Improving Neurologic Outcome in Off-Pump Surgery: The "No Touch" Technique
Background: As patients referred for cardiac surgery include increasingly older individuals, the prevalence of comorbid factors, such as previous cerebrovascular disease, carotid disease, aortic atherosclerosis, and reoperations, is on the rise. Avoiding manipulation of the ascending aorta in this high-risk subgroup may become a necessity to perform safe coronary artery bypass grafting (CABG) surgery.
Methods: We retrospectively reviewed our database of 640 off-pump CABG patients and identified 84 patients in whom we adopted the "no touch" technique (NTT). Revascularization was carried out with single or bilateral internal thoracic arteries (ITA) and by connecting additional coronary grafts (saphenous vein, radial artery) in a T or Y configuration. The right gastroepiploic artery was used as a conduit in 2 patients. The brachiocephalic artery was used as an alternative inflow site in 3 patients (reoperation).
Results: Age, sex, risk factors, functional class, and history of congestive heart failure were comparable in the two groups. In the NTT group, the frequencies were higher for severe atherosclerosis of the aorta (13% versus 0%; P = .00), carotid disease (25% versus 16%; P = .02), and history of previous cerebrovascular accidents (17% versus 8%; P = .04). Complete revascularization was achieved in 96% of the patients in the off-pump CABG group, compared with 90% in the NTT group (P = .17). No differences in the prevalence of postoperative low cardiac output syndrome, intra-aortic balloon pump use, perioperative myocardial infarction, or operative mortality at 30 days were observed between the two groups. In the NTT group, weak trends toward a lower incidence of postoperative delirium (8% versus 15%; P = .12), a lower incidence of stroke (0% versus 1%; P = .85), and a shorter intensive care unit stay (P = .07) were observed. Hospital stay was also shorter in the NTT group (P = .04).
Conclusion: Avoiding aortic manipulations in patients with severe atherosclerosis of the aorta, carotid disease, and a previous history of cerebrovascular accidents is technically feasible
Gurne O, Chenu P, Polidori C, et al. 1995. Functional evaluation of the internal mammary artery bypass grafts in the early and late postoperative periods. J Am Coll Cardiol 25:1120-8.nHorst M, Geissler HJ, Mehlhorn U, et al. 1999. Simultaneous carotid and coronary artery surgery: indications and perioperative outcome. J Thorac Cardiovasc Surg 47:328-32.nIaco AL, Contini M, Teodori G, et al. 1999. Off or on bypass: what is the safety threshold? Ann Thorac Surg 68:1486-9.nJones EL, Lattouf OM, Weintraub WS. 1989. Catastrophic consequences of internal mammary artery hypoperfusion. J Thorac Cardiovasc Surg 97:2402-5.nKirklin JK, Westaby S, Blackstone EH, Kirklin JW, Chenowith DE, Pacifico AD. 1983. Complement and the damaging effects of cardiopulmonary bypass. J Thorac Cardiovasc Surg 86:845-57.nMatthew JP, Parks R, Savino JS, et al. 1996. Atrial fibrillation following coronary artery bypass graft surgery. JAMA 276:300-6.nMcKhann GM, Goldsborough MA, Borowicz LM Jr, et al. 1997. Predictors of stroke risk in coronary artery bypass patients. Ann Thorac Surg 63:516-21.nMills NL, Everson CT. 1991. Atherosclerosis of the ascending aorta and coronary artery bypass. J Thorac Cardiovasc Surg 102:546-53.nPrice DL, Harris J. 1970. Cholesterol emboli in cerebral arteries as a complication of retrograde aortic perfusion during cardiac surgery. Neurology 20:1209-14.nReed GL III, Dinger DE, Picard EH, DeSanctis RW. 1988. Stroke following coronary artery bypass surgery. N Engl J Med 319:1246-50.nRicotta JJ, Faggioli GL, Castilone A, Hasset JM. 1995. Risk factors for stroke after cardiac surgery: Buffalo Cardiac-Cerebral Study Group. J Vasc Surg 21:359-64.nRoach GW, Kanchuger M, Mangano CM, et al. 1996. Adverse cerebral outcomes after coronary bypass surgery. N Engl J Med 335:1857-63.nRolfson DB, McElhaney JE, Jhangri GS, Rockwood K. 1999. Validity of the confusion assessment