Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Cardiac contractility modulation wikipedia , lookup
Saturated fat and cardiovascular disease wikipedia , lookup
Cardiovascular disease wikipedia , lookup
Remote ischemic conditioning wikipedia , lookup
Cardiothoracic surgery wikipedia , lookup
Quantium Medical Cardiac Output wikipedia , lookup
Dextro-Transposition of the great arteries wikipedia , lookup
History of invasive and interventional cardiology wikipedia , lookup
4 6 Surgical Treatment of Coronary Artery Disease William E. Cohn, O.H. Frazier, and Denton A. Cooley Standard Coronary Artery Bypass Grafting . . . . . . . . . 1052 Cardiopulmonary Bypass . . . . . . . . . . . . . . . . . . . . . . . . 1060 Off-Pump Coronary Artery Bypass . . . . . . . . . . . . . . . . 1061 Key Points • Techniques and technology for treating coronary artery disease (CAD) have evolved significantly over the past 40 years. • Although there are cases in which the best treatment approach (medical, surgical, or catheter-based) is clear, the best choice of intervention is not obvious for the majority of patients. • Five, 7, and 10 years after initial treatment, mortality is lower for coronary artery bypass grafting (CABG) than for medical treatment alone. These survival benefits of CABG are particularly substantial for patients with three-vessel or left main artery disease, severe angina, or a positive pretreatment exercise stress test. • Most trials comparing CABG with catheter-based interventions (CBIs) in patients with multivessel disease have shown similar short-term survival benefits for both treatments, but CBIs have been associated with less periprocedural morbidity and CABG with longer-lasting revascularization. • Substantial evidence suggests that CABG is preferable to CBI in certain types of patients, including the one third of CAD patients who have chronic total occlusion of one or more vessels, and those with diabetes mellitus. • Meta-analyses of large numbers of CABG studies report 30-day mortality rates in the 1% to 2% range. • Numerous CABG techniques have evolved that seem to produce equally good results. • Substantial evidence suggests that internal mammary artery grafts more effectively promote short- and longterm survival than do saphenous vein grafts, especially when used to graft the left anterior descending (LAD) coronary artery. In fact, the bulk of the evidence suggests that CABG with left internal mammary artery (LIMA)to-LAD grafting provides better long-term results than does either CABG with other types of conduits or CBI. • Technical innovations made in the attempt to reduce the negative impact of cardiopulmonary bypass (CPB) include Reducing the Invasiveness of Coronary Artery Bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1064 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1068 coating the internal surface with heparin or other polymers to reduce contact between blood and the CPB mechanism, minimizing hemodilution by shrinking the bypass circuit to reduce the amount of crystalloid prime needed to start CPB, and using hemofiltration to protect the heart and end organs. • Current United States estimates (based on industry reports) suggest that 18% to 25% of the 370,000 annual CABG procedures are performed without the use of CPB. • There is not yet complete agreement about the relative safety and efficacy of off-pump coronary artery bypass (OPCAB) and conventional CABG with CPB. • The difficulty in comparing the OPCAB and standard CABG stems in part from the low incidences of mortality and significant morbidity associated with both techniques. • A meta-analysis of 37 randomized, controlled trials of OPCAB suggests that it is associated with significantly decreased transfusion and inotrope requirements, atrial fibrillation, respiratory infections, ventilation time, intensive care unit stay, hospital stay, and overall in-hospital and (1-year) postdischarge costs compared with standard CABG. • Data from many large nonrandomized studies suggest that OPCAB is associated with a lower incidence of death, stroke, intraaortic balloon pump requirement, and postoperative transfusion, and a shorter average time on ventilator and length of hospital stay compared with conventional CABG. However, selection bias cannot be ruled out as a potential confounding variable in these data. • Devices and techniques for lateral and inferior wall exposure have enabled surgeons performing OPCAB to attach grafts to all aspects of the heart. Recent series show no difference in the average number of grafts constructed in OPCAB and standard CABG, and several series have shown excellent graft patency. • Off-pump bypass is ideal for patients with significant atheroma or calcification of the ascending aorta. 10 51 CAR046.indd 1051 11/24/2006 12:09:18 PM 10 5 2 chapter • A few studies have shown that OPCAB is associated with a reduced incidence of neurocognitive dysfunction compared with conventional CABG with CPB, but other studies have shown no significant differences. • Results of small randomized trials suggest that, in patients with stenosis of the proximal LAD, minimally invasive direct coronary artery bypass (MIDCAB) is associated with a longer in-hospital recovery period and higher costs than is direct stenting, but that MIDCAB produces similar or better short- and long-term outcomes. • Totally videoscopic LIMA-to-LAD procedures have been performed in which surgical robots were used to mobilize the LIMA and make the sutured anastomosis, but robots are not likely to be in widespread use for CABG in the near future because of their expense and the challenges involved in learning to use them. • Although port-access CPB has been used successfully in multivessel CABG performed through small fifth intercostal space thoracotomies, this procedure has fallen out of favor, partly because of the difficulty of constructing grafts of appropriate length and lie. Coronary artery bypass grafting (CABG) remains the primary invasive treatment for coronary artery occlusive disease, particularly in patients for whom catheter-based intervention (CBI) is not appropriate. It is estimated that 515,000 CABG procedures were performed in the United States in 2002.1 The answer to the question of who performed the fi rst successful CABG operation depends largely on one’s criteria for success. The most commonly accepted notion is that it was Sabiston,2 who in 1962 performed a bypass to the right coronary artery without using extracorporeal circulation. However, the patient died of a stroke 3 days after the operation; a blood clot was found at the origin of the graft in