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Ann Thorac Surg 2000;69:1042-1047
© 2000 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, East Carolina University, School of Medicine, Greenville, North Carolina, USA
Address reprint requests to Dr Koutlas, Division of Cardiothoracic Surgery, East Carolina University, School of Medicine, 600 Moye Blvd, Greenville, NC 27858-4354
e-mail: tkoutlas{at}brody.med.ecu.edu
Presented at the Forty-Sixth Annual Meeting of the Southern Thoracic Surgical Association, San Juan, Puerto Rico, Nov 4–6, 1999.
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Abstract |
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Methods. OP-CABs were performed in 53 patients aged 75 years and older, at Pitt County Memorial Hospital from January 1996 to October 1999, either through a median sternotomy or an anterior thoracotomy. These results were compared with 220 patients who underwent standard coronary artery bypass graft (CABG) operation using CPB during the same time period.
Results. Mean patient age for both groups was 79 ± 0.5 years and preoperative risk factors were similar. There were no differences in postoperative myocardial infarction, atrial fibrillation, bleeding, neurologic complications, or renal failure. There were no deaths after OP-CAB, compared with the 7.6% operative mortality rate after CABG (p < 0.05). The OP-CAB group had a significantly shorter postoperative length of stay (4.4 ± 0.4 days vs 8.4 ± 0.6 days) and lower transfusion requirements (0.4 ± 0.1 units packed red blood cells vs 1.9 ± 0.2 units packed red blood cells) than the CABG group.
Conclusions. Our data demonstrate that OP-CAB is a safe and efficacious method of myocardial revascularization in the elderly, and may actually be preferential in these patients when applicable.
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Introduction |
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Beating heart, or "off-pump," coronary artery bypass has gained popularity in the United States over the last few years, with the hope of lessening the morbidity of surgical coronary revascularization by avoiding the use of cardiopulmonary bypass. While there was initial concern regarding the long-term patency of bypass grafts using this technique, early results have shown beating heart procedures to be a safe alternative to conventional myocardial revascularization with cardiopulmonary bypass in selected individuals [4–7]. In addition, off-pump coronary artery bypass has been shown to significantly reduce transfusion requirements, postoperative length of stay, and hospital costs when compared with standard coronary artery bypass operations [5, 8, 9].
Elderly patients often have significant comorbid illnesses present (prior stroke, renal insufficiency, pulmonary disease, etc) that may increase the risk of standard coronary artery bypass operations that require cardiopulmonary bypass. While most studies on beating heart coronary artery bypass have focused on younger patients, elderly patients may in fact benefit the most from the routine use of off-pump procedures. To better assess the safety and efficacy of beating heart myocardial revascularization in the elderly patient population, we reviewed our experience with off-pump coronary artery bypass operations in patients 75 years of age and older. We then compared our results with a similar group of patients who had undergone standard coronary artery bypass operations using cardiopulmonary bypass during the same time period.
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Material and methods |
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The mean age for the overall study population was 78.7 ± 0.2 years. There were 144 males, and 129 females included in the study, for a male/female ratio of 1.1:1. Over 90% of patients were in New York Heart Association (NYHA) angina class III or IV, and overall mean ejection fraction was 50% ± 1%. Over 75% of patients were considered urgent status for surgery.
The OP-CAB procedures were performed by two surgeons in our group (JRE, TCK). The decision to perform an OP-CAB was surgeon preference, and depended on location and adequacy of target vessels as well as comorbid illnesses present. Those patients in the OP-CAB group had their revascularization performed either through a median sternotomy or an anterior thoracotomy, depending on the location of the target vessels (median sternotomy, 19; anterior thoracotomy, 34; anterior thoracotomy only, 25; anterior thoracotomy plus PTCA (hybrid procedure), 6; and anterior thoracotomy with conversion to median sternotomy, 3). Catheter-based interventions were performed additionally in 6 patients who underwent an anterior thoracotomy. These patients were part of a "hybrid" study group, combining minimally invasive direct coronary artery bypass (MIDCAB) with percutaneous transluminal coronary angioplasty. Angioplasty procedures were performed either before the OP-CAB or concomitantly, depending on the preference of the cardiologist. In 3 patients, off-pump procedures were attempted through an anterior thoracotomy, but the procedure required conversion to a standard CABG using a median sternotomy and cardiopulmonary bypass. This was due either to difficult access to the left anterior descending artery, or an intramyocardial or poor quality vessel. All 3 patients had unremarkable postoperative courses, and their data are then included in the CABG group.
A total of 223 patients underwent standard coronary artery bypass via median sternotomy, using hypothermic cardiopulmonary bypass and cold cardioplegic myocardial arrest. All the surgeons in our group performed procedures on patients in the CABG group. The CABG group served as a statistical control group for the OP-CAB group.
