Asian Cardiovasc Thorac Ann 1998;6:257-259
© 1998 Asia Publishing EXchange Pte Ltd
No-Touch Method for Off-Pump Coronary Artery Bypass Grafting
Bülent Tünerir, MD,
Recep Aslan, MD,
Tu
rul Kural, MD,
Yavuz Be
oul, MD
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Department of Cardiovascular Surgery Osmangazi University Medical School and Research Hospital Eskiehir, Turkey
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For reprint information contact: Bülent Tünerir, MD Hasan Polatkan Bulvari No. 122 D. 19 Eskiehir 26120, Turkey Tel: 90 222 225 0606 Fax: 90 222 230 6215 Email:utuneri1{at}akbank.com.tr
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ABSTRACT
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We describe a simple no-touch method of coronary artery bypass grafting that facilitates anastomosis on the beating heart by means of a blower. This technique avoids clamping or occluding the target coronary artery. We successfully performed 22 distal anastomoses in 12 direct off-pump coronary artery bypass operations with no in-hospital mortality or cardiac complications. Two patients underwent a left anterolateral small thoracotomy for single-vessel disease and 10 had a median sternotomy for double-vessel disease. The technique provided a dry operative field and adequate exposure at the moment of suture.
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INTRODUCTION
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Cardiopulmonary bypass (CPB) can be associated with several adverse effects including mechanical trauma to blood components, activation of complement, impaired hemostasis, and diminished oxygen delivery.1,2 Because of this, coronary artery bypass grafting (CABG) without CPB has become increasingly common.4–6 Currently, this procedure is successfully performed via a median sternotomy, minithoracotomy, parasternal incision, or partial sternotomy. In all of these techniques, CABG on the beating heart requires temporary interruption of coronary flow in the recipient artery by means of bulldog clamps, snares, silicone rubber surrounding sutures, or intraluminal occluders.6,7 Such maneuvers could cause severe transmural or intimal damage to the target coronary vessel with either acute thrombosis or later intimal hyperplasia or atherogenesis.8 We describe a simple no-touch method for CABG on the beating heart that facilitates the anastomosis and avoids coronary damage by means of a blower.
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PATIENTS AND METHODS
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From January 1996 to July 1997, 36 consecutive patients with single-vessel or double-vessel coronary disease underwent CABG without CPB. In 12 of these, target coronary artery clamping was not used. Two patients had isolated left anterior descending coronary artery (LAD) disease and 10 had LAD plus right coronary artery disease. Selection was based on a distal LAD or crux of theright coronary artery diameter of at least 1.5 mm at angiography and no calcification. We performed direct coronary grafting on a beating heart via a left anterolateral small thoracotomy in patients with isolated LAD disease and via a median sternotomy in patients with double-vessel disease.
LEFT ANTEROLATERAL SMALL THORACOTOMY
Anesthesia was induced with fentanyl and sodium thiopental and maintained with fentanyl. Muscular relaxation was obtained with pancuronium bromide. A double-lumen endotracheal tube was used to avoid left lung ventilation. The patient was positioned supine and a small rubber cushion (15 cm thick) was inserted above the head. The chest was opened via a left anterolateral small thoracotomy incision of 10 to 13 cm in the 5th intercostal space. The medial edge of the incision was 3 to 4 cm lateral to the left internal mammary artery (LIMA). The pleural cavity was opened, the lung was deflated, and the LIMA was identified by direct vision and palpation. With the patient in the Trendelenburg position, the LIMA was harvested as a pedicle from the first rib down to the 7th intercostal space. After harvesting the LIMA, 100 IU·kg–1 heparin sulfate was given. The pericardium was opened vertically to inspect the LAD and locate a site for the anastomosis. Two 4/0 polypropylene radial sutures were inserted through the fat surrounding the LAD on both sides and fixed to the edges of the wound to reduce movement of the artery and facilitate anastomosis. A cardioselective beta blocker was given intravenously to reduce the heart rate to 50 to 60 beats per minute and 2% lignocaine hydrochloride was applied topically to the epicardial surface to reduce cardiac excitability. A 5-mm to 8-mm length of the LAD was opened longitudinally and a blower (Visuflo SSVW-001; Research Medical, Inc., Midvale, UT, USA) was directed at the arteriotomy site to clear blood during suturing (Figure 1
). A second bacterial filter was added to the air line of the blower. The LIMA-to-LAD anastomosis was completed with a running 7/0 polypropylene suture by the parachute technique. Hemostasis was carefully checked, a drain was positioned in the left pleural cavity, and the wound was closed in the usual fashion.