the 46 aorta. Therefore, some argue that the first successful CABG procedure was performed in 1964 by Garrett,3 who, while performing an endarterectomy, encountered technical difficulties and was forced to bypass the left anterior descending (LAD) artery. This patient was still alive 7 years later.4 In any event, much of the pioneering work that followed was done by Favaloro,5 who popularized the use of autogenous saphenous vein grafts; by Kolesov, who performed the first mammary artery-to-coronary anastomosis in 1964;6 and later by Effler7 at the Cleveland Clinic and by Johnson and Lepley8 in Milwaukee. Since those first operations, CABG techniques and technology have evolved significantly. This chapter describes the various options available to surgeons performing CABG procedures and the evidence that supports the use of each approach in particular situations. Standard Coronary Artery Bypass Grafting Indications The major indications for coronary revascularization remain myocardial ischemia and disabling angina pectoris. It may also be performed as a concomitant procedure in patients with cardiac failure resulting from ventricular aneurysm, ventricular septal perforation, papillary muscle rupture, or valvular disease. Although there are cases in which the best treatment approach (medical, surgical, or catheter-based) is clear, and although the American Heart Association’s guidelines (Table 46.1) are often helpful in treatment selection, the best choice of intervention is not obvious for the majority of patients. TABLE 46.1. American Heart Association guidelines regarding indications for coronary artery bypass grafting (CABG) surgery 9.2.1 Asymptomatic or Mild Angina Class I 1. CABG should be performed in patients with asymptomatic or mild angina who have significant left main coronary artery stenosis. (Level of evidence: A) 2. CABG should be performed in patients with asymptomatic or mild angina who have left main equivalent: significant (greater than or equal to 70%) stenosis of the proximal LAD and proximal left circumflex artery. (Level of evidence: A) 3. CABG is useful in patients with asymptomatic ischemia or mild angina who have three-vessel disease. [Survival benefit is greater in patients with abnormal left ventricle (LV) function; e.g., left ventricular ejection fraction (LVEF) less than 0.50 and/or large areas of demonstrable myocardial ischemia.] (Level of evidence: C) Class IIa CABG can be beneficial for patients with asymptomatic or mild angina who have proximal LAD stenosis with one- or two-vessel disease. (This recommendation becomes a class I if extensive ischemia is documented by noninvasive study and/or LVEF is less than 0.50.) (Level of evidence: A) Class IIb CABG may be considered for patients with asymptomatic or mild angina who have one- or two-vessel disease not involving the proximal LAD. (If a large area of viable myocardium and high-risk criteria are met on noninvasive testing, this recommendation becomes class I). (Level of evidence: B) 9.2.2 Stable Angina Class I 1. CABG is recommended for patients with stable angina who have significant left main coronary artery stenosis. (Level of evidence: A) 2. CABG is recommended for patients with stable angina who have left main equivalent: significant (≥70%) stenosis of the proximal LAD and proximal left circumflex artery. (Level of evidence: A) 3. CABG is recommended for patients with stable angina who have three-vessel disease. (Survival benefit is greater when LVEF is less than 0.50.) (Level of evidence: A) CAR046.indd 1052 11/24/2006 12:09:18 PM su rgic a l t r e atm e n t of corona ry a rt e ry dise a se 10 5 3 TABLE 46.1. (continued) 4. CABG is recommended in patients with stable angina who have two-vessel disease with significant proximal LAD stenosis and either EF less than 0.50 or demonstrable ischemia on noninvasive testing. (Level of evidence: A) 5. CABG is beneficial for patients with stable angina who have one- or two-vessel CAD without significant proximal LAD stenosis but with a large area of viable myocardium and high-risk criteria on noninvasive testing. (Level of evidence: B) 6. CABG is beneficial for patients with stable angina who have developed disabling angina despite maximal noninvasive therapy, when surgery can be performed with acceptable risk. If angina is not typical, objective evidence of ischemia should be obtained. (Level of evidence: B) Class IIa 1. CABG is reasonable in patients with stable angina who have proximal LAD stenosis with one-vessel disease. (This recommendation becomes class I if extensive ischemia is documented by noninvasive study and/or LVEF is less than 0.50.) (Level of evidence: A) 2. CABG may be useful for patients with stable angina who have one- or two-vessel CAD without significant proximal LAD stenosis but who have a moderate area of viable myocardium and demonstrable ischemia on noninvasive testing. (Level of evidence: B) Class III 1. CABG is not recommended for patients with stable angina who have one- or two-vessel disease not involving significant proximal LAD stenosis, patients who have mild symptoms that are unlikely due to myocardial ischemia, or patients who have not received an adequate trial of medical therapy and: a. have only a small area of viable myocardium. (Level of evidence: B) b. have no demonstrable ischemia on noninvasive testing. (Level of evidence: B) 2. CABG is not recommended for patients with stable angina who have borderline coronary stenosis (50% to 60% diameter in locations other than the left main coronary artery) and no demonstrable ischemia on noninvasive testing. (Level of evidence: B) 3. CABG is not recommended for patients with stable angina who have insignificant coronary stenosis (less than 50% diameter reduction). (Level of evidence: B) 9.2.3 Unstable Angina/Non–ST-Segment Elevation MI (NSTEMI) Class I 1. CABG should be performed for patients with unstable angina/NSTEMI with significant left main coronary artery stenosis. (Level of evidence: A) 2. CABG should be performed for patients with unstable angina/NSTEMI who have left main equivalent: significant (greater than or equal to 70%) stenosis of the proximal LAD and proximal left circumflex artery. (Level of evidence: A) 3. CABG is recommended for unstable angina/NSTEMI in patients in whom revascularization is not optimal or possible, and who have ongoing ischemia not responsive to maximal nonsurgical therapy. (Level of evidence: B) Class IIa CABG is probably indicated for patients with unstable angina/NSTEMI who have proximal LAD stenosis with one- or two-vessel disease. (Level of evidence: A) Class IIb CABG may be considered