⫾ 16 minutes, and for OPCAB procedures was 117 ⫾ 34 minutes, whereas in group B operative time was 88 ⫾ 26 minutes for MIDCABG and 123 ⫾ 23 minutes for OPCAB (p ⫽ NS). The number of anastomoses performed per patient was 1.64 ⫾ 0.9 in group A compared with 1.51 ⫾ 0.9 in group B (Table 2). Intraoperative hemodynamic data from group A are shown in Figure 2.
Biochemical Markers No significant increase was noted in cardiac enzymes 6 hours after surgery for both groups (creatine kinase [CK] ⫽ 74 ⫾ 14 IU/L and creatine kinase MB fraction [CK-MB] ⫽ 5.7 ⫾ 2.4 IU/L in group A versus CK ⫽ 82 ⫾ 18 IU/L and CK-MB 7.4 ⫾ 3.2 IU/L in group B). Mean troponin T level was 0.09 ⫾ 0.02 ng/mL in group A and 0.12 ⫾ 0.03 ng/mL in group B. Five emergency cases with unstable angina in group B were excluded from these calculations. (Normal levels are CK ⬍ 80 IU/L, CK-MB ⬍ 9 IU/L, cardiac troponin-T ⬍ 0.10 ng/mL.) Preoperative renal function did not change (mean creatinine level was 1.6 ⫾ 0.5 mg/dL in group A compared with 1.5 ⫾ 0.5 mg/dL in
Perioperative ECG monitoring with automatic STsegment analysis displayed no signs of myocardial ischemia within the first 6 and 24 hours in group A. Four of 5 patients in group B with unstable angina showed slightly anterior ischemia signs during the surgical procedure; after emergency revascularization within the first 6 hours postoperatively, no further ECG changes were detectable in these patients. In group B the duration of mechanical ventilation was 4.8 ⫾ 3.1 hours. The duration of postoperative monitoring phase in the recovery room was 6.0 ⫾ 3.2 hours (group A). In group B intensive care unit stay was 12 ⫾ 6.8 hours. Patients remained hospitalized for 7.4 ⫾ 2.1 days in group A compared with 8.3 ⫾ 1.3 days in group B (Table 2).
Mortality and Morbidity There was one early death in group B. This patient died from severe respiratory failure and sepsis following longterm ventilation. No patient suffered spinal complications caused by placement of the epidural catheter. Transient Horner’s syndrome was observed in 2 group A patients.
Need for Analgesia and Visual Analog Scale Pain Scoring Because of continuous analgesic drug application through the epidural catheter for 3 postoperative days, pain perception was significantly lower in group A (VAS ⫽ 32 ⫾ 8 in group A compared with 58 ⫾ 11 in group B, p ⬍ 0.0001). Effective pain management resulted in faster postoperative mobilization in group A (see Table 2).
Coronary Angiography Quality of anastomoses were examined in all patients. Twenty-eight patients in group A underwent coronary angiography before discharge. In 7 patients multidetector computer tomography (MDCT) was performed to check graft patency. All grafts showed good function except for one proximal ITA occlusion in group A. Twenty-eight patients in group B had control angiography and 6 patients underwent MDCT to verify graft patency. In group B 1 patient had an ITA stenosis at the anastomotic site.
Comment Thoracic epidural anesthesia provides excellent conditions for OPCAB surgery by dilating the coronary arteries [20, 21] and the ITA, and by reducing heart rate and arrhythmias during manipulation of the heart [22, 23]. Somatosensory block of the thoracic segments enables even sternotomy and CABG in the awake patient. Besides these intraoperative advantages, postoperative pain management is facilitated by continuous epidural application of analgesic agents. Such effective pain management improves postoperative mobilization and recovery.