Surgical technique
OP-CABs performed via anterior thoracotomy utilized an 8-cm to 10-cm submammary incision. The pleural space was usually entered at the 4th intercostal space, without rib resection. The mammary artery was mobilized to the level of the subclavian vein under direct vision using a commercially available retractor (Thora-lift; U.S. Surgical Corp, Norwalk, CT; and LIMA-Vator; Genzyme Corporation, Cambridge, MA). In those patients who underwent a median sternotomy for the OP-CAB, the mammary artery and saphenous vein were harvested in standard fashion. In both instances, once procurement of the conduit was nearly completed, the patient was given half the calculated cardiopulmonary bypass dose of heparin. Activated clotting times were maintained during the remainder of the procedure at greater than 300 seconds. A specialized retractor and heart stabilizer were used (Genzyme Corporation). Either a proximal vessel occluder or an intraluminal shunt (Cardiothoracic Systems, Cupertino, CA) was used, depending on the nature of the proximal obstruction. This maintained a relatively bloodless field. Visualization of the anastomosis was additionally enhanced with the use of a humidified carbon dioxide blower. Proximal graft anastomoses were performed to the ascending aorta in standard fashion using an aortic partial occlusion clamp. Intraoperative angiography was performed on patients early in our experience, but generally a hand-held Doppler probe was used to evaluate blood flow in the bypass grafts. Once the revascularization was complete, heparin anticoagulation was reversed with protamine sulfate.
Postoperative care
Patients in the OP-CAB group who underwent an anterior thoractomy usually were given a dose of intrathecal narcotic before induction of general anesthesia. Most patients were extubated at the end of the procedure. After a brief stay in the postanesthesia care unit, they were transferred to a monitored "step-down" unit bed. OP-CAB patients who underwent median sternotomy were generally transferred directly to the Cardiac Surgery Intensive Care Unit after surgery, then extubated within a few hours of the operation.
Patients in the CABG group were transferred directly to the Cardiac Surgery Intensive Care Unit after surgery. Sedation was weaned 4 to 8 hours after the operation. The majority of patients were extubated within 24 hours of surgery.
There are no standard transfusion criteria for our cardiothoracic surgery division, and the decision to transfuse blood products was determined by the individual surgeon. However, our general indications for transfusion were no different between the two groups. In elderly patients, we usually try to maintain a postoperative hematocrit greater than 25%. The criteria for transfusion of coagulation factors was the presence of intraoperative coagulopathy, or abnormal coagulation times combined with postoperative mediastinal tube drainage greater than 100 cc/h.
Statistical analysis
Patient and outcome variables were expressed either as a percentage of the total or mean ± standard error of the mean. Student’s t test was used to analyze continuous variables, while Fisher’s exact test was used for discrete variables. The statistical analysis was performed using a computer software package (NCSS, Kayesville, UT). Statistical differences were considered significant if the p value was less than 0.05.
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Results |
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The perioperative usage of blood and blood products also differed significantly between the two groups (Fig 1). Patients in the CABG group averaged 1.9 ± 0.2 units of packed red blood cells during their operation and postoperative course, while mean perioperative blood use for the OP-CAB group was only 0.4 ± 0.1 units (p < 0.01). When total blood product use (including fresh-frozen plasma, cryoprecipitate, and platelets) was considered, this difference was even more pronounced. Average total blood product use per patient in the CABG group was 4.5 ± 0.8 units, compared with only 0.4 ± 0.1 units per patient in the OP-CAB group (p < 0.01).
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Comment |
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Widespread interest in minimally invasive approaches to cardiac surgery initiated new developments in off-pump coronary bypass surgery during the mid-1990s. Acuff and associates’ initial report of direct bypass of the left anterior descending coronary artery using a limited anterior thoracotomy sparked a great deal of interest in this technique [14]. Even though the use of minimally invasive direct coronary artery bypass (MIDCAB) operations rapidly increased, even in large institutions, this represented only a fraction of the volume of coronary artery bypass surgery, because most patients were referred with multivessel disease. Meanwhile, the safety of multivessel off-pump coronary bypass procedures was demonstrated by several large international series [15–17]. This stimulated considerable interest in off-pump coronary surgery in the United States. Since that time, operative techniques have been developed to enable exposure of most coronary vessels. The latest generation of stabilizing retractors, including the Octopus Tissue Stabilization System (Medtronic, Minneapolis, MN) and the Cohn Stabilizer (Genzyme Corp, Cambridge, MA), have permitted a smooth transition from limited off-pump procedures to complex multivessel coronary revascularizations on the beating heart.