in patients with unstable angina/NSTEMI who have one- or two-vessel disease not involving the proximal LAD when percutaneous revascularization is not optimal or possible. (If there is a large area of viable myocardium and high-risk criteria are met on noninvasive testing, this recommendation becomes Class I.) (Level of evidence: B) 9.2.4 ST-Segment Elevation MI (STEMI) Class I Emergency or urgent CABG in patients with STEMI should be undertaken in the following circumstances: a. Failed angioplasty with persistent pain or hemodynamic instability in patients with coronary anatomy suitable for surgery. (Level of evidence: B) b. Persistent or recurrent ischemia refractory to medical therapy in patients who have coronary anatomy suitable for surgery, who have a significant area of myocardium at risk, and who are not candidates for PCI. (Level of evidence: B) c. At the time of surgical repair of postinfarction ventricular septal rupture or mitral valve insufficiency. (Level of evidence: B) d. Cardiogenic shock in patients less than 75 years old with ST-segment elevation or left bundle branch block or posterior MI who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock, unless further support is futile because of patient’s wishes or contraindications/unsuitability for further invasive care. (Level of evidence: A) e. Life-threatening ventricular arrhythmias in the presence of ≥50% left main stenosis and/or triple-vessel disease. (Level of evidence: B) Class IIa 1. CABG may be performed as primary reperfusion in patients who have suitable anatomy and who are not candidates for or who have had failed fibrinolysis/percutaneous coronary intervention (PCI) and who are in the early hours (6 to 12 hours) of evolving STEMI. (Level of evidence: B) 2. In patients who have had an STEMI or NSTEMI, coronary artery bypass graft (CABG) mortality is elevated for the fi rst 3 to 7 days after infarction, and the benefit of revascularization must be balanced against this increased risk. Beyond 7 days after infarction, the criteria for revascularization described in previous sections are applicable. (Level of evidence: B) Class III 1. Emergency CABG should not be performed in patients with persistent angina and a small area of myocardium at risk who are hemodynamically stable. (Level of evidence: C) 2. Emergency CABG should not be performed in patients with successful epicardial reperfusion but unsuccessful microvascular reperfusion. (Level of evidence: C) (Continued) CAR046.indd 1053 11/24/2006 12:09:19 PM 10 5 4 chapter 46 TABLE 46.1. (continued) 9.2.5 Poor LV Function Class I 1. CABG should be performed in patients with poor LV function who have significant left main coronary artery stenosis. (Level of evidence: B) 2. CABG should be performed in patients with poor LV function who have left main equivalent: significant (≥70%) stenosis of the proximal LAD and proximal left circumflex artery. (Level of evidence: B) 3. CABG should be performed in patients with poor LV function who have proximal LAD stenosis with two- or three-vessel disease. (Level of evidence: B) Class IIa CABG may be performed in patients with poor LV function with significant viable noncontracting, revascularizable myocardium and without any of the above anatomic patterns. (Level of evidence: B) Class III CABG should not be performed in patients with poor LV function without evidence of intermittent ischemia and without evidence of significant revascularizable viable myocardium. (Level of evidence: B) 9.2.6 Life-Threatening Ventricular Arrhythmias Class I 1. CABG should be performed in patients with life-threatening ventricular arrhythmias caused by left main coronary artery stenosis. (Level of evidence: B) 2. CABG should be performed in patients with life-threatening ventricular arrhythmias caused by three-vessel coronary disease. (Level of evidence: B) Class IIa 1. CABG is reasonable in bypassable one- or two-vessel disease causing life-threatening ventricular arrhythmias. (This becomes a class I recommendation if the arrhythmia is resuscitated sudden cardiac death or sustained ventricular tachycardia.) (Level of evidence: B) 2. CABG is reasonable in life-threatening ventricular arrhythmias caused by proximal LAD disease with one- or two-vessel disease. (This becomes a class I recommendation if the arrhythmia is resuscitated sudden cardiac death or sustained ventricular tachycardia.) (Level of evidence: B) Class III CABG is not recommended in ventricular tachycardia with scar and no evidence of ischemia. (Level of evidence: B) 9.2.7 CABG After Failed Percutaneous Transluminal Coronary Angioplasty (PTCA) Class I 1. CABG should be performed after failed PTCA in the presence of ongoing ischemia or threatened occlusion with significant myocardium at risk. (Level of evidence: B) 2. CABG should be performed after failed PTCA for hemodynamic compromise. (Level of evidence: B) Class IIa 1. It is reasonable to perform CABG after failed PTCA for a foreign body in crucial anatomic position. (Level of evidence: C) 2. CABG can be beneficial after failed PTCA for hemodynamic compromise in patients with impairment of the coagulation system and without previous sternotomy. (Level of evidence: C) Class IIb CABG can be considered after failed PTCA for hemodynamic compromise in patients with impairment of the coagulation system and with previous sternotomy. (Level of evidence: C) Class III 1. CABG is not recommended after failed PTCA in the absence of ischemia. (Level of evidence: C) 2. CABG is not recommended after failed PTCA with inability to revascularize due to target anatomy or no-reflow state. (Level of evidence: C) 9.2.8 Patients with Previous CABG Class I 1. Coronary bypass should be performed in patients with prior CABG for disabling angina despite optimal nonsurgical therapy. (If angina is not typical, then objective evidence of ischemia should be obtained.) (Level of evidence: B) 2. Coronary bypass should be performed in patients with prior CABG without patent bypass grafts but with class I indications for surgery for native-vessel CAD (significant left main coronary stenosis, left main equivalent, three-vessel disease). (Level of evidence: B) Class IIa 1. Coronary bypass is reasonable in patients with prior CABG and bypassable distal vessel(s) with a large area of threatened myocardium by noninvasive studies. (Level of evidence: B) 2. Coronary bypass is reasonable in patients who have prior CABG if atherosclerotic vein grafts with stenoses greater than 50% supplying the LAD coronary artery or large areas of myocardium are present. (Level of evidence: B) LAD, left anterior descending; CABG, coronary