Combined use of off-pump techniques and a sutureless proximal aortic anastomotic device reduces cerebral microemboli generation during coronary artery bypass grafting

Department of Surgery, Duke University, Durham, North Carolina, United States
Journal of Thoracic and Cardiovascular Surgery (Impact Factor: 3.99). 11/2003; 126(5):1561-7. DOI: 10.1016/S0022-5223(03)01039-0
Source: PubMed

ABSTRACT Intraoperative cerebral microemboli are associated with the development of postoperative stroke and neurocognitive decline in patients undergoing coronary artery bypass grafting. Although cardiopulmonary bypass is responsible for the generation of a significant number of such emboli, the elimination of cardiopulmonary bypass alone has not been conclusively shown to improve neurocognitive outcome. The current study was performed to determine the effects of combined off-pump coronary artery bypass grafting and sutureless proximal aortic anastomotic techniques on the generation of intraoperative cerebral microemboli compared with standard coronary artery bypass grafting techniques of cardiopulmonary bypass and hand-sewn proximal anastomoses.
Fifty-three patients underwent off-pump coronary artery bypass grafting by using the sutureless Symmetry aortic connector device (St Jude Medical, St Paul, Minn) for all proximal anastomoses. Eighteen of these patients received intraoperative transcranial Doppler ultrasonography to determine right- and left-sided cerebral microembolic counts. These results were compared with those obtained from a similar group of 17 patients undergoing standard coronary artery bypass grafting, in whom cardiopulmonary bypass and hand-sewn proximal anastomoses were used.
Our use of the proximal anastomotic device in patients undergoing coronary artery bypass grafting was safe, with no aortic complications, postoperative strokes, or in-hospital deaths. Microembolic counts to both the right and left cerebral circulation were significantly reduced in the patients undergoing off-pump coronary artery bypass grafting (right = 21.9 +/- 20.7 emboli, left = 24.9 +/- 19.2 emboli) compared with those in patients undergoing standard coronary artery bypass grafting (right = 181.6 +/- 85.3, left = 189.9 +/- 60.401, P <.0001).
Our use of a sutureless proximal anastomotic device during off-pump coronary artery bypass grafting is safe and significantly decreases cerebral microembolism when compared with standard coronary artery bypass grafting with cardiopulmonary bypass and hand-sewn anastomoses. Long-term follow-up is needed to determine the effects of this technical strategy on neurocognitive outcome.

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    ABSTRACT: The first part of the paper analyses off pump coronary bypass surgery (OPCAB), which is compared with traditional on-pump procedures (ONCAB). Furthermore ,the paper evaluates the use of a new automatic device for performance of the proximal anastomosis and finally the effect of intracoronary shunt on myocardial ischemia during OPCAB. The main goal of the paper is to demonstrate the importance of careful clinical studies during introduction of the new techniques in cardiac surgery. Statistical analysis was performed on a large clinical database from Buffalo, NY, USA comparing OPCAB and ONCAB. Subsequently, a sequential controlled clinical study compared patients operated with a new automatic connector device to patients operated with classic suture technique. Finally a randomized study was performed to evaluate the effect of the use of an intracoronary shunt during construction of distal anastomosis. The studies from Buffalo demonstrated reduced complications rates in high risk patients when OPCAB techniques were used. The use of connector devices in saphenous venous anastomosis was clearly inferior to standard technique. Intracoronary shunt was found to be beneficial by preventing ischemia. Numerous studies have studied the results of OPCAB vs ONCAB and although results are variable it seems that OPCAB is advantageous in high risk patients, while in low risk patients there are much less if any benefit. The results of the studies of connector devices caused the product to be taken off the market. The value of shunt in OPCAB was clearly demonstrated by the randomized studies. The investigations presented in this paper clearly demonstrates the importance of well-designed studies when new surgical methods are introduced. In the present period of rapid technological development, carefully controlled, un-biased clinical trials are crucial to preserve patient safety and avoid unjustified societal cost.
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    ABSTRACT: The benefit of off-pump coronary artery bypass (OPCAB) surgery may be reduced by strokes caused by microemboli produced after aortic side-clamping for proximal bypass anastomoses. The Heartstring device allows constructing proximal bypass anastomoses without side-clamping of the aorta. This retrospective study describes 260 consecutive patients who underwent OPCAB surgery; 442 proximal anastomoses were performed with the Heartstring device in this series. Ten percent of the patients were randomly sampled before discharge to undergo a coronary angiogram for assessment of graft patency. Intraoperative Doppler measurements confirmed regular bypass function. Early mortality occurred in 4 patients (1.5%), and stroke occurred in 2 patients (0.8%). Device-related bleeding was negligible, and there were no cases of aortic dissection. Perioperative ischemia occurred in 8 patients (3.1%). Predischarge coronary angiography evaluations in 25 of the patients (of 260) showed that all 42 Heartstring-assisted anastomoses (of 442) were patent. Clampless performance of proximal bypass anastomoses combined with OPCAB is associated with a very low incidence of stroke complications. Short-term follow-up has shown excellent results regarding bypass patency and other adverse events. Prospective randomized trials are required to confirm the advantage of this technique.
    Heart Surgery Forum 12/2011; 14(6):E360-5. DOI:10.1532/HSF98.20111036 · 0.56 Impact Factor

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