The risks of TEA are infection and hematoma in rare cases. Reports state a risk of peridural hematoma or infection of 1 in 50,000 to 1 in 100,000 [5, 6, 20, 21]. Therefore we weaned patients in group A from antiplatelet-inhibiting drugs 6 days before surgery and stopped intravenous heparin application 6 hours before TEA catheter placement. Patients underwent routine heparinization with 10,000 IU during surgery without a target activated clotting time and protamine chloride is given after anastomosis. We used partial lower ministernotomy to access the ITA and the heart. This surgical approach provides extrapleural access to the target structures, to avoid impairment of spontaneous respiration during surgery. Furthermore, a conversion to full sternotomy, which was not required in this study, is much easier than in a left anterior small thoracotomy (LAST) approach. The entry into the chest cavity by the LAST approach constitutes a compromise between ITA dissection and access to the LAD. The technique usually exposes only a few segments of the LAD, whereas in the partial lower ministernotomy technique the whole length of the vessel is exposed. Moreover, LAST inevitably causes pneumothorax, which impairs spontaneous breathing. Complete median sternotomy with the avoidance of general anesthesia and positive pressure ventilation for CABG has not been described yet in literature. This standard approach in heart surgery allows ideal access to all regions of the heart and multi-vessel revascularization. In these patients double or triple bypass grafting was performed using arterial grafts while the patients were conscious, whereas in this initial series only the anterior wall of the heart was revascularized. The awake status of the patient provides an important advantage in beating heart procedures. During stabilization, the systemic blood pressure may drop to a critical level. In patients who have undergone general anesthesia, this level remains unknown (usually a blood pressure of at least 80 mm Hg is considered mandatory). In awake patients we have the best type of monitoring, namely neurologic vigilance. Another advantage is that the potential risks of endotracheal intubation, such as trauma to teeth or vocal cords or peri-intubational hypoxia, are avoided. Some patients experience hemodynamic compromise related to narcotic medication before intubation, which carries the risk of preoperative myocardial ischemia or infarction in patients with severe coronary artery disease [9, 10, 20, 21]. Patients with certain risk profiles including chronic obstructive lung disease, coagulation disorders, and neurologic conditions appear to derive the most benefit from operations without cardiopulmonary bypass [11]. However, major complications after CABG surgery are often associated with preexisting pulmonary disease or reduced general status. This condition often requires prolonged postoperative ventilatory support and prolonged intensive care unit stay. With ACAB the risk of postoperative pulmonary failure and long-term ventilation may be reduced. Therefore we believe that ACAB is a promising adjunct to current minimally invasive CABG tech-
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niques. Another impact on the CABG patient population could be a potential use of this procedure in a hybrid technique, which is a coronary revascularization technique using the combination of interventional cardiologic and cardiac surgical methods. The direct transfer of ACAB patients from the operating room to the recovery room ward is a novelty that has been reported as a fast-track pathway by several groups [24]. In ACAB, however, patients receive no sedative drugs and are thus more vigilant than patients after general anesthesia and early extubation. Compared with sedated patients, ACAB patients in this study had significantly less pain as measured by VAS, showing faster mobilization and even activities of daily living a few hours after surgery. All patients recovered well but remained hospitalized for 7.4 ⫾ 2.1 days because of local reimbursement regulations. Combining the benefits of beating heart CABG without CPB, a small incision, avoidance of general anesthesia and positive pressure ventilation, and effective pain management, the ACAB technique brings the long-term benefits of surgical revascularization closer to catheterbased interventional technique than any other current minimally invasive approach. Such innovation with excellent patient acceptance and presumably lower costs may lead to a new standard for CABG with the final vision of ambulatory heart surgery.
References 1. Nollert G, Reichart B. Cardiopulmonary bypass and cerebral injury in adults. Shock 2001;16(Suppl 1):16 –9. 2. Calafiore AM, Vitolla G, Iovino T, Iaco AL, Mazzei V, Commodo M. Left anterior small thoracotomy (LAST): midterm results in single vessel disease. J Card Surg 1998;13: 306 –9. 3. Diegeler A, Matin M, Falk V, et al. Coronary bypass grafting without cardiopulmonary bypass technical considerations, clinical results, and follow-up. Thorac Cardiovasc Surg 1999; 47:14 –8. 4. Falk V, Diegeler A, Walther T, et al. Endoscopic coronary artery bypass grafting on the beating heart using a computer enhanced telemanipulation system. Heart Surg Forum 1999; 2:199 –205. 5. Kirklin JK, Blackstone EH, Kirklin JW. Cardiopulmonary bypass: studies on its damaging effects. Blood Purif 1987;5: 168 –78. ¨ zerdem G, Battaloglu B, Korkmaz 6. Karagoz H, Kurtoglu M, O S, Bayazit K. Minimally invasive coronary artery bypass grafting: the rib cage-lifting. J Thorac Cardiovas Surg 1998; 116:354 –6. 7. Kirklin JK, Westaby S, Blackstone EH, Kirklin JW, Chenoweth Pacifico AD. Complement and damaging effect of cardiopulmonary bypass. J Thorac Cardiovasc Surg 1983;86: 845–57. 8. Fung BK, Chan MY. Incidence of oral tissue trauma after the administration of general anesthesia. Acta Anaesthesiol Sin 2001;39:163–7. 9. Tarhan S, Moffitt EA, Taylor WF, Giuliani ER. Myocardial infarction after general anesthesia. JAMA 1972;220:1451–4. 10. Seegobin RD, Goodland FC, Wilmshurst TH, et al. Postoperative myocardial damage in patients with coronary artery disease undergoing major noncardiac surgery. Can J Anaesth 1991;38:1005–11. 11. Fawcett WJ, Edwards RE, Quinn AC, et al. Thoracic epidural
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12. CARDIOVASCULAR
13.
14. 15.
16. 17. 18.
AYBEK ET AL AWAKE CABG
analgesia started after cardiopulmonary bypass. Adrenergic, cardiovascular and respiratory sequelae. Anesthesia 1997;52: 1090 –113. Horlocker TT, Wedel DJ. Anticoagulation and neuraxial block: historical perspective, anesthetic implications, and risk management. Reg Anesth Pain Med 1998;23(Suppl 2): 129 –34. Fillinger MP, Yeager MP, Dodds TM, Fillinger MF, Whalen PK, Glass DD. Epidural anesthesia and analgesia: effects on recovery from cardiac surgery. J Cardiothorac Vasc Anesth 2002;16:15–20. Steneth R. Thoracic epidural analgesia in aortocoronary bypass surgery; hemodynamic effects and endocrine metabolism. Acta Anesthesiol Scand 1994;38:826 –39. Tenling A, Joachimsson PO, Tyden H, Hedenstierna G. Thoracic epidural analgesia as an adjunct to general aneasthesia for cardiac surgery. Acta Anaesthesiol Scand 2000;44: 1071–6. Karagoz H, So¨ nmez B, Bakkaloglu B, et al. Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia. Ann Thorac Surg 2000;70:91–6. Geissler HJ, Holzl P, Marohl S, et al. Risk stratification in heart surgery. Comparison of six score systems. Eur J Cardiothorac Surg 2000;17:400 –6. Trzcieniecka-Green A, Steptoe A. The effects of stress management on the quality of life of patients following acute
Ann Thorac Surg 2003;75:1165–70
19. 20.