artery bypass grafting; LV, left ventricle; LVEF, left ventricular ejection fraction; CAD, coronary artery disease; MI, myocardial infarction; PCI, percutaneous coronary intervention; PCTA, percutaneous transluminal angioplasty. CAR046.indd 1054 11/24/2006 12:09:19 PM 10 5 5 su rgic a l t r e atm e n t of corona ry a rt e ry dise a se Comparing Coronary Artery Bypass Grafting and Medical Treatment Stenting 96 CABG 94 92 p = .75 0 A 0 60 120 180 240 300 360 100 Comparing Coronary Artery Bypass Grafting and Catheter-Based Interventions 98 96 94 CABG 92 Stenting p = .71 90 0 B 0 60 120 180 240 300 360 100 Event-free survival (%) In the treatment of coronary artery disease, CBIs have the advantage of being minimally invasive, thereby promoting faster recovery and earlier hospital discharge than is usual with standard CABG surgery. For this reason, coronary CBIs are now performed twice as often as CABG surgery in the U.S. Nonetheless, CABG has advantages that have kept this procedure in use. Reviews of trials comparing CABG with CBI in patients with multivessel disease have found that, in most trials, CABG and CBI show similar short-term survival benefits, but CBI is associated with less periprocedural morbidity.10,11 However, CABG tends to produce longer-lasting revascularization. In the Medicine, Angioplasty, or Surgery Study (MASS II) trial, in which 611 CAD patients were randomly assigned to medical therapy, multivessel CBI, or CABG, 8.3% of the medical group and 13.3% of the CBI group required repeat revascularization within a year of treatment, compared with 0.5% of the CABG patients (Fig. 46.1).12 Similarly, 98 90 Event-free survival (%) It has been known for some time that CABG produces better outcomes than does medical treatment alone for patients with significant coronary artery disease (CAD). A metaanalysis of follow-up data from randomized trials performed in the 1970s and 1980s, including the Veterans Administration Cooperative Trial, the Coronary Artery Surgery Study (CASS), and the European Coronary Surgery Study, found that mortality is lower for CABG than for medical treatment alone 5 years (10.2% vs. 15.8%), 7 years (15.8% vs. 21.7%), and 10 years (26.4% vs. 30.5%) after initial treatment.9 The survival benefits of CABG were particularly substantial for patients with three-vessel or left main artery disease, more severe angina, or a positive pretreatment exercise stress test. Survival (%) 100 95 CABG 90 85 80 75 Stenting p < .001 70 0 0 60 120 180 240 300 360 C Days since randomization FIGURE 46.2. Patients in the ARTS trial who underwent coronary artery bypass grafting (CABG) or catheter-based intervention (CBI) with stenting had similar outcomes when actuarial survival (A) and survival without myocardial infarction or cerebrovascular events (B) were considered. However, when repeat revascularization was combined with these other end points (C), outcomes were better in CABG patients. 1.00 Freedom from additional PCI CABG MT 0.95 PCI 0.90 0.85 0.80 p = .0001 0 2 4 6 8 Months after study entry 10 12 FIGURE 46.1. Freedom from additional revascularization among coronary artery disease (CAD) patients in the MASS-II trial who received medical treatment only (MT), coronary artery bypass grafting (CABG), or percutaneous coronary intervention (PCI). CAR046.indd 1055 the randomized, 1000-patient Arterial Revascularization Therapies Study Group (ARTS) trial showed 1-year repeatrevascularization rates of 16.8% in CBI patients and 3.1% in CABG patients (Fig. 46.2).13 Finally, in the Stent or Surgery (SoS) trial, in which 1000 CAD patients at 53 centers were randomly assigned to multivessel stenting or CABG, 21% of the CBI patients required additional revascularization at a median follow-up of 2 years, compared with only 6% of the CABG patients (Fig. 46.3).14 Substantial evidence suggests that CABG is preferable to CBI in certain types of patients. For example, one third of CAD patients who require more than medical therapy alone have chronic total occlusion of one or more vessels.15 Two trials of CABG and CBI that included patients with totally occluded vessels have shown that CBI does not produce adequate revascularization in these vessels. In the Randomized 11/24/2006 12:09:19 PM 10 5 6 chapter Cumulative proportion at risk (%) 30 Hazard ratio 3.85 (95% CI 2.56−5.79),p <.0001 25 PCI 20 15 10 CABG 5 0 0 1 2 Time since randomization (years) 3 Numbers at risk PCI 488 393 228 64 CABG 500 478 281 83 FIGURE 46.3. In the SoS trial, risk of repeat revascularization was considerably greater in CAD patients who underwent percutaneous coronary intervention (PCI) than in those who underwent coronary artery bypass grafting (CABG). 46 Intervention Treatment of Angina (RITA) trial,16 only 48% of attempts to revascularize totally occluded arteries with CBI were considered successful (i.e., reduced stenosis to 50% or less). In the Coronary Angioplasty versus Bypass Revascularization Investigation (CABRI) trial,17 only 70% of occluded arteries were successfully revascularized with CBI. There are other subgroups of CAD patients that may also benefit more from CABG than from CBI. For example, in patients with left main artery disease, this vessel may be particularly vulnerable to restenosis after CBI.18 Additionally, CAD patients with diabetes mellitus have better 5-year survival after CABG with internal mammary artery (IMA) grafts than after CBI.19 Coronary Artery Bypass Grafting Techniques The technology used in CABG surgery has evolved substantially over the past three decades. Refinements in operative technique (Figs. 46.4 to 46.8) have continued to improve outcomes in a patient population that is increasingly infirm. Meta-analyses of large numbers of CABG studies report 30day mortality rates in the 1% to 2% range.20,21 It is interesting to note that numerous CABG techniques have evolved that seem to produce equally good results. Some FIGURE 46.4. Surgical anatomy of the coronary system. (A) The right coronary system has several branches that can be considered for bypass. In some instances, the acute marginal branch (AM) is bypassed, particularly if it has a large retrograde collateral blood supply to the left system. Most anastomoses are made at the area of the crux. The posterior ventricular branch (PVB), posterior descending branches (PD), or their distal branches may be grafted. The dotted line indicates the area of the interventricular septum as denoted by the right coronary vein. RCA, right coronary artery. (B) In the left anterior descending coronary artery (LAD) system, the fi rst septal perforator (1st SPL) is usually just