- Email: [email protected]
Towards Stroke-Free Coronary Surgery
EDITORIAL
Editorial
Towards Stroke-Free Coronary Surgery Donald E. Ross Royal North Shore Hospital, Sydney, Australia Available online 26 August 2004
T
he occurrence of a stroke after an otherwise perfect coronary operation is fraught with grief, frustration and until now helplessness. Despite careful assessment of carotids and the state of the ascending aorta with epiaortic ultrasound most contemporary “still heart” CABG series report a 1–2% incidence of major stroke.1,2 This low incidence of obvious cerebral infarction is due to the relatively small embolic insult generated by the aortic cross clamp. This insult, however, is bound to increase as our patients are triaged by invasive cardiology, diabetes, and age.3 When off pump CABG became routine with some surgeons, great advantages were predicted by the avoidance of pump related complications. The pump, however, is now so sophisticated that in itself, it adds very little in the way of morbidity.3 The big-ticket advantage for off pump is turning out to be a marked reduction in the incidence of cerebral infarction due to elimination of the emboli from the clamped aorta.4,5 Early off pump series did not show this because post-operative strokes due to hypercoaguaion and embolism generated by partial clamping were responsible for cerebral events.6,7 Now, with aggressive anti-platelet therapy and the avoidance of all aortic clamping an increasing number of off pump series are reporting no neurological events.8,12 The partial occluding clamp, which is traditionally used for, anastomosing grafts to the aorta can not only generate athero-embolism but also cause aortic dissection, which is usually fatal. The goal of performing aortic top ends without a clamp has driven industry to produce a number of anastomotic devices, all of which are predictably disposable and expensive. A clamp free, stapled, vein anastomotic device is popular despite a high incidence of complications including bleeding, thrombosis and aortic dissection. There were 192 adverse events reported to the FDA in 2-year period, sixteen of which were fatal.9,10 The best way to avoid aortic violation is to “go topless”; using other forms of inflow such as the mammary arteries, but this is not always possible for anatomical or technical reasons.11 E-mail address: [email protected] (D.E. Ross).
In this issue of “Heart Lung and Circulation” Vettath and colleagues describe a reusable obturator which occludes a punched hole in the aorta and enables a sutured anastomosis to be constructed without any clamping of the aorta. They used it for 269 vein to ascending aorta grafts without incident. This device allows a regular sutured anastomosis, the patency and safety of which is established. I have used a 5 mm Hagar’s dilator in a similar way, using it to occlude a 3.5 mm punched hole in the aorta. The weight of the instrument keeps it in place and there is no need for the purse string suture described by Vettath. It works well for arterial and vein grafts. Coronary surgery done without undue aortic manipulation will eliminate the most common cause of perioperative cerebral infarction. Having had the pleasure of no strokes in over 1000 off pump cases I am clearly biased but very happy to have avoided the grief and frustration on at least 10 occasions.
References 1. Taggart DP, Westaby S. Neurologicaland cognitive disorders after coronary artery bypass grafting. Curr Opin Cardiol 2001;16(5):271–6. 2. Borger MA, Ivanov J, Weisel RD, Rao V, Peniston CM. Stroke during coronary bypass surgery: principal role of cerebral macroemboli. Eur J Cardiothorac Surg 2001;19(5):627–32. 3. Lev-Ran O, Loberman D, Matsa M, Pevni D. Reduced strokes in the elderly: the benefits of untouched aorta off-pump coronary surgery. Ann Thorac Surg 2004;77:102–7. 4. Lund C, Hol PK, Lundblad R. Comparison of cerebral embolization during off-pump and on-pump coronary artery bypass surgery. Ann Thorac Surg 2003;76:765–70. ¨ 5. Boivie P, Hansson M, Engstrom KG. Embolic material generated by multiple aortic crossclamping: a perfusion model with human cadaveric aorta. J Thorac Cardiovasc Surg 2003;125:1451–60. 6. Cheng W, Denton TA, Fontana GP, Raissi S, Blanche C, Kass RM, Magliato KE, Mirocha J, Trento A. Off-pump coronary surgery: effect on early mortality and stroke. J Thorac Cardiovasc Surg 2002;124(2):313–20. 7. Quigley RL, Fried DW, Pym J, Highbloom RY. Off-pump coronary artery bypass surgery may produce a hypercoagulable patient. Heart Surg Forum 2002;6(2). 8. Singh SK, Mishra SK, Kumar D, Yadave RD, Agarwal R, Sinha SK. Total arterial revascularization on beating heart: experience in 803 cases. Asian Cardiovasc Thorac Ann 2003;11:107–12. 9. www.fda.gov/cdrh/maude.html search for “Symmetry bypass system”.
© 2004 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2004.04.006
236
Ross Editorial
EDITORIAL
10. Donsky AS, Schussler JM, Donsky MS, et al. Thromboticocclusion of the aortic ostia of saphenous venous grafts early after coronary artery bypass grafting by using the symmetry aortic connector system. J Thorac Cardiovasc Surg 2002;124:397–9. 11. Muneretto C, Negri A, Manfredi J, Terrini A, Rodella G, ElQarra S, Bisleri G. Safety and usefulness of compos-
Heart Lung and Circulation 2004;13:235–236
ite grafts for total arterial myocardial revascularization: A prospective randomized evaluation. J Thorac Cardiovasc Surg 2003;125:826–35. 12. Kobayashi J, Tagusari FO, Bando K, Niwaya FK, Nakajima H. Total arterial off-pump coronary revascularization with only internal thoracic artery and composite radial artery grafts. Heart Surg Forum 2002;6(1).
