Avoidance of Aortic Side-Clamping for Proximal Bypass Anastomoses: Better Short-term Outcome?
DOI:
https://doi.org/10.1532/HSF98.20111036Abstract
Objectives: 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.
Methods: 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.
Results: 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. Conclusions: 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.
References
Athanasiou T, Ashrafian H, Krasopoulos G, et al. 2006. Clampless arterial coronary artery bypass grafting with the use of magnetic coupling devices. J Card Surg 21:69-74; discussion 75-6.nBarbut D, Hinton RB, Szatrowski TP, et al. 1994. Cerebral emboli detected during bypass surgery are associated with clamp removal. Stroke 25:2398-402.nBerson AJ, Smith JM, Woods SE, Hasselfeld KA, Hiratzka LF. 2004. Off-pump versus on-pump coronary artery bypass surgery: does the pump influence outcome? J Am Coll Surg 199:102-8.nCarrel TP, Eckstein FS, Englberger L, Windecker S, Meier B. 2003. Pitfalls and key lessons with the Symmetry proximal anastomotic device in coronary artery bypass surgery. Ann Thorac Surg 75:1434-6.nCavendish JJ, Penny WF, Madani MM, et al. 2004. Severe ostial saphenous vein graft disease leading to acute coronary syndromes following proximal aorto-saphenous anastomoses with the symmetry bypass connector device: is it a suture device or a "stent"? J Am Coll Cardiol 43:133-9.nDi Giammarco G, Pano M, Cirmeni S, Pelini P, Vitolla G, Di Mauro M. 2006. Predictive value of intraoperative transit-time flow measurement for short-term graft patency in coronary surgery. J Thorac Cardiovasc Surg 132:468-74.nGuerrieri Wolf L, Abu-Omar Y, Choudhary BP, Pigott D, Taggart DP. 2007. Gaseous and solid cerebral microembolization during proximal aortic anastomoses in off-pump coronary surgery: the effect of an aortic side-biting clamp and two clampless devices. J Thorac Cardiovasc Surg 133:485-93.nKanemitsu S, Tanaka K, Suzuki H, Tokui T, Kinoshita T. 2006. The HEARTSTRING proximal seal system is a possible source of atheroembolism. Circ J 70:638-40.nKapetanakis EI, Stamou SC, Dullum MK, et al. 2004. The impact of aortic manipulation on neurologic outcomes after coronary artery bypass surgery: a risk-adjusted study. Ann Thorac Surg 78:1564-71.nKitamura H, Okabayashi H, Hanyu M, et al. 2005. Early and midterm patency of the proximal anastomoses of saphenous vein grafts made with a Symmetry Aortic Connector System. J Thorac Cardiovasc Surg 130:1028-31.nMark DB, Newman MF. 2002. Protecting the brain in coronary artery bypass graft surgery. JAMA 287:1448-50.nMartens S, Dietrich M, Herzog C, et al. 2004. Automatic connector devices for proximal anastomoses do not decrease embolic debris compared with conventional anastomoses in CABG. Eur J Cardiothorac Surg 25:993-1000.nMedalion B, Meirson D, Hauptman E, Sasson L, Schachner A. 2004. Initial experience with the Heartstring proximal anastomotic system. J Thorac Cardiovasc Surg 128:273-7.nMurkin JM, Boyd WD, Ganapathy S, Adams SJ, Peterson RC. 1999. Beating heart surgery: why expect less central nervous system morbidity? Ann Thorac Surg 68:1498-501.nNewman MF, Grocott HP, Mathew JP, et al. 2001. Report of the substudy assessing the impact of neurocognitive function on quality of life 5 years after cardiac surgery. Stroke 32:2874-81.nNollert G, Oberhoffer M, Reichart B, Vicol C. 2003. Combination of the HEARTSTRING proximal seal system with a blower mister: a possible source of gas emboli. J Thorac Cardiovasc Surg 126:1192-4.nPugsley W, Klinger L, Paschalis C, Treasure T, Harrison M, Newman S. The impact of microemboli during cardiopulmonary bypass on neuropsychological functioning. Stroke 25:1393-9.nReuthebuch O, Kadner A, Lachat M, Kunzli A, Schurr UP, Turina MI. 2004. Early bypass occlusion after deployment of nitinol connector devices. J Thorac Cardiovasc Surg 127:1421-6.nScarborough JE, White W, Derilus FE, Mathew JP, Newman MF, Landolfo KP. 2003. Combined use of off-pump techniques and a sutureless proximal aortic anastomotic device reduces cerebral microemboli generation during coronary artery bypass grafting. J Thorac Cardiovasc Surg 126:1561-7.nSyburra T, Reuthebuch O, Graves K, Genoni M. 2009. Aortic posterior wall perforation with automatic aortic cutter during routine off-pump coronary bypass grafting. Interact Cardiovasc Thorac Surg 9:840-1.nTraverse JH, Mooney MR, Pedersen WR, et al. 2003. Clinical, angiographic, and interventional follow-up of patients with aortic-saphenous vein graft connectors. Circulation 108:452-6.nVicol C, Oberhoffer M, Nollert G, et al. 2005. First clinical experience with the HEARTSTRING, a device for proximal anastomoses in coronary surgery. Ann Thorac Surg 79:1732-7; discussion 1737.nWijeysundera DN, Beattie WS, Djaiani G, et al. 2005. Off-pump coronary artery surgery for reducing mortality and morbidity: meta-analysis of randomized and observational studies. J Am Coll Cardiol 46:872-82.nZangrillo A, Crescenzi G, Landoni G, et al. 2005. Off-pump coronary artery bypass grafting reduces postoperative neurologic complications. J Cardiothorac Vasc Anesth 19:193-6.n
