- Email: [email protected]
Minimally Invasive Cardiac Surgery
0800–1000 Room: Miramar 3–4
Tuesday, September 11, 2001 PII: S0967-2109(01)00067-9
Session VII Minimally Invasive Cardiac Surgery Co-Chairmen: Yasuyuki Hosada, Japan; James DeWeese, USA 7.1 Off-Pump CABG Versus On-Pump in 600 Patients S. BARTOCCIONI, P. FIASCHINI, G. DI MANICI, D. DI LAZZARO, C. FEDELI, C.M. DE FILIPPO, G. MINNITI and U. DA COL, Perugia, Italy Retrospective review of last 300 consecutive OPCAB operations, operated by us from February 1st 1999, compared to a group of other 300 patients who underwent during the same time on-pump myocardial revascularization (CPB). Currently, OPCAB are 62% of total CABGs performed at our institution. Euroscore Age (mean) ⬎70 yrs
Red
Emergency
Sex (m/f) %
Opcab
3.6
41.00%
5.90%
0.90%
74.7/25.3
CPB
3.1
27.50%
2.20%
5.10%
83.2/16.8
The preferrred approach was median sternotomy, but in elected cases (3%), we performed OPCAB through left anterior thoracotomy (MIDCABG). Mean number of grafts per patient: 2.2 vs. 3.3 for the CPB group. Rate of conversions to CPB 1.6%, due to cardiac arrest with one death among them, assigned to OPCAB group. Mean LABP Intubation time of post-op ⬍6h operation
Hospital discharge ⬍24h
discharge ⬎7 days
Opcab 182 min
0.10%
18.30%
71.20%
47.00%
CPB
3.50%
6.70%
67.60%
44.30%
250 min
Mortality 1.6%vs. 3.8 of the control group. 66.3% was transfused vs. 40.7% of the CPB group. Renal insufficiency 2% vs 3.8%, dialisis required in 0.3% vs. 0.6%. Atrial fibrillation 24.7% vs 26.8%. Even if it isn’t possible draw definitive conclusions from a retrospective study, some standpoints can be established. OPCAB has lesser mortality, even if patients belong to a slightly higher risk score than control group, as regards morbidity, we had faster extubations and lesser transfusions, compared to on-pump patients. The lesser average number of grafts for the OPCAB group is explained by the fact that a lesser number of vessels to revascularize is a further incentive to perform an OPCAB operation.
7.2 Use of Right Internal Mammary Artery Graft for Left Anterior Descending Artery Revascularization During Off-Pump Surgery P. MILOJEVIC, B. DJUKANOVIC, M. JAKOVLJEVIC, V. NESKOVIC, Z. JANKOVIC and S. NASTASIC, Belgrade, Serbia, Yugoslavia Background: Right internal mammary artery (RIMA) has the similar histologic and physiologic characteristics as the left internal mammary artery (LIMA). We report our experience with LAD revascularization using pedicled RIMA graft during off-pump myocardial revascularization (OPCAB) in multivessel coronary disease. Methods: Between March–September, 2000, 21 patients with good ejection fraction and proximal LAD lesion underwent OPCAB. We used RIMA pedicular graft for LAD revascularization and LIMA as a second pedicular graft for the circumflex artery system. As a third/fourth graft radial artery was used 5 times and right gastroepiploic artery once. All patients were operated by the same surgeon and Octopus 2 was used for mechanical stabilization of the target vessel. Anaesthesia with propofol and remifentanyl infusion combined with high thoracic epidural analgesia was used and early extubation was considered in all cases. Results: A total of 50 anastomoses were performed, 2.4⫾0.6 per patient (range 2–4). All patients were extubated within 12 hours. There was no 30-day mortality and perioperative myocardial infarctions. One patient (4.8%) had pneumothorax, 2 (9.5%) underwent retoracotomy due to postoperative bleeding and only these 2 patients received postoperative blood transfusion. One patient (4.8%) had superficial wound infection. Early postoperative coronary angiography was performed in 7/21 patients, revealing excellent patency of all grafts. Conclusions: Use of the RIMA pedicular graft for LAD revascularization modifies approach to total myocardial revascularization and both IMA arteries can be used for the left side myocardial revascularization during OPCAB.
