Which Is First: Left Anterior Descending Artery Anastomosis or Right Coronary Artery Anastomosis in Off-Pump Coronary Artery Bypass Grafting?


  • Necmettin Yakut
  • Engin Tuluko?lu
  • Bilgin Emrecan
  • Serdar Bayrak
  • Levent Y?l?k
  • Tayfun Gökto?an
  • Ali Gürbüz




Objectives: The sequence of the distal anastomosis for revascularization in off-pump coronary artery bypass grafting (OPCABG) surgery is under debate. The hypothesis in this study was that an analysis of cardiac markers would reveal that anastomosing the left anterior descending coronary artery (LAD) before the right coronary artery (RCA) would decrease myocardial damage in OPCABG surgery for 2-vessel disease.

Methods: Forty patients with stable angina who underwent OPCABG surgery and who had LAD and RCA lesions were randomized into 2 groups of 20 patients each. The LAD was revascularized first in group 1, and the RCA was revascularized first in group 2. Cardiac troponin I, creatine kinase (CK), and CK myocardial band (CK-MB) were measured in the 2 groups before surgery and at 8, 24, and 48 hours after surgery.

Results: No mortality occurred in the 2 groups. The groups were similar with respect to sex, age, durations of anastomosis of the left internal thoracic artery to the LAD and of the saphenous vein graft to the RCA, and preoperative CK, CK-MB, and troponin I levels. Postoperative CK-MB levels were significantly higher in group 2 in the eighth and 24th postoperative hours than in group 1 (P = .009 and .041, respectively). Similarly, troponin I levels were significantly higher in group 2 in the eighth, 24th, and 48th hours than in group 1 (P = .003, .003, and .006, respectively).

Conclusions: Anastomosis to the LAD first in OPCABG surgery led to a slight reduction in myocardial enzyme release against the occlusion of the target vessels during anastomoses in patients with RCA and LAD stenoses.


Baumgartner FJ, Cheisssari A, Capouya ER, Panagiotides GP, Katouzian A, Yokoyama T. 1999. Technical aspects of total revascularization in off-pump coronary bypass via sternotomy approach. Ann Thorac Surg 67:1653-8.nBleier J, Vorderwinkler KP, Falkensammer J, et al. 1998. Different intracellular compartmentations of cardiac troponins and myosin heavy chains: a causal connection to their different early release after myocardial damage. Clin Chem 44:1912-8.nCalafiore AM, Di Mauro M, Canosa C, Di Giammarco G, Iacò AL, Contini M. 2003. Myocardial revascularization with and without cardiopulmonary bypass: advantages, disadvantages and similarities. Eur J Cardiothorac Surg 24:953-60.nCarrier M, Pellerin M, Perrault LP, Solymoss BC, Pelletier LC. 2000. Troponin levels in patients with myocardial infarction after coronary artery bypass grafting. Ann Thorac Surg 69:435-40.nDewey TM, Mack MJ. 2003. Myocardial revascularization without cardiopulmonary bypass. In: Cohn LH, Edmunds LH, eds. Cardiac surgery in the adult. 2nd ed. New York: McGraw-Hill. p 609-25.nDi Mauro M, Iacò AL, Contini M, et al. 2005. Reoperative coronary artery bypass grafting: analysis of early and late outcomes. Ann Thorac Surg 79:81-7.nFrench JK, White HD. 2004. Clinical implications of the new definition of myocardial infarction. Heart 90:99-106.nGürbüz A, Emrecan B, Yilik L, et al. 2006. Intracoronary shunt reduces postoperative troponin leaks: a prospective randomized study. Eur J Cardiothorac Surg 29:186-9.nHangler HB, Pfaller K, Ruttmann E, et al. 2004. Effects of intracoronary shunts on coronary endothelial coating in the human beating heart. Ann Thorac Surg 77:776-80.nLaurikka J, Wu ZK, Iisalo P, et al. 2002. Regional ischemic preconditioning enhances myocardial performance in off-pump coronary artery bypass grafting. Chest 121:1183-9.nRivetti RA, Gandra SMA. 1997. Initial experience using an intraluminal shunt during revascularization of the beating heart. Ann Thorac Surg 63:1742-7.nSadony V, Körber M, Albes G, et al. 1998. Cardiac troponin I plasma levels for diagnosis and quantitation of perioperative myocardial damage in patients undergoing coronary artery bypass surgery. Eur J Cardiothorac Surg 13:57-65.nYeatman M, Caputo M, Narayan P, Ghosh AK, Ascione R, Angelini GD. 2001. Intracoronary shunts reduce transient intraoperative myocardial dysfunction during off-pump coronary operations. Ann Thorac Surg 73:1411-7.n



How to Cite

Yakut, N., Tuluko?lu, E., Emrecan, B., Bayrak, S., Y?l?k, L., Gökto?an, T., & Gürbüz, A. (2009). Which Is First: Left Anterior Descending Artery Anastomosis or Right Coronary Artery Anastomosis in Off-Pump Coronary Artery Bypass Grafting?. The Heart Surgery Forum, 12(5), E256-E260. https://doi.org/10.1532/HSF98.20091075