ORIGINAL ARTICLES  CARDIAC SECTION 

The Journal of Cardiovascular Surgery 2001 August;42(4):451-6

Copyright © 2009 EDIZIONI MINERVA MEDICA

lingua: Inglese

Off-pump coronary artery bypass grafting. Excellent results in a group of selected high-risk patients

Bittner H. B., Savitt M. A., McKeown P. P., Lucke J. C.

From the Division of Cardiovascular and Thoracic Surgery University of Minnesota Minneapolis MN, and *VAMC Asheville, NC, USA

Background. Off-­pump cor­o­nary ­artery ­bypass graft­ing (­OPCABG) ­has ­assumed an increas­ing ­role in ­many sur­gi­cal prac­tic­es. The ­ideal can­di­date ­has ­not ­been ­defined, ­but ­high-­risk ­patients ­seem to ben­e­fit ­most ­when car­di­o­pul­mo­nary ­bypass (­CPB), aor­tic ­cross clamp­ing ­and car­di­o­pleg­ic ­arrest ­are avoid­ed.
Methods. Fourteen ­high-­risk ­patients (­age 52 to 81 ­years, 1 ­female, EF 44%±8, Parsonnet ­score 23±4) ­were stud­ied. They pre­sent­ed ­with ­acute cor­o­nary syn­droms on plate­let gly­co­pro­tein IIb/IIIa antag­o­nists, ­acute myo­car­dial infarc­tion, wors­en­ing ­renal fail­ure, decom­pen­sat­ing ischem­ic car­di­om­yo­pa­thy, relig­ious ­beliefs ­and deni­al of ­blood trans­fu­sion, ­and ­severe periph­er­al/cereb­ro­vas­cu­lar dis­ease (­total ­bilateral inter­nal carot­id artery occlu­sion ­and/or >90% sten­o­sis). These ­patients under­went ­OPCABG ­via ster­not­o­my ­with ­the inten­tion of com­plete cor­o­nary revas­cu­lar­iza­tion.
Results. An aver­age of 2.3 ­grafts/­patient ­were per­formed ­and ­the pos­te­ri­or descend­ing ­artery (­PDA) ­and mar­gi­nal branch­es of ­the cir­cum­flex ­artery (­LCX) ­were graft­ed in 79% of ­the ­patients. There ­were 3 ­events of ­intraoperative car­diac ­arrest pre­cip­i­tat­ed by occlu­sion of ­right cor­o­nary ­artery (­RCA) or posi­tion­ing a car­di­om­e­ga­ly ­heart lead­ing to imme­di­ate intra­vas­cu­lar shunt­ing (2) ­and/or con­ver­sion to ­CPB (1). One ­patient ­was con­vert­ed to ­CPB ­and ­graft revi­sion (­intraoperative ultra­sound ­and prob­ing). The mor­tal­ity ­rate ­was 0% ­and ­one ­stroke ­was ­observed on ­post-operative ­day 1. Coronary angio­gra­phy (n=6) ­showed no sig­nif­i­cant sten­o­sis.
Conclusions. ­OPCABG com­plete revas­cu­lar­iza­tion is fea­sible in ­high-­risk ­patients ­with ­low mor­bid­ity ­and mor­tal­ity ­and excel­lent ear­ly ­results. ­OPCABG ­may be indi­cat­ed in ­patients on plate­let recep­tor antag­o­nists pre­vent­ing bleed­ing com­pli­ca­tions. Cardiomegaly ­can ­cause dif­fi­cult ­off-­pump ­LCX ­and ­PDA expo­sure ­and sta­bil­iza­tion. ­RCA graft­ing ­off-­pump is ­less tol­er­at­ed ­and ­PDA graft­ing is pre­ferred. High-­risk ­patients ­for ­CPB ­are ­the ­ones ­who ­may ben­e­fit ­the ­most ­from ­OPCABG.