7.3 Partial Median Sternotomy as a Minimal Access for Off-Pump CABG: Feasibility of the Lower-End Sternal Splitting (LESS) Approach H. NIINAMI, Y. TAKEUCHI, S. ICHIKAWA, T. BAN, R. HIGASHIDA, Y. SUDA, H. OGASAWARA and M. YAMAMOTO, Tokyo, Japan Background: Off-pump CABG (OPCAB) can be performed in several ways using a minimally invasive approach. Using the left
CARDIOVASCULAR SURGERY
SEPTEMBER 2001
27
25th World Congress of the ISCVS anterior small thoracotomy approach, only the LAD can be grafted. We have employed a partial sternotomy without a transverse cut. Through this approach, the LAD and RCA can be revascularized via a single small incision without the risk of damaging the tissue around the intercostal space when the sternum is transversely divided. This study is to demonstrate the feasibility and safety of this technique. Methods: Since November 1999, we have applied OPCAB through a lower midline skin incision from the 4th intercostal space to the xiphoid process with longitudinal division of the lower half sternum up to the 3rd rib, without making either a T- or reversed-L shaped division of the sternum. A total of 22 patients have undergone surgery using this approach. Sixteen patients were men. Mean age was 69.5⫾6.1 years (range 55–77). Two of them were redo CABG patients. Results: Mean length of the skin incision was 8.5⫾1.4 cm (range 7–12). No hospital death or morbidity was observed. No patient required blood transfusion. All patients had arterial conduits: LIMA, in 20; RIMA, in 3; RGEA, in 4; and RA, in 1. Mean number of grafts per patient was 1.3⫾0.6 (range 1–3). The patency rate was 96%. Conclusions: Our experience demonstrates that the lower-end sternal splitting approach for OPCAB is technically feasible and can be used with excellent cosmetic results and safety. Although our experience is limited, we conclude this less invasive cosmetic results and safety. Although our experience is limited, we conclude this less invasive surgical technique can be used as an alternative approach for MIDCAB in patients with LAD and/or RCA disease.
7.4 Hemodynamic and Angiographic Evaluation of the Off-Pump Coronary Bypass Surgery, During and After Operation ´ NCHEZ, A. DE LA I. MORIONES, R. SA ´ NDEZ and R. LEZAUN, FUENTE, J.L. FERNA Pamplona, Navarra, Spain Background: The purpose of this study was to analyze the hemodynamic changes during coronary grafts anastomosis caused by the displacement of the heart and the correlation of intraoperative flow measurement with postoperative angiographic patency. Methods: Ninety-two patients (74 men and 18 women) underwent off-pump coronary artery by pass grafting. Mean age was 64⫾8 years and ejection fraction was 0.54. The number of the coronary grafts were 184 (2 grafts per patients). Hemodynamic variables like: Cardiac output, venous O2 saturation and atrial filling was determined by means of Swan-Ganz catheter in all patients. The arterial pressure was determined by radial puncture. These values were collected before, during and after positioning the heart for anastomosis. We measured also the flows after anastomosis in all grafts and correlated this value with angiography made before hospital delivery of the patients. Results: The cardiac output mean values were 4.1⫾0.6, 2.8⫾0.7 and 4.2⫾0.8 (p<0.001) before, during and after completion the anastomosis. Venous SO2 values were 79⫾2, 64⫾8 and 74⫾5% (p<0.001). Arterial pressure changed from 135⫾17 to 92⫾8 and 108⫾11 mmHg (p<0.001). Diastolic pulmonary pressure were 15⫾2, 13.6⫾4 and 14⫾5 mmHg respectively (p=n.s). We evaluated angiographic results in 129 grafts. The rate of permeability was 94%. In 6% of the grafts we find some stenotic lesions in the anastomosis. The mean flow of these grafts was 40⫾26 and increased to 74⫾24 cc/min after Papaverine. 13 grafts had bad flows with no increase in the flows after Papaverine (21 to 23 cc/min). When we correlate intraoperative flow with angiography results; in normal flow coronary
28
grafts the permeability was 96% and in the vessels with no proper flow the correct permeability index was only 30%. The mortality was 3.3% (3 pts.) and the postoperative infarction 4.3% (4 pts.) Conclusions: 1. The off-pump surgery produces very important changes in cardiac function parameters during distal coronary grafts anastomosis. 2. The flow measurements, were well correlated with the angiographic results. For this reason, the flow measurement is mandatory for this kind of cardiac surgical technique.