opposite the fi rst diagonal (1st DX) branch or is proximal to it. It descends posteriorly into the interventricular septum and may be an important artery. The 1st DX and second diagonal (2nd DX) branches arise from the LAD. The distal LAD usually supplies the apex of the left ventricle. The ramus medialis branch (RM) arises between the circumflex (CX) and the LAD and may be in the DX or obtuse marginal position. (C) The CX coronary system shows the fi rst branch as the fi rst obtuse marginal (1st OM) and the second branch as the second obtuse marginal (2nd OM) or posterior lateral branch (PLB) of the CX system. The main CX trunk is in the atrioventricular groove in close association with the coronary sinus vein. CAR046.indd 1056 11/24/2006 12:09:19 PM su rgic a l t r e atm e n t of corona ry a rt e ry dise a se 10 5 7 FIGURE 46.5. Saphenous vein graft to the right coronary artery. (A) The right coronary artery is isolated by placing a traction suture in the myocardium beneath the right coronary artery. (Inset) The vein is beveled, depending on the length of the anastomosis and the size of the vein. (B) The coronary artery is incised, and the incision is extended with the use of Potts scissors. (C) The right coronary anastomosis is begun at the distal portion of the artery and the toe of the vein graft. (D) The anastomosis is sutured on the right side fi rst, from the artery to the vein. (E) The anastomosis is completed from the left side. The suture is usually tied at or to the right of the apex. (F) The proximal anastomosis is completed with the aid of either complete or partial aortic occlusion. (G) The clamp is removed, and air is evacuated from the vein graft. The vein graft may be clamped with a small bulldog clamp to avoid introducing more air into the coronary system. centers perform only the distal anastomoses while the heart is arrested and perform the proximals with a side-biting clamp and bypass, whereas other centers keep the heart arrested while all grafts are performed. Cardioplegia techniques vary widely among surgeons and institutions in terms of the use of warm blood, cold blood, or crystalloid, the number and timing of doses, and the route by which doses are given (anterograde or retrograde), but there is not widespread agreement about which of these methods is best. One area of bypass surgery in which the evidence does favor particular options is choice of conduit. Saphenous vein harvest has become more sophisticated and less invasive over the past several years, producing venous segments of similar quality to those harvested with open techniques CAR046.indd 1057 while causing fewer complications.22–24 However, there is plenty of evidence to suggest that IMA grafts (Fig. 46.9) more effectively promote short- and long-term survival than do saphenous vein grafts, especially when used to graft the LAD (Fig. 46.10).25–28 Additionally, a long-term study has shown that left IMA (LIMA)-to-LAD grafts have an 88% patency rate 15 years after surgery (Fig. 46.11).29 In fact, the bulk of the evidence suggests that CABG with LIMA-to-LAD grafting provides better long-term results than does either CABG with other types of conduits or CBI.14,19,30 Grafts constructed from the radial artery may also be associated with superior postoperative survival, freedom from adverse events, and long-term graft patency compared 11/24/2006 12:09:22 PM 10 5 8 chapter FIGURE 46.6. Incisions are made in the aorta for the proximal anastomoses. 46 FIGURE 46.7. Proximal anastomosis of the right coronary artery bypass graft. FIGURE 46.8. Saphenous vein graft to the left circumflex system. (A) The left anterior descending coronary artery (LAD) is identified and incised. The incision is enlarged with a Potts scissors. (B) The probe is passed into the distal LAD to ensure patency. (C) The distal anastomosis is created by attaching the heel of the graft to the proximal portion of the artery, from outside the artery to inside the vein. Left-side suturing is completed around the toe of the graft to approximately the midportion of the right side of the artery. (D) The other end of the suture is then sutured from the heel of the graft, passing the vein to the artery. The graft is then tied in the midportion of the artery. (E) To expose the obtuse marginal artery, the heart is retracted to the right by an assistant. The obtuse marginal branch is then incised. (F,G) Anastomosis of the obtuse marginal (OM) branch is begun at the proximal portion of the artery, placing the heel of the graft to the proximal portion of the artery. Suturing is accomplished on the left side of the graft, from outside the artery to inside the vein. The anastomosis is completed on the right side by suturing from outside the vein to inside the artery. The sutures are usually tied at or near the apex. (H) The aorta is incised. (I) The proximal anastomoses are completed. CAR046.indd 1058 11/24/2006 12:09:26 PM 10 5 9 su rgic a l t r e atm e n t of corona ry a rt e ry dise a se FIGURE 46.9. Technique for obtaining the internal mammary artery (IMA) for use as a bypass conduit. (A) The IMA is mobilized from the chest wall with cautery. Parallel incisions are made on each side of the pedicle, which includes the vein, artery, lymphatics, fascia, and muscle. (B) Only the tissue around the IMA should be handled with forceps. The distal intercostal arteries and branches are electrocoagulated. Metal clips or ligatures are placed on the proximal branches. (C) The distal portion of the pedicle around the IMA has been removed, and a metallic clip has been placed on the distal mammary artery. Metallic clips are used to gain hemostasis of the pedicle without trauma to the artery. (D) The pedicle is cleaned of its distal portion, and the artery is exposed. (E) A solution of papaverine (30 mg/100 mL) is injected into the mammary artery with a syringe. Papaverine solution is also applied to the pedicle. (F) After the graft is dilated, flow is assessed. If flow is less than 60 to 100 mL/min, a more proximal portion with a higher flow rate should be obtained. (G), The LAD is isolated, and the graft is aligned. (H) The anastomosis is completed. Care must be taken to ensure proper alignment of the graft on the myocardium, especially with respect to the pericardium, the pleura, the lung, and the beating heart. LIMA LAD FIGURE 46.10. Angiogram showing a left internal mammary artery (LIMA) graft to the left anterior descending coronary artery (LAD), which confers a survival advantage over saphenous vein grafts. CAR046.indd 1059 11/24/2006 12:09:27 PM 10 6 0 chapter Percent 100 90 80 70 60 50 40 30 20 10 0 0 Yrs 5 Yrs 10 Yrs 15 Yrs FIGURE 46.11. Data from a large coronary artery bypass grafting study by Tatoulis et al. show the 15-year patency rates of coronary conduits made from the left internal mammary artery (diamonds, n = 1345), right internal mammary artery (boxes, n = 605), radial artery (triangles, n = 177), and saphenous vein (circles, n = 3714). 