Editorial
Towards Stroke-Free Coronary Surgery Donald E. Ross Royal North Shore Hospital, Sydney, Australia Available online 26 August 2004
T
he occurrence of a stroke after an otherwise perfect coronary operation is fraught with grief, frustration and until now helplessness. Despite careful assessment of carotids and the state of the ascending aorta with epiaortic ultrasound most contemporary “still heart” CABG series report a 1–2% incidence of major stroke.1,2 This low incidence of obvious cerebral infarction is due to the relatively small embolic insult generated by the aortic cross clamp. This insult, however, is bound to increase as our patients are triaged by invasive cardiology, diabetes, and age.3 When off pump CABG became routine with some surgeons, great advantages were predicted by the avoidance of pump related complications. The pump, however, is now so sophisticated that in itself, it adds very little in the way of morbidity.3 The big-ticket advantage for off pump is turning out to be a marked reduction in the incidence of cerebral infarction due to elimination of the emboli from the clamped aorta.4,5 Early off pump series did not show this because post-operative strokes due to hypercoaguaion and embolism generated by partial clamping were responsible for cerebral events.6,7 Now, with aggressive anti-platelet therapy and the avoidance of all aortic clamping an increasing number of off pump series are reporting no neurological events.8,12 The partial occluding clamp, which is traditionally used for, anastomosing grafts to the aorta can not only generate athero-embolism but also cause aortic dissection, which is usually fatal. The goal of performing aortic top ends without a clamp has driven industry to produce a number of anastomotic devices, all of which are predictably disposable and expensive. A clamp free, stapled, vein anastomotic device is popular despite a high incidence of complications including bleeding, thrombosis and aortic dissection. There were 192 adverse events reported to the FDA in 2-year period, sixteen of which were fatal.9,10 The best way to avoid aortic violation is to “go topless”; using other forms of inflow such as the mammary arteries, but this is not always possible for anatomical or technical reasons.11 E-mail address: [email protected] (D.E. Ross).
In this issue of “Heart Lung and Circulation” Vettath and colleagues describe a reusable obturator which occludes a punched hole in the aorta and enables a sutured anastomosis to be constructed without any clamping of the aorta. They used it for 269 vein to ascending aorta grafts without incident. This device allows a regular sutured anastomosis, the patency and safety of which is established. I have used a 5 mm Hagar’s dilator in a similar way, using it to occlude a 3.5 mm punched hole in the aorta. The weight of the instrument keeps it in place and there is no need for the purse string suture described by Vettath. It works well for arterial and vein grafts. Coronary surgery done without undue aortic manipulation will eliminate the most common cause of perioperative cerebral infarction. Having had the pleasure of no strokes in over 1000 off pump cases I am clearly biased but very happy to have avoided the grief and frustration on at least 10 occasions.
References 1. Taggart DP, Westaby S. Neurologicaland cognitive disorders after coronary artery bypass grafting. Curr Opin Cardiol 2001;16(5):271–6. 2. Borger MA, Ivanov J, Weisel RD, Rao V, Peniston CM. Stroke during coronary bypass surgery: principal role of cerebral macroemboli. Eur J Cardiothorac Surg 2001;19(5):627–32. 3. Lev-Ran O, Loberman D, Matsa M, Pevni D. Reduced strokes in the elderly: the benefits of untouched aorta off-pump coronary surgery. Ann Thorac Surg 2004;77:102–7. 4. Lund C, Hol PK, Lundblad R. Comparison of cerebral embolization during off-pump and on-pump coronary artery bypass surgery. Ann Thorac Surg 2003;76:765–70. ¨ 5. Boivie P, Hansson M, Engstrom KG. Embolic material generated by multiple aortic crossclamping: a perfusion model with human cadaveric aorta. J Thorac Cardiovasc Surg 2003;125:1451–60. 6. Cheng W, Denton TA, Fontana GP, Raissi S, Blanche C, Kass RM, Magliato KE, Mirocha J, Trento A. Off-pump coronary surgery: effect on early mortality and stroke. J Thorac Cardiovasc Surg 2002;124(2):313–20. 7. Quigley RL, Fried DW, Pym J, Highbloom RY. Off-pump coronary artery bypass surgery may produce a hypercoagulable patient. Heart Surg Forum 2002;6(2). 8. Singh SK, Mishra SK, Kumar D, Yadave RD, Agarwal R, Sinha SK. Total arterial revascularization on beating heart: experience in 803 cases. Asian Cardiovasc Thorac Ann 2003;11:107–12. 9. www.fda.gov/cdrh/maude.html search for “Symmetry bypass system”.
© 2004 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2004.04.006
236
Ross Editorial
EDITORIAL
10. Donsky AS, Schussler JM, Donsky MS, et al. Thromboticocclusion of the aortic ostia of saphenous venous grafts early after coronary artery bypass grafting by using the symmetry aortic connector system. J Thorac Cardiovasc Surg 2002;124:397–9. 11. Muneretto C, Negri A, Manfredi J, Terrini A, Rodella G, ElQarra S, Bisleri G. Safety and usefulness of compos-
Heart Lung and Circulation 2004;13:235–236
ite grafts for total arterial myocardial revascularization: A prospective randomized evaluation. J Thorac Cardiovasc Surg 2003;125:826–35. 12. Kobayashi J, Tagusari FO, Bando K, Niwaya FK, Nakajima H. Total arterial off-pump coronary revascularization with only internal thoracic artery and composite radial artery grafts. Heart Surg Forum 2002;6(1).