7.5 An Experimental Model of Coronary Anastomosis Without Suturing G.J. VAN NOOTEN, Y. VAN BELLEGHEM, L. FOUBERT, K. FRANC ¸ OIS, F. CAES, H. VAN OVERBEKE and Y. TAEYMANS, Ghent, Belgium Objective: The aim of the study is to explore the feasibility and mid-term patency of an easier anastomotic technqiue for Minimally Invasive Direct Coronary Bypass Grafting (MIDCAB). Method: Eight mongrel dogs (⫾15kg) underwent direct anastomosis between the left internal mammary artery (LIMA) and the left anterior descending coronary artery (LAD) via inferior sternotomy on the beating heart. After positioning the graft, the distal part of the LAD was opened to allow retrograde filling of the LIMA-graft. The anastomosis was secured by the use of biological glue (BioGlue, Cryolife, Atlanta, USA). No intravascular suture material was used. Ischemic time average 6 min. The proximal LAD was occluded upstream the arteriotomy. All survivors were angiographically controlled for patency after 6 to 8 weeks. Consequently, four dogs were sacrificed after 6 weeks and the remaining after 3 months for anatomo-pathological and histological examination by light and electron microscopy of the anastomotic site. Results: All procedures were successful except for one animal that died of uncontrollable bleeding at the anastomotic site. Another sustained post-operative transmural anterior myocardial infarction due to a late graft occlusion. All angiographically controlled grafts were patent with two vascular strings near the anastomotic site. Histology showed early macrophage infiltration into the glue. At post-mortem examination, new endothelialisation was noticed in 80% of the cases. However, ultrastructural examination detected marked differences in endothelial fibroblastic lining compared to normal histology. Conclusions: Good mid-term permeability of the LIMA grafts was observed in this new anastomotic technique for MIDCAB in the canine model. Although neo-endothelialization was present in most cases, ultrastructural differences were noticed after 3 months in the neo-intima compared to normal.
7.6 Off-Pump Coronary Bypass Grafting Can Expect Less Perioperative Central Nervous System Morbidity S. OZAKI, A. AMANO, N. NAGANO, A. BITO, S. YAMAMOTO and K. HISAMOCHI, Matsudo, Japan Objective: In cardiac surgery, stroke is one of the most serious complications, significantly increasing morbidity and mortality. With
CARDIOVASCULAR SURGERY
SEPTEMBER 2001
25th World Congress of the ISCVS off-pump coronary artery bypass (OPCABG), there exist the potential to decrease the perioperative stroke rate after CABG. In order to reduce the incidence of perioperative stroke, we tried to increase to use arterial grafts and to avoid proximal aortic anastomoses. We performed a retrospective study (January 1, 1996 to February 29, 2000) comparing the incidence of stroke in two groups of patients revascularized with and without extracorporeal circulation. Methods: The first group comprised patients with coronary artery disease operated on with standard revascularization technique with cardiopulmonary bypass (group 1, n=628). The second group included patients who had OPCABG (group 2, n=259). Results: The two groups were similar in terms of age, male/female ratio, presence of unstable angina prior to surgery, reoperative surgery, and perioperative risk factors. However there was significant difference in the history of cerebrovascular accident prior to surgery between the groups (group 1: 11.8% vs. group 2: 21.6%, p=0.001). Group 1 had an average of 3.6⫾1.1 grafts compared to 2.1⫾1.0 grafts in group 2 (p<0.01). The number of proximal anastomoses in group 1 was significantly higher than those in group 2 (group 1: 25.7% vs. group 2: 16.8%, p<0.0001). The incidence of stroke was significantly higher in group 1 compared with group 2 (group 1: 1.6% vs. group 2: 0%, p=0.04). Similar results were obtained for atrial fibrillation (p=0.04) and pulmonary complication rate (p<0.001). Conclusions: We concluded from our experience that a decrease in perioperative stroke can be achieved by using the off-pump technique.