21.
22.
23.
24.
myocardial infarction or coronary bypass surgery. Eur Heart J 1996;17:1663–70. Bodian CA, Freedman G, Hossain S, Eisenkraft JB, Beilin Y. The visual analog scale for pain: clinical significance in postoperative patients. Anesthesiology 2001;95:1356 –61. Olausson K, Magnusdottir H, Lurje L, Wennerblom B, Emanuelsson H, Ricksten SE. Anti-ischemic and antianginal effects of thoracic epidural anesthesia versus those of conventional medical therapy in the treatment of severe refractory unstable angina pectoris. Circulation 1997;96: 2178 –82. Blomberg S, Emanuelsson H, Kvist H, et al. Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Anesthesiology 1990;73:840 –7. Mark DB, Lam LC, Lee KL, et al. Effects of coronary angioplasty, coronary bypass surgery, and medical therapy on employment in patients with coronary artery disease. A prospective comparison study. Ann Intern Med 1994;120: 111–7. Ribakove GH, Miller JS, Anderson RV, et al. Minimally invasive port-access coronary artery bypass grafting with early angiographic follow-up: initial clinical experience. J Thorac Cardiovasc Surg 1998;115:1101–10. Westaby S, Pillai R, Parry A, et al. Does modern cardiac surgery require conventional intensive care? Eur J Cardiothorac Surg 1993;7:313–8.
The Society of Thoracic Surgeons: Fortieth Annual Meeting Mark your calendars for the Fortieth Annual Meeting of The Society of Thoracic Surgeons, which will be held in San Antonio, Texas, January 26 –28, 2004. The program will provide in-depth coverage of thoracic surgical topics selected to enhance and broaden the knowledge of practicing thoracic and cardiac surgeons. Traditional abstract presentations as well as topic-specific ancillary sessions and courses will make up the continuing medical education opportunities that will be offered at the Fortieth Annual Meeting. Advance registration forms, hotel reservation forms, and details regarding transportation arrangements, as well as the complete meeting program, will be mailed to Society members. Also, complete meeting information
© 2003 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
will be available on the Society’s Web site located at http://www.sts.org. Nonmembers wishing to receive information on attending the meeting may contact The Society’s Secretary, Gordon F. Murray. Gordon F. Murray, MD Secretary The Society of Thoracic Surgeons 633 N Saint Clair St, Suite 2320 Chicago, IL 60611-3658 Telephone: (312) 202-5800; fax: (312) 202-5801 e-mail: [email protected] Web site: http://www.sts.org
Ann Thorac Surg 2003;75:1170
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0003-4975/03/$30.00
Background. Off-pump coronary artery bypass grafting (OPCAB) was implemented to reduce trauma during surgical coronary revascularization. High thoracic epidural anesthesia further reduced intraoperative stress and postoperative pain. This technique also supports awake coronary artery bypass (ACAB), completely avoiding the drawbacks of mechanical ventilation and general anesthesia in high-risk patients. We compared our first results of the ACAB procedure with the conventional OPCAB operation. Methods. Thirty-five patients underwent ACAB (group A) with left internal mammary artery to left anterior descending coronary artery grafting using a partial lower ministernotomy (n ⴝ 25) or double bypass grafting (n ⴝ 9) and even triple vessel coronary artery revascularization (n ⴝ 1) through complete median sternotomy. Thirty-four patients (group B), matched for age, sex, and comorbidity with group A, underwent either partial lower ministernotomy (n ⴝ 24) or OPCAB by complete sternotomy (n ⴝ 10). We recorded clinical outcomes and postoperative visual analog scale pain scores.
Results. In group A, 32 patients remained awake throughout the entire procedure. Three patients required secondary intubation because of incomplete analgesia (n ⴝ 1) or pneumothorax (n ⴝ 2). Patients in group A had a recovery room stay of 6.0 ⴞ 3.2 hours. In group B, mechanical ventilation was implemented for 4.8 ⴞ 3.1 hours and intensive care unit stay lasted 12 ⴞ 6.8 hours. Group A had no in-hospital deaths, compared with 1 death in the conventional OPCAB group. Each group had 1 patient with graft stenosis detected on the predischarge angiogram. Early postoperative pain was significantly less in group A than in group B (visual analog scale of 32 ⴞ 8 compared with 58 ⴞ 11, p < 0.0001). Conclusions. The present data demonstrate the feasibility and safety of surgical coronary revascularization without general anesthesia. Continuation of thoracic epidural analgesia provides better pain control and faster mobilization after such procedures. Surprisingly, the ACAB procedure was well accepted by the patients. (Ann Thorac Surg 2003;75:1165–70) © 2003 by The Society of Thoracic Surgeons
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geons to carry out coronary artery bypass surgery in the awake patient. Awake coronary artery bypass (ACAB) through a left anterior small thoracotomy was first reported by Karagoz and colleagues [16]. To evaluate clinical outcome of the new technique, we compared standard OPCAB and minimally invasive direct coronary artery bypass grafting (MIDCABG) procedures with ACAB.