Early enthusiasm for off-pump procedures was dampened by the technical concerns of performing a coronary anastomosis on the beating heart. Gundry and associates reported the Loma Linda experience with off-pump coronary revascularizations in 1997, which demonstrated on long-term follow-up a twofold increase in the frequency of recatheterization after beating heart procedures compared with CABG using cardiopulmonary bypass [6]. Subramanian and associates demonstrated significant improvement in early graft patency once the use of a mechanical stabilizer became routine [7]. Subsequent studies utilizing mechanical stabilizing systems demonstrated excellent early graft patency [4, 8].
Once the safety of off-pump coronary procedures had been established, more recent studies of the use of beating heart surgery have focused on improving operative outcome by eliminating the morbidity of cardiopulmonary bypass. Significant improvements in postoperative length of stay have been demonstrated using off-pump techniques [5, 8, 9, 18]. This has resulted in significant reductions in hospital costs when compared with traditional CABG procedures [9, 18]. Limited studies have also suggested improvements in both postoperative neurologic and renal function in off-pump procedures when compared with CABG using cardiopulmonary bypass [19, 20].
Our current contraindications to performing off-pump coronary bypass procedures hinge mainly on the coronary artery anatomy. Small or diffusely diseased target vessels do not lend themselves readily to beating heart operations. Location of target vessels has become less of an obstacle in off-pump surgery. Although lesions involving the circumflex system remain the most problematic, exposure is usually sufficient, except for obtuse marginal branches that require grafting close to the atrio-ventricular groove. Hemodynamic instability may occur with difficult exposure of coronary vessels, but in general, this is not a problem. Finally, morbid obesity is a relative contraindication to off-pump procedures, especially those requiring an anterior thoracotomy approach.
The treatment of symptomatic coronary artery disease in the elderly patient presents several difficult issues for the healthcare provider. The risk of major morbidity or death is significantly higher for elderly patients after coronary artery bypass surgery. The incidence of nonfatal complications reported for elderly patients after coronary artery bypass ranges from 30% to 73% [21, 22]. In-hospital mortality rates for elderly patients undergoing isolated coronary artery bypass procedures range from 5% to 24% [21–24]. Likewise, the results of angioplasty procedures in the elderly reflect higher risks. Elderly patients have a higher rate of procedure-related complications, and reported percutaneous transluminal coronary angioplasty procedural mortality rates of 2% to 7% [25, 26]. Long-term follow-up has also demonstrated a higher risk of restenosis in the elderly [26]. Despite the increase in morbidity and mortality in elderly patients, symptom relief, independence, and long-term survival after coronary bypass operations are quite good. Over 80% of elderly patients remain free of anginal symptoms postoperatively [24, 27]. Studies have shown over 90% of patients were discharged home after surgery, and only 6% required discharge to a skilled-care facility. Recent long-term follow-up data from the Coronary Artery Surgery Study (CASS) showed 59% of patients aged 75 years at the time of surgery are alive 10 years after surgery, while 33% are alive at 15 years [28]. These data appear to support an aggressive approach to the treatment of coronary artery disease in the elderly.
This study reviewed our initial results with OP-CAB surgery in patients 75 years of age and older. The operative mortality rate of 7.6% after standard coronary artery bypass in this series is comparable with earlier studies focusing on myocardial revascularization in elderly patients [21–24]. Despite relatively similar preoperative risk profiles and predicted mortality, there were no operative deaths in the OP-CAB group. Even in high-risk elderly patients, there was a significant reduction in postoperative length of stay after OP-CAB procedures. Likewise, our study also demonstrated the transfusion requirement after off-pump coronary procedures to be significantly less than after standard coronary artery bypass. These results support previous studies of beating heart bypass procedures.
The major limitation of this study involves patient selection for the OP-CAB group. There were no major differences in preoperative risk factors between the two groups. If anything, our trend has been to utilize off-pump procedures in the elderly patient whose preoperative risk profile precludes the use of cardiopulmonary bypass. A true prospective, randomized study comparing beating heart surgery with CABG using cardiopulmonary bypass would be quite difficult to perform, because subtle variations in coronary artery anatomy may limit the use of off-pump procedures. At this time, we prefer to individualize the use of off-pump coronary bypass techniques, in an attempt to compliment our traditional methods of coronary artery bypass, rather than replace them.
In summary, OP-CAB is a safe and effective method of myocardial revascularization in elderly patients. Operative mortality rate, postoperative length of stay, and perioperative blood usage were improved by the use of OP-CAB in this patient population when compared with standard CABG. While we do not recommend this technique for all coronary revascularization procedures, consideration should be given to the use of beating heart techniques in the elderly if possible.
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