ited. Nevertheless, the number of off-pump coronary procedures is increasing worldwide. Minimally invasive direct coronary artery bypass grafting (MIDCAB), in selected patient, is a safe procedure with good early and mid term results. Advantages of off-pump coronary artery bypass grafting (OPCAB) are particularly evident in critical patients. Methods: Of 1984 consecutive pts undergone CABG in our institution from January 1997 to November 2000, 273 (13.5%) were operated without using ECC, where 147 underwent MIDCAB. Indication for MIDCAB was proximal disease of the LAD in pts that were no matching PTCA indications. Indication for OPCAB was multivessel disease (except marginal branches), dilated left ventricle, severe COPD, obese patients. All the MIDCAB pts were evaluated by transthoracic Echo-Doppler examination immediately after the operation. In suspected cases coronary angiography was performed. Results: The 30 days mortality was 4 patients (1.4%): causes were two MOP, one LOS and one intestinal infarction. Six MIDCAB and one OPCAB pts needed to be converted to conventional CABG. Major complications were two perioperative MI, one stroke, three postoperative bleeding. Mean ICU stay was 12 hrs; mean hospital stay was 5 days. No other major complication was reported in surviving patients. Conclusion: MIDCAB appears to be a safe and effective technique in selected pts. OPCAB, when feasible, helps to reduce morbidity in critical ill pts. With improvement of adequate surgical techniques an increasing number of patients can achieve coronary revascularization without ECC with excellent results and low morbidity and mortality.
7.7 Coronary Artery Revascularization on the Beating Heart: Four Years Experience E. COSCIONI, P. MASIELLO, A. PANZA, G. MASTROGIOVANNI, S. IESU and G. DI BENEDETTO, Salerno, Italy Background: Quality of surgical beating heart revascularization is frequently questioned, particularly when the surgical access is lim-
CARDIOVASCULAR SURGERY
SEPTEMBER 2001
29
Tuesday, September 11, 2001 PII: S0967-2109(01)00067-9
Session VII Minimally Invasive Cardiac Surgery Co-Chairmen: Yasuyuki Hosada, Japan; James DeWeese, USA 7.1 Off-Pump CABG Versus On-Pump in 600 Patients S. BARTOCCIONI, P. FIASCHINI, G. DI MANICI, D. DI LAZZARO, C. FEDELI, C.M. DE FILIPPO, G. MINNITI and U. DA COL, Perugia, Italy Retrospective review of last 300 consecutive OPCAB operations, operated by us from February 1st 1999, compared to a group of other 300 patients who underwent during the same time on-pump myocardial revascularization (CPB). Currently, OPCAB are 62% of total CABGs performed at our institution. Euroscore Age (mean) ⬎70 yrs
Red
Emergency
Sex (m/f) %
Opcab
3.6
41.00%
5.90%
0.90%
74.7/25.3
CPB
3.1
27.50%
2.20%
5.10%
83.2/16.8
The preferrred approach was median sternotomy, but in elected cases (3%), we performed OPCAB through left anterior thoracotomy (MIDCABG). Mean number of grafts per patient: 2.2 vs. 3.3 for the CPB group. Rate of conversions to CPB 1.6%, due to cardiac arrest with one death among them, assigned to OPCAB group. Mean LABP Intubation time of post-op ⬍6h operation
Hospital discharge ⬍24h
discharge ⬎7 days
Opcab 182 min
0.10%
18.30%
71.20%
47.00%
CPB
3.50%
6.70%
67.60%
44.30%
250 min
Mortality 1.6%vs. 3.8 of the control group. 66.3% was transfused vs. 40.7% of the CPB group. Renal insufficiency 2% vs 3.8%, dialisis required in 0.3% vs. 0.6%. Atrial fibrillation 24.7% vs 26.8%. Even if it isn’t possible draw definitive conclusions from a retrospective study, some standpoints can be established. OPCAB has lesser mortality, even if patients belong to a slightly higher risk score than control group, as regards morbidity, we had faster extubations and lesser transfusions, compared to on-pump patients. The lesser average number of grafts for the OPCAB group is explained by the fact that a lesser number of vessels to revascularize is a further incentive to perform an OPCAB operation.