inimally invasive cardiac surgery has several advantages: First, operations without cardiopulmonary bypass reduce inflammatory whole body response and potential emboli generation [1]. Second, such procedures minimize incisions and surgical trauma [2–7]. Minimally invasive surgery may obviate the need for general anesthesia and its potential disadvantages [8 –10]. Thoracic epidural anesthesia (TEA) provides excellent perioperative pain management and favorable conditions for off-pump coronary artery bypass surgery by dilating the coronary arteries and the internal thoracic artery (ITA) and by reducing heart rate and arrhythmias during manipulation of the heart [11, 12]. Thoracic epidural anesthesia improves postoperative outcome and accelerates recovery [13–15]. Combining off-pump coronary artery bypass grafting (OPCAB) with TEA seems advantageous, as the combination would enable sur-
Accepted for publication Oct 24, 2002. Address reprint requests to Dr Aybek, Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University Frankfurt, Theodor Stern Kai 7, 60590 Frankfurt, Germany; e-mail: [email protected].
© 2003 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Patients and Methods Between March 2001 and August 2002, 35 CABG procedures were performed in conscious patients using TEA in our department (group A). Twenty-five patients underwent MIDCABG through a partial lower ministernotomy. Off-pump coronary artery bypass grafting was performed in 10 patients of group A. Patient selection criteria included restriction to significant (⬎ 70%) stenoses of the left anterior descending coronary artery (LAD), This article has been selected for the open discussion forum on the CTSNet Web site: http://www.ctsnet.org/discuss 0003-4975/03/$30.00 PII S0003-4975(02)04710-0
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Table 1. Patient Demographics and Preoperative Data Group A
Group B
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Patient Demographics
MIDCABG (n ⫽ 25)
OPCAB (n ⫽ 10)
MIDCABG (n ⫽ 24)
OPCAB (n ⫽ 10)
Age, y Sex ratio, F:M BSA, m2 CCS preoperative, score Left ventricle ejection fraction Previous myocardial infarction, n Emergency cases, n Chronic obstructive lung disease, n Renal disease, n Dialysis, n Peripheral vascular disease, n Diabetes mellitus, n Risk score, Euro High-risk patients, n
66 ⫾ 8 6:19 1.88 ⫾ 0.1 2.8 ⫾ 0.6 0.61 ⫾ 0.11 6 ... 6 4 1 5 4 3.5 ⫾ 1.7 6
65 ⫾ 12 2:8 1.84 ⫾ 0.1 3.1 ⫾ 0.8 0.63 ⫾ 0.13 2 ... 2 3 1 3 3 2.6 ⫾ 2.3 3
63 ⫾ 11 7:17 1.86 ⫾ 0.1 3.0 ⫾ 0.7 0.63 ⫾ 0.6 6 4 5 3 ... 2 2 2.9 ⫾ 1.8 5
69 ⫾ 9 2:8 1.89 ⫾ 0.1 3.2 ⫾ 0.7 0.58 ⫾ 0.11 2 1 5 5 2 4 3 3.4 ⫾ 1.7 5
a
Group A versus group B for MIDCAB.
b
pa
pb
NS NS NS NS NS
NS NS NS NS NS
NS NS
NS NS
Group A versus group B for OPCAB.
Values are mean ⫾ SD unless otherwise indicated. Patients with Euro scores 0 to 2 are considered to be low risk, scores 3 to 5 medium risk, and scores ⬎ 5 high risk. BSA ⫽ body surface area; CCS ⫽ Canadian Cardiovascular Society; OPCAB ⫽ off-pump coronary artery bypass grafting.
MIDCABG ⫽ minimally invasive direct coronary artery bypass grafting;
diagonal branches, or the right coronary artery, as well as a cooperative patient. Presence of comorbidity did not affect patient selection, with the exception of impaired lung function (forced expiratory volume in 1 second ⬍ 50%). In group B (n ⫽ 34) MIDCABG was performed in 24 patients through partial lower sternotomy and 10 patients had various OPCAB procedures through complete median sternotomy. All patients in group B had conventional general anesthesia and early extubation after the operation. Demographic data and preoperative status of all patients are provided in Table 1. Eighteen patients in group A had significant comorbidity such as obstructive lung disease, peripheral vascular disease, renal failure, or diabetes. To assess preoperative risk for death, Euro scoring [17] was calculated for all patients. Euro scores of 0 to 2 were considered to indicate low risk, scores of 3 to 5 were considered to indicate medium risk, and scores of more than 5 were considered to indicate high risk (Table 1). To ensure equivalency between both groups, patients had to be appropriate candidates for either procedure to be included in this prospective study. Individuals were selected for each group by the surgeon, in consultation with the patient. Written informed consent was obtained from all patients. The study was approved by the local ethics committee. Activities of daily living were assessed to evaluate the patients’ grade of mobilization on the day of surgery [18]. Postoperative pain perception was assessed by the patients themselves using visual analog scale (VAS) on the second and third day after the operation [19]. All data were reviewed prospectively. Data are ex-
pressed as mean ⫾ standard deviation. Continuous clinical data were compared by t test and categorical variables were compared using the Mann-Whitney U test. The tests were carried out using the Stat View statistical software package 5.0.1 (Abacus Concepts, Inc, Cary, NC).