46 with saphenous vein grafts,26,31–33 although there is not total agreement on this point.34–36 Additionally, endoscopic harvesting of radial artery segments has recently been introduced and appears to produce good results (Fig. 46.12).37–39 However, there is some evidence that radial grafts are less effective when used to graft noncritically stenosed vessels or the right coronary artery.29,33,40–42 Cardiopulmonary Bypass One of the chief obstacles to producing favorable outcomes after CABG is the effects of cardiopulmonary bypass (CPB) (Figs. 46.13 and 46.14). Although CPB and cardioplegia remove motion and blood from the surgical field, contact FIGURE 46.12. Videoscopic radial artery harvest allows the artery to be removed through a 3-cm incision at the wrist. At many centers, radial artery conduits are thought to be superior to saphenous vein conduits and are used in most cases. between blood and the artificial materials within the CPB pump can provoke a systematic inflammatory response (SIR) that may cause coagulopathy, third-space fluid retention, and impaired end-organ function, which can lead to significant morbidity in patients with preexisting end-organ dysfunction.43 Several technical innovations have been made in an attempt to reduce the negative impact of CPB. These include reducing contact between blood and the CPB mechanism by coating the internal surface with heparin or other polymers,44–46 minimizing hemodilution by shrinking the bypass circuit to reduce the amount of crystalloid prime needed to start CPB,47 and using hemofiltration to protect the heart and end organs.48,49 Preliminary evidence suggests that preoperative administration of antiinflammatory drugs reduces SIR FIGURE 46.13. The modern heart-lung machine is highly evolved, with computer-controlled pumps and state-ofthe-art materials and design. CAR046.indd 1060 11/24/2006 12:09:29 PM 10 61 su rgic a l t r e atm e n t of corona ry a rt e ry dise a se Cardioplegia deuvery line Aortic vent Suction Non-vented male luer cap Aortic canulae Cardioplegia line Pressure gauge Suctioh line Male luer sup Arterial line Strajght connector with luer Arterial fkl ter purge line Syringe Venous cannulae Vented female luer cap 2-way stopcock Saphenous vein cannulae saphenous vein clamp 3-way stopcock Color-coded tape CP LO KCL Bubble sensor Monitor line Blooo Y connector with luer O5 RL Prebypass fil ter 1-way valve Pressure transducer 100 mm hg Straight connector 1/4* perfusion adapter connector Arterial blood gas sensor Ph - 7.40 PCO2 - 40 PO2 - 100 Air aspirator needle Retrograde cannulae Arterial filter bypass Diaphrgam Vent line Rressure isolator CP LO KCL Arteperial filter Male luer lock Cardioplegia filter Cable tie hand tension Vented male lueer cap Over safety rpessure valve Cable tie cut Transfusion filter 100 Perfusion adapter set Stopcock Spike Female luer Roberts clamp Y connector -30 Pressure oisplay set 70% O2 SAT Praidprime line Softy Hemoconcentrator Venous uhe Venous saturation connector Postive pressure Caroioplegia pressure reuef line pruef valve 4000 3000 2400 2000 1600 1000 800 400 200 100 20 Haro shell venous reservolr Negative pressure reuef valve Level sensor Membrane osygenator Vacuum reoul ator HF-6000 LIFESTRE AM Vacuum line Moisture trap Cardioplegia Cardioplegia temp Vacuum une Vacuum gauge Membrane Purge Gas blender/ Flowmeter Oxygen filter Oxygen Cardioplegia bridge Oxygen line Blood cardiplegia line Membrane recirculation line Arterial temp Gas outlet Large bore male luee large bore female luee RL Pump header Nonvented cap Reducer connector Apterial line Venous/arterial 100/RPM Forward Hot/cold water Cardiac suction 30 RPM Vent suction 20 Forward RPM Forward Stop Stop Stop Reverse Reverse Reverse Roller pump 4:1 cardioplegia 10 RPM Forward Stop Reverse Cranr/turner/2001 Hot/cold water Hard shell roller pump circult FIGURE 46.14. A schematic of a cardiopulmonary bypass (CPB) circuit. The particular components of CPB circuits vary in several ways according to the individual patient’s circumstances and the surgeon’s preferences, including the type of pump (roller vs. centrifugal) and reservoir (open vs. closed) used, and the routes by which cardioplegia is delivered. and may improve surgical outcomes.50–53 Avoiding the use of cardiotomy suction devices (which tend to induce hemolysis) has also been tried with some success,54,55 and some evidence suggests that using a cell saver instead of a cardiotomy reservoir reduces lipid microembolization56 and improves the biocompatibility of the bypass circuit.57 Finally, there is the option to forgo CPB altogether. whose grasping surfaces have suction ports that improve their grip without the need for greater downward force; and capture-type stabilizers, fenestrated platforms through which silicone elastic tapes are passed, looped under the coronary artery, and pulled tight to hold the epicardium against the underside of the platform (Figs. 46.15 to 46.17). Off-Pump Coronary Artery Bypass Current U.S. estimates (based on industry reports) suggest that 18% to 25% of CABG procedures are performed without the use of CPB. The majority of these procedures are performed by a small percentage of heart surgeons who specialize in off-pump coronary artery bypass (OPCAB); the majority of surgeons perform OPCAB in less than 5% of patients requiring bypass surgery. Technical Aspects Keeping the coronary arteries in place during beating-heart bypass necessitates using one of three types of coronary stabilizers: compression-type stabilizers, which use two-pronged forks that grasp the epicardium on either side of the artery to be bypassed; suction-type stabilizers, which use forks CAR046.indd 1061 FIGURE 46.15. Some stabilizers use a combination of silicone elastic tapes under the artery and a fenestrated platform to provide a motionless, blood-free field. 