| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2004;77:379-380
© 2004 The Society of Thoracic Surgeons
Service de Chirurgie Cardiaque, CHU Grenoble, BP 217 Grenoble Cedex 9, France
e-mail: ochavanon{at}chu-grenoble.fr
To the Editor:
We read with great interest the article by Haase and colleagues [1] comparing off-pump coronary artery bypass grafting (OPCAB) using an arterial graft with standard CABG. Although it was not clear whether venous grafts were used for the standard CABG group, we agree with the policy of combining OPCAB with arterial grafts. The OPCAB procedure has well-known advantages (decrease in myocardial injury, avoidance of cardiopulmonary bypass [CPB] economic considerations), and the use of an arterial graft is justified because of the superiority of these grafts compared with venous conduits with reference to long-term patency and patient survival.
However, a third justification for this combined approach should be stressed: avoidance of manipulation of the aorta, ie, absolutely no touching this vessel. In patients undergoing cardiac surgical procedures, significant atheromatous disease of the ascending aorta ranging between 14% and 29% [2] is clinically underestimated because epiaortic ultrasonography is not routinely used, and such disease is strongly associated with perioperative stroke. The use of OPCAB can decrease the risk of neurologic complication, mainly by avoiding the risk related to cannulation of the aorta and aortic cross-clamping, but aortic side-clamping is often required for reimplanting a saphenous vein graft or a free arterial graft. Moreover, lateral clamping of the aorta during OPCAB may increase the risk of intimal lesions that can lead to aortic dissection because the systemic systolic arterial pressure is pulsatile and higher than under CPB [3].
The "no-touch" aortic technique is a very elegant method that uses a pedicled arterial graft (left internal mammary artery [LIMA], right internal mammary artery [RIMA], gastroepiploic artery [GEA]) and radial artery with a T or Y graft in multiple combinations. A recent study of ours [4] compared the early and midterm results of total arterial CABG using the LIMA and the GEA, both as pedicled arterial grafts, with and without CPB. The homogeneous OPCAB group (group A, 91 patients; average of 2.26 distal anastomoses per patient) was compared with a group of patients having operation with CPB and cardioplegia with the same grafts (group B, 80 patients; average of 2.5 distal anastomoses per patient). Although the patients were more ill in group A (EuroSCORE, 3.4 versus 2.5 [p < 0.05]; mean left ventricular ejection fraction, 0.546 versus 0.631 [p < 0.001]; severe aortic calcification, 6 patients versus 0 patients), transfusion, atrial fibrillation, postoperative inotropic support, and hospital stay were similar in both groups. A decrease in myocardial injury in the OPCAB group was also evident, with fewer myocardial infarctions in group A (one versus four), and no postoperative intraaortic balloon pump requirement in group A (versus 2 in group B). It should be noted that when first seen, 2 patients in group B had sustained an embolic stroke versus none in group A, although this was not significant as in the study of Haase and co-workers [1]. Patients showed good functional results at midterm follow-up.
To date, we have operated on a total of 246 patients using total arterial revascularization with an OPCAB technique ("no-touch" method) with at least two coronary anastomoses per patient: 56, LIMA alone (sequential graft); 147, GEA–LIMA; 20, RIMA–LIMA; 22, GEA–RIMA–LIMA; and 1, GEA–RIMA. Indications were based on favorable anatomy (of left anterior descending coronary artery alone or territories of it and right coronary artery) territory, or necessity: aortic calcification or need of dialysis. Comparison with a matched cohort using CPB and venous conduits confirmed that OPCAB with arterial grafts was safe, even in high-risk and select patients.
This strategy involving arterial grafts, OPCAB, and the "no-touch" aortic technique may usefully complete the surgeon's armamentarium in the field of CABG, particularly when there is an atheroma of the ascending aorta. However, it may not be feasible in every instance because of technical factors: inability to use the OPCAB procedure and risk of inadequate flow in arterial conduits related to the coronary target.
Acknowledgments
We thank Dr Emmanuel Colle for editing the text.
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