Anesthesia for Awake Coronary Artery Bypass High TEA was used in group A only. The objective of this approach was to achieve somatosensory and motor block at the T1 to T8 level. The maximum permissible block level was C6, which was monitored by the development of Horner’s syndrome. One of the major objectives was to achieve motor block of the intercostal muscles while preserving diaphragmatic respiration. Antiplatelet therapy was stopped 5 days before surgery in all cases. One day before elective surgery a thoracic epidural catheter (20 G; B. Braun Melsungen AG, Melsungen, Germany) was inserted at the T2-T3 level. On the day of surgery patients were premedicated orally with 7.5 mg midazolam (Hoffmann-LA Roche AG, GrenzachWyhlen, Germany). In the operating room patients received an infusion of ropivacaine 0.5% (Astra Zeneca, Wedel, Germany) with sufentanil 1.66 g/mL (Janssen Cilag, Neuss, Germany) into the epidural space. Sensory level was tested every 5 minutes. Thus sensory block was achieved between the neck and the abdomen, including both arms. Patients breathed O2 at 5 L/min through a facemask. Monitoring included arterial and central venous blood pressure, electrocardiogram (ECG) (II, aVF, V5), pulse oximetry, and end-tidal CO2 (Hellige Marquette Solar 8000 Patient Monitor, Marquette Medical Systems, Milwaukee, WI). Patients received no sedative medication or intravenous analgesic agents during the
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Table 2. Perioperative Data
Operative Data Procedure time, min Number of anastomosis, n Conversion to intubation, n Extubation in operating room, n Ventilation time, min Chest tube drainage, mL Recovery room stay, hours ICU stay, hours Hospital stay, days Pain VAS score, 0 –100 Need for analgesia within 3 days Dipidolor (mg) Diclofenac (mg) ADL (day of surgery) a
Group A versus group B for MIDCAB.
b
Group B OPCAB (n ⫽ 10)
MIDCABG (n ⫽ 24)
OPCABG (n ⫽ 10)
78 ⫾ 16 1 3 3 ... 150 ⫾ 79 4.1 ⫾ 3 ... 6.6 ⫾ 1.3 30 ⫾ 7
117 ⫾ 34 2.8 ⫾ 0.6 ... ... ... 287 ⫾ 99 7.6 ⫾ 3.2 ... 8.4 ⫾ 1.9 34 ⫾ 8
88 ⫾ 26 1 ... 6 4.3 ⫾ 2.5 212 ⫾ 171 ... 8.3 ⫾ 5.2 7.1 ⫾ 1.0 56 ⫾ 7
123 ⫾ 23 2.7 ⫾ 1.4 ... 2 5.8 ⫾ 4.1 368 ⫾ 87 ... 19.4 ⫾ 2.4 9.5 ⫾ 4.5 65 ⫾ 6
1.1 ⫾ 2.7 44 ⫾ 40 17/(25)
1.7 ⫾ 3.3 59 ⫾ 54 6/(10)
7.9 ⫾ 4.3 140 ⫾ 42 3/(24)
8.8 ⫾ 3.1 180 ⫾ 48 1/(10)
pa
pb
NS NS
NS NS
NS
NS
NS ⬍ 0.0001
NS ⬍ 0.0001
⬍ 0.0001 ⬍ 0.0001 ⬍ 0.0001
⬍ 0.0001 ⬍ 0.0001 ⬍ 0.0001
Group A versus group B for OPCAB.
Values are mean ⫾ SD unless otherwise indicated. ADL ⫽ activities of daily living; ICU ⫽ intensive care unit; MIDCAB ⫽ minimally invasive direct coronary artery bypass grafting; off-pump coronary artery bypass grafting; VAS ⫽ visual analog scale.
procedure. After wound closure, the anesthetic regimen was changed to ropivacaine 0.16% and sufentanil 1 g/mL at 2 to 5 mL/h to provide postoperative analgesia. The thoracic epidural catheter was used for postoperative pain management for as long as 3 days. Group B received general anesthesia with intravenous propofol (Astra Zeneca, Wedel, Germany), sufentanil (Janssen Cilag), and cisatracurium (GlaxoSmithKline, Munich, Germany). Patients underwent standard monitoring perioperatively and were extubated in the early postoperative period. Criteria for extubation were a normothermic patient, stable hemodynamic and respiratory conditions, and an unremarkable neurologic examination. Pain relief was provided with intravenous Dipidolor (Janssen Cilag) or diclofenac suppositories (Novartis Pharma, Nu¨ rnberg, Germany). The amount of analgesic medication in both groups is listed in Table 2.
OPCAB ⫽
Operative Technique for Group B Group B patients were anesthetized using standard narcotic medications (see above) and were intubated conventionally. The chest was opened by either complete sternotomy for double or triple CABG or partial lower ministernotomy for single CABG. Internal thoracic artery takedown was then conducted under direct vision. The same surgical techniques were used for the anastomoses as in group A.