11/24/2006 12:09:30 PM 10 6 2 chapter FIGURE 46.16. A number of self-retaining stabilizers are commercially available. When used correctly, these allow multivessel bypass to be performed safely and reproducibly in the majority of patients. The blood-free, motionless field these devices provide allows anastomotic precision very similar to what is achieved with cardiopulmonary bypass and an arrested heart. In some patients, the left hemisternum can block the surgeon’s view of the proximal obtuse marginal and posterolateral branches of the circumflex arteries, making it difficult to graft coronary arteries onto the lateral and posterolateral areas of the heart. Attempts to correct this problem by forcing the heart to the right with stabilization devices may compromise both blood flow and stability. However, several devices and techniques have been developed to improve exposure while maintaining hemodynamic stability during OPCAB. Deep pericardial sutures (Fig. 46.18), first described by Lima,58 can be tightened to create a pericardial 46 FIGURE 46.18. Sutures placed deep in the pericardial sac, when tightened, facilitate rotation of the heart up and to the right. This rotation allows off-pump bypass to be performed to the inferior and lateral aspects of the beating heart without hemodynamic compromise in most patients. ridge that supports the base of the lateral left ventricle, allowing the heart to be rotated to the right so that the apex points upward through the sternotomy incision. This provides adequate exposure of the lateral and inferior left ventricle. Apical suction devices, which enable the surgeon to pull the apex of the heart away from the base and pivot the cardiac axis, can also be used for this purpose; animal studies have shown that these devices are as effective as deep pericardial sutures59,60 and may cause less hemodynamic interference.59 When it is difficult to expose the lateral wall, right pleurotomy and right vertical pericardiotomy (Fig. 46.19) may be used in addition to deep pericardial sutures to allow the heart to herniate into the right pleural space while maintaining right ventricular end-diastolic volume (Fig. 46.20). Performing asymmetric right hemisternal elevation in addition to the preceding techniques permits even greater lateral wall exposure, bringing the proximal obtuse marginal and posterolateral branches into the center of the operative field. Results of Off-Pump Coronary Artery Bypass FIGURE 46.17. The Octopus stabilizer (Medtronic, Minneapolis, MN) uses suction to grip the epicardial surface so that less downward pressure is required, which improves the stability of the coronary artery in some situations. CAR046.indd 1062 As stated in the 2004 American Heart Association guidelines, there is not yet complete agreement about the relative safety and efficacy of OPCAB and conventional CABG with CPB.61 The difficulty in comparing the two approaches stems in part from the low incidences of mortality and significant morbidity associated with both techniques.62–73 A large prospective randomized trial (i.e., with 1000 patients or more) has not been performed to date. However, a meta-analysis of 37 randomized, controlled trials of OPCAB suggests that it is associated with significantly decreased transfusion and inotrope requirements, atrial fibrillation, respiratory infec- 11/24/2006 12:09:31 PM su rgic a l t r e atm e n t of corona ry a rt e ry dise a se FIGURE 46.19. Vertical pericardiotomy allows the heart to be rotated into the right chest to facilitate exposure of the posterior and lateral aspects during off-pump coronary artery bypass. This technique is particularly useful in patients with large hearts. tions, ventilation time, intensive care unit stay, hospital stay, and overall in-hospital and (1-year) postdischarge costs compared with standard CABG.21 These findings may be explained by the results of several small randomized trials, which suggest that OPCAB is associated with lower postoperative isoenzyme of creatine kinase with muscle and brain units (CK-MB)73–75 and troponin levels,73,76 and less activation of complement factors C5a and TCC77 than is standard CABG. Additionally, these studies suggest that OPCAB patients may have less blood loss during surgery75 and a higher postoperative hematocrit.73 They may also be less likely to require postoperative transfusions of red cells or clotting factors, or to require reoperation for bleeding.73,76 Furthermore, reports of several large, retrospective, nonrandomized multicenter series indicate that OPCAB is associated with a lower incidence of death, stroke, and intraaortic balloon pump requirement and a shorter average time on ventilator and length of hospital stay compared with conventional CABG performed at the same institutions.62,64,65,67–70,72 National database statistics show a similar trend,66,71 as do meta-analyses of randomized and nonrandomized comparisons of CABG and OPCAB.78,79 Additionally, a recent study suggests that OPCAB and percutaneous angioplasty with sirolimus-coated stents are associated with similar early and late mortality rates, but that OPCAB patients have a lower rate of reoperation and return of angina.80 Finally, among CABG and OPCAB patients surveyed an average of 10.8 months after surgery, OPCAB patients reported having better physical functioning and emotional well-being.81 Although selection bias cannot be ruled out as a potential confounding variable in these data, a study in which propensity scores (based on major cardiac and noncardiac morbidities) were used in an attempt to decrease the impact of selection bias also showed that OPCAB produces results CAR046.indd 1063 10 6 3 superior to those of standard CABG.82 Furthermore, a study of patients not considered to be at high risk for CPB who were randomized to CABG or OPCAB showed that the OPCAB patients had less need for postoperative mechanical ventilation and had shorter intensive care unit and hospital stays.83 However, these data do not account for intraoperative findings that might make surgeons more likely to choose CPB, such as small, calcified, diffusely atherosclerotic coronary arteries, intramyocardial or intra-adipose coronary arteries, or other conditions that make revascularization more complex. Surgeons who include these considerations in their clinical decision-making may tend to choose conventional CABG for technically difficult revascularizations. Despite these potential biases in the data, existing studies nonetheless strongly suggest several advantages of OPCAB over conventional CABG. These include a decrease in postoperative coagulopathy and a reduced need for postoperative transfusion, which have been found consistently in virtually all OPCAB series reported to date.62–73 These findings may be attributable to the lower heparin requirements and preservation of platelet function associated with OPCAB, as a prospective randomized study has shown.73 Early OPCAB procedures were limited in terms of the adequacy of revascularization and the quality and reproducibility of