7.2 Use of Right Internal Mammary Artery Graft for Left Anterior Descending Artery Revascularization During Off-Pump Surgery P. MILOJEVIC, B. DJUKANOVIC, M. JAKOVLJEVIC, V. NESKOVIC, Z. JANKOVIC and S. NASTASIC, Belgrade, Serbia, Yugoslavia Background: Right internal mammary artery (RIMA) has the similar histologic and physiologic characteristics as the left internal mammary artery (LIMA). We report our experience with LAD revascularization using pedicled RIMA graft during off-pump myocardial revascularization (OPCAB) in multivessel coronary disease. Methods: Between March–September, 2000, 21 patients with good ejection fraction and proximal LAD lesion underwent OPCAB. We used RIMA pedicular graft for LAD revascularization and LIMA as a second pedicular graft for the circumflex artery system. As a third/fourth graft radial artery was used 5 times and right gastroepiploic artery once. All patients were operated by the same surgeon and Octopus 2 was used for mechanical stabilization of the target vessel. Anaesthesia with propofol and remifentanyl infusion combined with high thoracic epidural analgesia was used and early extubation was considered in all cases. Results: A total of 50 anastomoses were performed, 2.4⫾0.6 per patient (range 2–4). All patients were extubated within 12 hours. There was no 30-day mortality and perioperative myocardial infarctions. One patient (4.8%) had pneumothorax, 2 (9.5%) underwent retoracotomy due to postoperative bleeding and only these 2 patients received postoperative blood transfusion. One patient (4.8%) had superficial wound infection. Early postoperative coronary angiography was performed in 7/21 patients, revealing excellent patency of all grafts. Conclusions: Use of the RIMA pedicular graft for LAD revascularization modifies approach to total myocardial revascularization and both IMA arteries can be used for the left side myocardial revascularization during OPCAB.
7.3 Partial Median Sternotomy as a Minimal Access for Off-Pump CABG: Feasibility of the Lower-End Sternal Splitting (LESS) Approach H. NIINAMI, Y. TAKEUCHI, S. ICHIKAWA, T. BAN, R. HIGASHIDA, Y. SUDA, H. OGASAWARA and M. YAMAMOTO, Tokyo, Japan Background: Off-pump CABG (OPCAB) can be performed in several ways using a minimally invasive approach. Using the left
CARDIOVASCULAR SURGERY
SEPTEMBER 2001
27
25th World Congress of the ISCVS anterior small thoracotomy approach, only the LAD can be grafted. We have employed a partial sternotomy without a transverse cut. Through this approach, the LAD and RCA can be revascularized via a single small incision without the risk of damaging the tissue around the intercostal space when the sternum is transversely divided. This study is to demonstrate the feasibility and safety of this technique. Methods: Since November 1999, we have applied OPCAB through a lower midline skin incision from the 4th intercostal space to the xiphoid process with longitudinal division of the lower half sternum up to the 3rd rib, without making either a T- or reversed-L shaped division of the sternum. A total of 22 patients have undergone surgery using this approach. Sixteen patients were men. Mean age was 69.5⫾6.1 years (range 55–77). Two of them were redo CABG patients. Results: Mean length of the skin incision was 8.5⫾1.4 cm (range 7–12). No hospital death or morbidity was observed. No patient required blood transfusion. All patients had arterial conduits: LIMA, in 20; RIMA, in 3; RGEA, in 4; and RA, in 1. Mean number of grafts per patient was 1.3⫾0.6 (range 1–3). The patency rate was 96%. Conclusions: Our experience demonstrates that the lower-end sternal splitting approach for OPCAB is technically feasible and can be used with excellent cosmetic results and safety. Although our experience is limited, we conclude this less invasive cosmetic results and safety. Although our experience is limited, we conclude this less invasive surgical technique can be used as an alternative approach for MIDCAB in patients with LAD and/or RCA disease.