Operative Technique for Awake Coronary Artery Bypass The patients were conscious and fully alert throughout the procedure (Fig 1). The chest was opened either by complete sternotomy for double or triple CABG and by partial lower ministernotomy for single CABG. Careful dissection of the ITA was necessary to avoid pneumothorax in the spontaneously breathing patient. For multivessel CABG an additional radial artery graft was dissected after application of local anesthesia. After creating a pericardial cradle, the surgeon exposed the target vessels and used traction sutures for mechanical stabilization of the target vessels. Anastomoses were performed in standard beating-heart bypass technique using proximal control of the target vessel and a blower mister to clear the anastomotic site.
Fig 1. Coronary artery bypass grafting through a lower ministernotomy while the patient is awake.
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group B). (The normal level for serum creatinine is ⬍ 1.0 mg/dL.)
Clinical Outcome Variables CARDIOVASCULAR Fig 2. Intraoperative hemodynamics in group A. ⴛ, SAP ⫽ systolic arterial pressure (mm Hg); E, Sao2 ⫽ oxygen saturation (%); , HR ⫽ heart rate (beats per minute); ●, CVP ⫽ central venous pressure (mm Hg). Time points: 1 ⫽ induction of epidural anesthesia; 2 ⫽ sternotomy; 3 ⫽ anastomosis; 4 ⫽ sternal closure; 5 ⫽ 1 hour after the operation. (Mean value ⫾ standard deviations.)
Results Perioperative Data In group A, 25 patients underwent single-vessel CABG, 9 patients had double-vessel CABG, and 1 patient had triple-vessel CABG. Three patients in this series required secondary intubation after completion of ITA harvesting because of incomplete analgesia of the upper chest (n ⫽ 1) or pneumothorax (n ⫽ 2) with consecutive coughing and chest discomfort. These patients underwent postoperative extubation in the operating room. Mean length of skin incision was 7.4 ⫾ 0.8 cm in group A (MIDCABG subgroup, n ⫽ 25) versus 7.5 ⫾ 0.6 cm in group B (MIDCABG subgroup, n ⫽ 24). Operative time in group A for MIDCABG procedures was 78 ⫾ 16 minutes, and for OPCAB procedures was 117 ⫾ 34 minutes, whereas in group B operative time was 88 ⫾ 26 minutes for MIDCABG and 123 ⫾ 23 minutes for OPCAB (p ⫽ NS). The number of anastomoses performed per patient was 1.64 ⫾ 0.9 in group A compared with 1.51 ⫾ 0.9 in group B (Table 2). Intraoperative hemodynamic data from group A are shown in Figure 2.
Biochemical Markers No significant increase was noted in cardiac enzymes 6 hours after surgery for both groups (creatine kinase [CK] ⫽ 74 ⫾ 14 IU/L and creatine kinase MB fraction [CK-MB] ⫽ 5.7 ⫾ 2.4 IU/L in group A versus CK ⫽ 82 ⫾ 18 IU/L and CK-MB 7.4 ⫾ 3.2 IU/L in group B). Mean troponin T level was 0.09 ⫾ 0.02 ng/mL in group A and 0.12 ⫾ 0.03 ng/mL in group B. Five emergency cases with unstable angina in group B were excluded from these calculations. (Normal levels are CK ⬍ 80 IU/L, CK-MB ⬍ 9 IU/L, cardiac troponin-T ⬍ 0.10 ng/mL.) Preoperative renal function did not change (mean creatinine level was 1.6 ⫾ 0.5 mg/dL in group A compared with 1.5 ⫾ 0.5 mg/dL in
Perioperative ECG monitoring with automatic STsegment analysis displayed no signs of myocardial ischemia within the first 6 and 24 hours in group A. Four of 5 patients in group B with unstable angina showed slightly anterior ischemia signs during the surgical procedure; after emergency revascularization within the first 6 hours postoperatively, no further ECG changes were detectable in these patients. In group B the duration of mechanical ventilation was 4.8 ⫾ 3.1 hours. The duration of postoperative monitoring phase in the recovery room was 6.0 ⫾ 3.2 hours (group A). In group B intensive care unit stay was 12 ⫾ 6.8 hours. Patients remained hospitalized for 7.4 ⫾ 2.1 days in group A compared with 8.3 ⫾ 1.3 days in group B (Table 2).
Mortality and Morbidity There was one early death in group B. This patient died from severe respiratory failure and sepsis following longterm ventilation. No patient suffered spinal complications caused by placement of the epidural catheter. Transient Horner’s syndrome was observed in 2 group A patients.
Need for Analgesia and Visual Analog Scale Pain Scoring Because of continuous analgesic drug application through the epidural catheter for 3 postoperative days, pain perception was significantly lower in group A (VAS ⫽ 32 ⫾ 8 in group A compared with 58 ⫾ 11 in group B, p ⬍ 0.0001). Effective pain management resulted in faster postoperative mobilization in group A (see Table 2).
Coronary Angiography Quality of anastomoses were examined in all patients. Twenty-eight patients in group A underwent coronary angiography before discharge. In 7 patients multidetector computer tomography (MDCT) was performed to check graft patency. All grafts showed good function except for one proximal ITA occlusion in group A. Twenty-eight patients in group B had control angiography and 6 patients underwent MDCT to verify graft patency. In group B 1 patient had an ITA stenosis at the anastomotic site.