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Figure 1. Clear and dry operative field on a beating heart by using a blower at the arteriotomy site on the left anterior descending coronary artery.
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MEDIAN STERNOTOMY
Patients with two-vessel disease underwent a standard median sternotomy. After harvesting the LIMA and heparinization, the pericardium was opened. The LIMA-to-LAD anastomosis was completed first to reduce the left heart ischemic time. Then, a saphenous vein graftwas anastomosed to the crux of the right coronary artery. Both anastomoses were carried out as described aboveon the beating heart using the Visuflo blower without coronary artery clamping.
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RESULTS
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The operative times in the 2 thoracotomy patients were 57 and 72 minutes and the mean operative time in the10 sternotomy patients was 120 ± 12 minutes. The mean anastomosis time was 9 ± 4.1 minutes (range, 5 to 13 minutes) in the total of 22 distal anastomoses. Postoperative ventilatory support was required for 2.8 and5.2 hours in the thoracotomy patients and for a mean period of 8 ± 2.1 hours in sternotomy group. Postoperative blood loss was 270 and 291 mL in the thoracotomy patients and a mean of 460 ± 33 mL after sternotomy.No patient required donor blood transfusion. There were no in-hospital deaths and no cardiac or noncardiac complications.
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DISCUSSION
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In spite of the widespread clinical success and reliability of CPB, extracorporeal circuits expose blood to shear stresses and to contact with large areas of synthetic surfaces. This results in mechanical damage to blood components and activation of biological cascades, which may contribute to the development of a generalized inflammatory response and organ dysfunction.1,2 Minimally invasive direct coronary artery bypass grafting performed on a beating heart avoids the use of CPB.9This technique has given encouraging early clinical results although there is concern regarding its technical limitations and the quality of anastomosis as well as lesions at the snare sites on the target coronary arteries.11–12
CABG on the beating heart requires temporary interruption of flow in the target artery and stabilization of the anastomosis site. Snaring sutures, tourniquets, bulldog clamps, or intraluminal occluders have been placed around or on the coronary vessel to achieve a bloodless field. Borst and colleagues8 warned of the risk in exerting traction on the proximal and distal coronary occlusion slings to improve coronary stabilization; too much traction might injure the coronary wall and result in focal stenosis due to intimal hyperplasia. We believe that mechanical coronary-occluding maneuvers should be avoided as far as possible to minimize intimal damage in the target artery. The use of a blower facilitates anastomosis on the beating heart by providing a bloodless and dry operative field with good vision during suturing.
Another important consideration is that mechanical devices for cardiac wall immobilization might be extremely traumatic for target vessels. We prefer to use pharmacological immobilization (pharmacologically-induced bradycardia) and double-sided epicardial traction sutures for our off-pump coronary grafting operations. We believe that mechanical immobilization procedures such as coronary clamping, occluding, snaring, or applying a wall immobilizer may cause transmural or intimal damage.8 This damage may lead to either acute thrombosis or later intimal hyperplasia or atherogenesis; thus early or late failure of the coronary bypass graft might occur.
Although we recognize that longer follow-up and experience are needed, we believe that the no-touch method we have described here will have its place among the techniques of myocardial revascularization on the beating heart.
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REFERENCES
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ABSTRACT
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