7.4 Hemodynamic and Angiographic Evaluation of the Off-Pump Coronary Bypass Surgery, During and After Operation ´ NCHEZ, A. DE LA I. MORIONES, R. SA ´ NDEZ and R. LEZAUN, FUENTE, J.L. FERNA Pamplona, Navarra, Spain Background: The purpose of this study was to analyze the hemodynamic changes during coronary grafts anastomosis caused by the displacement of the heart and the correlation of intraoperative flow measurement with postoperative angiographic patency. Methods: Ninety-two patients (74 men and 18 women) underwent off-pump coronary artery by pass grafting. Mean age was 64⫾8 years and ejection fraction was 0.54. The number of the coronary grafts were 184 (2 grafts per patients). Hemodynamic variables like: Cardiac output, venous O2 saturation and atrial filling was determined by means of Swan-Ganz catheter in all patients. The arterial pressure was determined by radial puncture. These values were collected before, during and after positioning the heart for anastomosis. We measured also the flows after anastomosis in all grafts and correlated this value with angiography made before hospital delivery of the patients. Results: The cardiac output mean values were 4.1⫾0.6, 2.8⫾0.7 and 4.2⫾0.8 (p<0.001) before, during and after completion the anastomosis. Venous SO2 values were 79⫾2, 64⫾8 and 74⫾5% (p<0.001). Arterial pressure changed from 135⫾17 to 92⫾8 and 108⫾11 mmHg (p<0.001). Diastolic pulmonary pressure were 15⫾2, 13.6⫾4 and 14⫾5 mmHg respectively (p=n.s). We evaluated angiographic results in 129 grafts. The rate of permeability was 94%. In 6% of the grafts we find some stenotic lesions in the anastomosis. The mean flow of these grafts was 40⫾26 and increased to 74⫾24 cc/min after Papaverine. 13 grafts had bad flows with no increase in the flows after Papaverine (21 to 23 cc/min). When we correlate intraoperative flow with angiography results; in normal flow coronary
28
grafts the permeability was 96% and in the vessels with no proper flow the correct permeability index was only 30%. The mortality was 3.3% (3 pts.) and the postoperative infarction 4.3% (4 pts.) Conclusions: 1. The off-pump surgery produces very important changes in cardiac function parameters during distal coronary grafts anastomosis. 2. The flow measurements, were well correlated with the angiographic results. For this reason, the flow measurement is mandatory for this kind of cardiac surgical technique.
7.5 An Experimental Model of Coronary Anastomosis Without Suturing G.J. VAN NOOTEN, Y. VAN BELLEGHEM, L. FOUBERT, K. FRANC ¸ OIS, F. CAES, H. VAN OVERBEKE and Y. TAEYMANS, Ghent, Belgium Objective: The aim of the study is to explore the feasibility and mid-term patency of an easier anastomotic technqiue for Minimally Invasive Direct Coronary Bypass Grafting (MIDCAB). Method: Eight mongrel dogs (⫾15kg) underwent direct anastomosis between the left internal mammary artery (LIMA) and the left anterior descending coronary artery (LAD) via inferior sternotomy on the beating heart. After positioning the graft, the distal part of the LAD was opened to allow retrograde filling of the LIMA-graft. The anastomosis was secured by the use of biological glue (BioGlue, Cryolife, Atlanta, USA). No intravascular suture material was used. Ischemic time average 6 min. The proximal LAD was occluded upstream the arteriotomy. All survivors were angiographically controlled for patency after 6 to 8 weeks. Consequently, four dogs were sacrificed after 6 weeks and the remaining after 3 months for anatomo-pathological and histological examination by light and electron microscopy of the anastomotic site. Results: All procedures were successful except for one animal that died of uncontrollable bleeding at the anastomotic site. Another sustained post-operative transmural anterior myocardial infarction due to a late graft occlusion. All angiographically controlled grafts were patent with two vascular strings near the anastomotic site. Histology showed early macrophage infiltration into the glue. At post-mortem examination, new endothelialisation was noticed in 80% of the cases. However, ultrastructural examination detected marked differences in endothelial fibroblastic lining compared to normal histology. Conclusions: Good mid-term permeability of the LIMA grafts was observed in this new anastomotic technique for MIDCAB in the canine model. Although neo-endothelialization was present in most cases, ultrastructural differences were noticed after 3 months in the neo-intima compared to normal.