method in detecting postoperative delirium in the elderly. Int Psychogeriatr 11:431-8.nRolfson DB, McElhaney JE, Rockwood K, et al. 1999. Incidence and risk factors for delirium and other adverse outcomes in older adults after coronary artery bypass graft surgery. Can J Cardiol 15:771-6.nWendler O, Hennen B, Markwirth T, et al. 1999. Grafts with the right internal thoracic artery to the left internal thoracic artery vs. the left internal thoracic artery and radial artery: flow dynamics in the left thoracic artery main stem. J Thorac Cardiovasc Surg 118:841-8.nAldea GS, Lilly K, Gaudiani JM, et al. 1997. Heparin-bonded circuits improve clinical outcomes in emergency coronary artery bypass grafting. J Card Surg 12:389-97.n[APA] American Psychiatric Association. 1994. Diagnostic and statistical manual of mental disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association. p 123-33.nArom KV, Flavin T, Emery RW, Kshettry VR, Janey PA, Petersen RJ. 2000. Safety and efficacy of off-pump coronary artery bypass grafting. Ann Thorac Surg 69:704-10.nBal-El Y, Goor DA. 1992. Clamping of the atherosclerotic ascending aorta during coronary artery bypass operations: its cost in stroke. J Thorac Cardiovasc Surg 102:469-74.nBarbut D, Yao FF, Lo YW, et al. 1997. Determination of size of aortic emboli and embolic load during coronary artery bypass. Ann Thorac Surg 63:1262-7.nBlauth CI, Cosgrove DM, Webb BW, et al. 1992. Atheroembolism from the ascending aorta. J Thorac Cardiovasc Surg 103:1104-12.nBowles BJ, Lee JD, Dang CR, et al. 2001. Coronary artery bypass performed without the use of cardiopulmonary bypass is associated with reduced cerebral microemboli and improved clinical results. Chest 119:25-30.nRoyse AG, Royse CF, Raman JS. 1999. Exclusive Y graft operation for multivessel coronary revascularization. Ann Thorac Surg 68:1612-8.nShimizu T, Hirayama T, Suesada H, Ikeda K, Ito S, Ishimaru S. 2000. Effect of flow competition on internal thoracic artery graft: postoperative velocimetric and angiographic study. J Thorac Cardiovasc Surg 120:459-65.nSuma H. 1989. Coronary artery bypass grafting in patients with calcified ascending aorta: aortic no-touch technique. Ann Thorac Surg 48:728-30.nTector AJ, Amundsen S, Shmahl TM, Kress DC, Peter M. 1994. Total revascularization with T grafts. Ann Thorac Surg 57:33-8.nTobler HG, Edwards JE. 1988. Frequency and location of atherosclerotic plaques in the ascending aorta. J Thorac Cardiovasc Surg 96:304-6.nvan der Linden J, Casimir-Ahn H. 1991. When do cerebral emboli appear during open heart operations? A transcranial Doppler study. Ann Thorac Surg 51:237-41.nWareing TH, Davila-Roman VG, Barzillai B, Murphy SF, Kouchoukos NT. 1992. Management of the severely atherosclerotic ascending aorta during cardiac operations. J Thorac Cardiovasc Surg 103:453-62.nBrown WR, Moody DM, Challa VR, Stump DA, Hammon JW. 2000. Longer duration of cardiopulmonary bypass is associated with greater numbers of cerebral microemboli. Stroke 31:707-13.nButler J, Rocker GM, Westaby S. 1993. Inflammatory response to cardiopulmonary bypass. Ann Thorac Surg 55:552-8.nCartier R, Brann S, Dagenais F, Martineau R, Couturier A. 2000. Systematic off-pump coronary artery revascularization in multivessel disease: experience of three hundred cases. J Thorac Cardiovasc Surg 119:221-9.nClark RE, Brillman J, Davis DA, Lovell MR, Price TR, Magovern GJ.1995. Microemboli during coronary artery bypass grafting: genesis and effect on outcome. J Thorac Cardiovasc Surg 109:249-57.nDas SK, Brown TD, Pepper J. 2000. Continuing controversy in the management of concomitant coronary and carotid disease: an overview. Int J Cardiol 74:47-65.nDavis Z, Jacobs K, Bonilla J, Anderson RR, Thomas C, Forst W. 2000. Retaining the aortic fat pad during cardiac surgery decreases postoperative atrial fibrillation. Heart Surg Forum 3:108-12.nGaudino M, Glieca F, Alessandrini F, et al. 2000. The unclampable ascending aorta in coronary artery bypass patients. Circulation 102:1497-502.n
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