Comment Thoracic epidural anesthesia provides excellent conditions for OPCAB surgery by dilating the coronary arteries [20, 21] and the ITA, and by reducing heart rate and arrhythmias during manipulation of the heart [22, 23]. Somatosensory block of the thoracic segments enables even sternotomy and CABG in the awake patient. Besides these intraoperative advantages, postoperative pain management is facilitated by continuous epidural application of analgesic agents. Such effective pain management improves postoperative mobilization and recovery.
The risks of TEA are infection and hematoma in rare cases. Reports state a risk of peridural hematoma or infection of 1 in 50,000 to 1 in 100,000 [5, 6, 20, 21]. Therefore we weaned patients in group A from antiplatelet-inhibiting drugs 6 days before surgery and stopped intravenous heparin application 6 hours before TEA catheter placement. Patients underwent routine heparinization with 10,000 IU during surgery without a target activated clotting time and protamine chloride is given after anastomosis. We used partial lower ministernotomy to access the ITA and the heart. This surgical approach provides extrapleural access to the target structures, to avoid impairment of spontaneous respiration during surgery. Furthermore, a conversion to full sternotomy, which was not required in this study, is much easier than in a left anterior small thoracotomy (LAST) approach. The entry into the chest cavity by the LAST approach constitutes a compromise between ITA dissection and access to the LAD. The technique usually exposes only a few segments of the LAD, whereas in the partial lower ministernotomy technique the whole length of the vessel is exposed. Moreover, LAST inevitably causes pneumothorax, which impairs spontaneous breathing. Complete median sternotomy with the avoidance of general anesthesia and positive pressure ventilation for CABG has not been described yet in literature. This standard approach in heart surgery allows ideal access to all regions of the heart and multi-vessel revascularization. In these patients double or triple bypass grafting was performed using arterial grafts while the patients were conscious, whereas in this initial series only the anterior wall of the heart was revascularized. The awake status of the patient provides an important advantage in beating heart procedures. During stabilization, the systemic blood pressure may drop to a critical level. In patients who have undergone general anesthesia, this level remains unknown (usually a blood pressure of at least 80 mm Hg is considered mandatory). In awake patients we have the best type of monitoring, namely neurologic vigilance. Another advantage is that the potential risks of endotracheal intubation, such as trauma to teeth or vocal cords or peri-intubational hypoxia, are avoided. Some patients experience hemodynamic compromise related to narcotic medication before intubation, which carries the risk of preoperative myocardial ischemia or infarction in patients with severe coronary artery disease [9, 10, 20, 21]. Patients with certain risk profiles including chronic obstructive lung disease, coagulation disorders, and neurologic conditions appear to derive the most benefit from operations without cardiopulmonary bypass [11]. However, major complications after CABG surgery are often associated with preexisting pulmonary disease or reduced general status. This condition often requires prolonged postoperative ventilatory support and prolonged intensive care unit stay. With ACAB the risk of postoperative pulmonary failure and long-term ventilation may be reduced. Therefore we believe that ACAB is a promising adjunct to current minimally invasive CABG tech-
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niques. Another impact on the CABG patient population could be a potential use of this procedure in a hybrid technique, which is a coronary revascularization technique using the combination of interventional cardiologic and cardiac surgical methods. The direct transfer of ACAB patients from the operating room to the recovery room ward is a novelty that has been reported as a fast-track pathway by several groups [24]. In ACAB, however, patients receive no sedative drugs and are thus more vigilant than patients after general anesthesia and early extubation. Compared with sedated patients, ACAB patients in this study had significantly less pain as measured by VAS, showing faster mobilization and even activities of daily living a few hours after surgery. All patients recovered well but remained hospitalized for 7.4 ⫾ 2.1 days because of local reimbursement regulations. Combining the benefits of beating heart CABG without CPB, a small incision, avoidance of general anesthesia and positive pressure ventilation, and effective pain management, the ACAB technique brings the long-term benefits of surgical revascularization closer to catheterbased interventional technique than any other current minimally invasive approach. Such innovation with excellent patient acceptance and presumably lower costs may lead to a new standard for CABG with the final vision of ambulatory heart surgery.