7.6 Off-Pump Coronary Bypass Grafting Can Expect Less Perioperative Central Nervous System Morbidity S. OZAKI, A. AMANO, N. NAGANO, A. BITO, S. YAMAMOTO and K. HISAMOCHI, Matsudo, Japan Objective: In cardiac surgery, stroke is one of the most serious complications, significantly increasing morbidity and mortality. With
CARDIOVASCULAR SURGERY
SEPTEMBER 2001
25th World Congress of the ISCVS off-pump coronary artery bypass (OPCABG), there exist the potential to decrease the perioperative stroke rate after CABG. In order to reduce the incidence of perioperative stroke, we tried to increase to use arterial grafts and to avoid proximal aortic anastomoses. We performed a retrospective study (January 1, 1996 to February 29, 2000) comparing the incidence of stroke in two groups of patients revascularized with and without extracorporeal circulation. Methods: The first group comprised patients with coronary artery disease operated on with standard revascularization technique with cardiopulmonary bypass (group 1, n=628). The second group included patients who had OPCABG (group 2, n=259). Results: The two groups were similar in terms of age, male/female ratio, presence of unstable angina prior to surgery, reoperative surgery, and perioperative risk factors. However there was significant difference in the history of cerebrovascular accident prior to surgery between the groups (group 1: 11.8% vs. group 2: 21.6%, p=0.001). Group 1 had an average of 3.6⫾1.1 grafts compared to 2.1⫾1.0 grafts in group 2 (p<0.01). The number of proximal anastomoses in group 1 was significantly higher than those in group 2 (group 1: 25.7% vs. group 2: 16.8%, p<0.0001). The incidence of stroke was significantly higher in group 1 compared with group 2 (group 1: 1.6% vs. group 2: 0%, p=0.04). Similar results were obtained for atrial fibrillation (p=0.04) and pulmonary complication rate (p<0.001). Conclusions: We concluded from our experience that a decrease in perioperative stroke can be achieved by using the off-pump technique.
ited. Nevertheless, the number of off-pump coronary procedures is increasing worldwide. Minimally invasive direct coronary artery bypass grafting (MIDCAB), in selected patient, is a safe procedure with good early and mid term results. Advantages of off-pump coronary artery bypass grafting (OPCAB) are particularly evident in critical patients. Methods: Of 1984 consecutive pts undergone CABG in our institution from January 1997 to November 2000, 273 (13.5%) were operated without using ECC, where 147 underwent MIDCAB. Indication for MIDCAB was proximal disease of the LAD in pts that were no matching PTCA indications. Indication for OPCAB was multivessel disease (except marginal branches), dilated left ventricle, severe COPD, obese patients. All the MIDCAB pts were evaluated by transthoracic Echo-Doppler examination immediately after the operation. In suspected cases coronary angiography was performed. Results: The 30 days mortality was 4 patients (1.4%): causes were two MOP, one LOS and one intestinal infarction. Six MIDCAB and one OPCAB pts needed to be converted to conventional CABG. Major complications were two perioperative MI, one stroke, three postoperative bleeding. Mean ICU stay was 12 hrs; mean hospital stay was 5 days. No other major complication was reported in surviving patients. Conclusion: MIDCAB appears to be a safe and effective technique in selected pts. OPCAB, when feasible, helps to reduce morbidity in critical ill pts. With improvement of adequate surgical techniques an increasing number of patients can achieve coronary revascularization without ECC with excellent results and low morbidity and mortality.
7.7 Coronary Artery Revascularization on the Beating Heart: Four Years Experience E. COSCIONI, P. MASIELLO, A. PANZA, G. MASTROGIOVANNI, S. IESU and G. DI BENEDETTO, Salerno, Italy Background: Quality of surgical beating heart revascularization is frequently questioned, particularly when the surgical access is lim-
CARDIOVASCULAR SURGERY
SEPTEMBER 2001
29