References 1. Nollert G, Reichart B. Cardiopulmonary bypass and cerebral injury in adults. Shock 2001;16(Suppl 1):16 –9. 2. Calafiore AM, Vitolla G, Iovino T, Iaco AL, Mazzei V, Commodo M. Left anterior small thoracotomy (LAST): midterm results in single vessel disease. J Card Surg 1998;13: 306 –9. 3. Diegeler A, Matin M, Falk V, et al. Coronary bypass grafting without cardiopulmonary bypass technical considerations, clinical results, and follow-up. Thorac Cardiovasc Surg 1999; 47:14 –8. 4. Falk V, Diegeler A, Walther T, et al. Endoscopic coronary artery bypass grafting on the beating heart using a computer enhanced telemanipulation system. Heart Surg Forum 1999; 2:199 –205. 5. Kirklin JK, Blackstone EH, Kirklin JW. Cardiopulmonary bypass: studies on its damaging effects. Blood Purif 1987;5: 168 –78. ¨ zerdem G, Battaloglu B, Korkmaz 6. Karagoz H, Kurtoglu M, O S, Bayazit K. Minimally invasive coronary artery bypass grafting: the rib cage-lifting. J Thorac Cardiovas Surg 1998; 116:354 –6. 7. Kirklin JK, Westaby S, Blackstone EH, Kirklin JW, Chenoweth Pacifico AD. Complement and damaging effect of cardiopulmonary bypass. J Thorac Cardiovasc Surg 1983;86: 845–57. 8. Fung BK, Chan MY. Incidence of oral tissue trauma after the administration of general anesthesia. Acta Anaesthesiol Sin 2001;39:163–7. 9. Tarhan S, Moffitt EA, Taylor WF, Giuliani ER. Myocardial infarction after general anesthesia. JAMA 1972;220:1451–4. 10. Seegobin RD, Goodland FC, Wilmshurst TH, et al. Postoperative myocardial damage in patients with coronary artery disease undergoing major noncardiac surgery. Can J Anaesth 1991;38:1005–11. 11. Fawcett WJ, Edwards RE, Quinn AC, et al. Thoracic epidural
CARDIOVASCULAR
Ann Thorac Surg 2003;75:1165–70
1170
12. CARDIOVASCULAR
13.
14. 15.
16. 17. 18.
AYBEK ET AL AWAKE CABG
analgesia started after cardiopulmonary bypass. Adrenergic, cardiovascular and respiratory sequelae. Anesthesia 1997;52: 1090 –113. Horlocker TT, Wedel DJ. Anticoagulation and neuraxial block: historical perspective, anesthetic implications, and risk management. Reg Anesth Pain Med 1998;23(Suppl 2): 129 –34. Fillinger MP, Yeager MP, Dodds TM, Fillinger MF, Whalen PK, Glass DD. Epidural anesthesia and analgesia: effects on recovery from cardiac surgery. J Cardiothorac Vasc Anesth 2002;16:15–20. Steneth R. Thoracic epidural analgesia in aortocoronary bypass surgery; hemodynamic effects and endocrine metabolism. Acta Anesthesiol Scand 1994;38:826 –39. Tenling A, Joachimsson PO, Tyden H, Hedenstierna G. Thoracic epidural analgesia as an adjunct to general aneasthesia for cardiac surgery. Acta Anaesthesiol Scand 2000;44: 1071–6. Karagoz H, So¨ nmez B, Bakkaloglu B, et al. Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia. Ann Thorac Surg 2000;70:91–6. Geissler HJ, Holzl P, Marohl S, et al. Risk stratification in heart surgery. Comparison of six score systems. Eur J Cardiothorac Surg 2000;17:400 –6. Trzcieniecka-Green A, Steptoe A. The effects of stress management on the quality of life of patients following acute
Ann Thorac Surg 2003;75:1165–70
19. 20.
21.
22.
23.
24.
myocardial infarction or coronary bypass surgery. Eur Heart J 1996;17:1663–70. Bodian CA, Freedman G, Hossain S, Eisenkraft JB, Beilin Y. The visual analog scale for pain: clinical significance in postoperative patients. Anesthesiology 2001;95:1356 –61. Olausson K, Magnusdottir H, Lurje L, Wennerblom B, Emanuelsson H, Ricksten SE. Anti-ischemic and antianginal effects of thoracic epidural anesthesia versus those of conventional medical therapy in the treatment of severe refractory unstable angina pectoris. Circulation 1997;96: 2178 –82. Blomberg S, Emanuelsson H, Kvist H, et al. Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Anesthesiology 1990;73:840 –7. Mark DB, Lam LC, Lee KL, et al. Effects of coronary angioplasty, coronary bypass surgery, and medical therapy on employment in patients with coronary artery disease. A prospective comparison study. Ann Intern Med 1994;120: 111–7. Ribakove GH, Miller JS, Anderson RV, et al. Minimally invasive port-access coronary artery bypass grafting with early angiographic follow-up: initial clinical experience. J Thorac Cardiovasc Surg 1998;115:1101–10. Westaby S, Pillai R, Parry A, et al. Does modern cardiac surgery require conventional intensive care? Eur J Cardiothorac Surg 1993;7:313–8.
The Society of Thoracic Surgeons: Fortieth Annual Meeting Mark your calendars for the Fortieth Annual Meeting of The Society of Thoracic Surgeons, which will be held in San Antonio, Texas, January 26 –28, 2004. The program will provide in-depth coverage of thoracic surgical topics selected to enhance and broaden the knowledge of practicing thoracic and cardiac surgeons. Traditional abstract presentations as well as topic-specific ancillary sessions and courses will make up the continuing medical education opportunities that will be offered at the Fortieth Annual Meeting. Advance registration forms, hotel reservation forms, and details regarding transportation arrangements, as well as the complete meeting program, will be mailed to Society members. Also, complete meeting information
© 2003 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
will be available on the Society’s Web site located at http://www.sts.org. Nonmembers wishing to receive information on attending the meeting may contact The Society’s Secretary, Gordon F. Murray. Gordon F. Murray, MD Secretary The Society of Thoracic Surgeons 633 N Saint Clair St, Suite 2320 Chicago, IL 60611-3658 Telephone: (312) 202-5800; fax: (312) 202-5801 e-mail: [email protected] Web site: http://www.sts.org
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