the distal anastomosis, leading surgeons to perform slightly fewer grafts in OPCAB patients than in conventional CABG patients.68,69 However, subsequent refinement of devices and techniques for lateral and inferior wall exposure (vide supra) has enabled surgeons experienced with OPCAB to perform grafts to all aspects of the heart, and more recent series show no difference in the average number of grafts constructed.73 Furthermore, several series have shown excellent graft patency,72,84,85 although at least one has not.76 Several retrospective nonrandomized series have shown that OPCAB may be associated with decreased operative risk in some high-risk groups,62,86–88 including elderly patients, patients with reduced ejection fraction, and patients with FIGURE 46.20. Elevating the right half of the sternum and widely opening the right pleura and pericardium allows the heart to be rotated into the right chest, producing excellent exposure of the obtuse marginal territory. This patient experienced little hemodynamic compromise with this maneuver. 11/24/2006 12:09:33 PM 10 6 4 chapter renal failure.63,89–93 Furthermore, several reports have associated OPCAB with decreased risk in repeat CABG patients.94–96 This is because reoperative OPCAB often can be performed without dissecting out the ascending aorta or manipulating diseased grafts. It is less clear whether OPCAB is better than standard CABG for patients with left ventricular dysfunction.97,98 In dealing with heavily diseased but patent vein grafts, many surgeons reject OPCAB because of the risk of graft embolization while the heart is being repositioned. However, in patients with patent LIMA-to-LAD grafts, a tailored left thoracotomy approach for reoperative grafting of the lateral wall allows the construction of a graft from the descending thoracic aorta to the lateral wall branches and avoids the potential complications of LIMA-graft mobilization.99,100 Similarly, lower sternotomy and upper abdominal incisions have been described for constructing grafts to the inferior wall with the right gastroepiploic artery.101,102 Long-term patency data for these types of grafts are not yet available. Off-pump bypass is ideal for patients with significant atheroma or calcification of the ascending aorta. In these cases, free grafts are attached either to the side of the in-situ LIMA, as first described by Tector et al.,103 or to the innominate artery if it is disease-free. Alternatively, free grafts can be attached to a disease-free area of the aorta with an automated anastomotic device or a clampless anastomotic facilitator that obviates the need for a partial-occluding clamp. Palpation and epiaortic echo, when used together, can frequently identify an appropriate dime-sized area of relatively normal aorta. OPCAB enables relatively easy revascularization of these high-risk patients and avoids the certain hazards of cannulation and cross-clamping of the diseased aorta. Neurocognitive Functioning After Off-Pump Coronary Artery Bypass The incidence of new onset of subtle neurocognitive dysfunction (NCD) after CABG has been reported to be between 5% and 60%, depending on the sensitivity of the tests used. Specific deficits include short-term memory loss, impaired performance of simple calculations, and personality and mood disturbances.104–106 Many factors related to CPB have been implicated in post-CABG NCD, including the SIR, alterations in cerebral blood flow, and microembolization caused by the CPB circuit or by cannulation and crossclamping.106,107 Indeed, diffusion-weighted magnetic resonance imaging studies have shown that 26% to 45% of patients recovering from CABG with CPB have focal, ischemic brain lesions.108–110 Additionally, a study of 312 CABG patients showed that more than 17% had retinal infarcts.111 A few studies have shown that OPCAB is associated with a reduced incidence of NCD compared with conventional CABG with CPB.107,112 However, other studies have shown no significant differences.113–115 Although several groups have reported that OPCAB is associated with significantly less SIR than is CABG,63,116,117 the magnitude of SIR has not been shown to correlate with the severity of NCD in individual patients.43 The failure of OPCAB to reduce postoperative NCD has been largely attributed to the liberation of microemboli during application and removal of the partialocclusion aortic clamp. Although OPCAB eliminates the need for a perfusion catheter for CPB or a cross-clamp for CAR046.indd 1064 46 cardiac arrest, the side-biting partial occlusion clamp, which is routinely used at many centers during construction of proximal anastomoses, may be equally traumatic. However, at least one small, randomized, prospective study has shown that OBCAB is associated with reduced microembolization—but not a reduced incidence of NCD—compared with standard CABG.118 Additionally, avoiding aortic manipulation by performing OPCAB using composite grafts arising from the in-situ LIMA has been shown to reduce the risk of postoperative stroke.119,120 Several new devices allow offpump construction of proximal anastomoses without application of the partial occlusion clamp, but it is not clear what impact these devices will have on NCD after OPCAB. Reducing the Invasiveness of Coronary Artery Bypass Although median sternotomy is a very well tolerated incision, it does restrict patients from heavy lifting for 8 weeks and is associated with some degree of perioperative discomfort. In addition, postoperative wound complications, although infrequent, may require surgical revision or even sternal resection and plastic surgical reconstruction with tissue-transfer flaps. Patient perception of a 20-cm incision and a “cracked” chest are also important considerations. Furthermore, some data suggest that the magnitude of musculoskeletal trauma is proportional to systemic inflammation.121,122 As such, many attempts to refine coronary bypass procedures have focused on finding ways to decrease the size of the incision and the degree of morbidity associated with it. Minimally Invasive Direct Coronary Artery Bypass First introduced by Benetti in 1995,123 the minimally invasive direct coronary artery bypass (MIDCAB) procedure involves performing a 7-cm anterior lateral thoracotomy, usually in the fifth intercostal space. By this route, singlevessel off-pump bypass can be performed, using the LIMA to bypass the LAD. In several early studies, this technique shortened hospital length of stay and reduced transfusion requirements relative to standard CABG.99,124–126 Results of small randomized trials suggest that, in patients with stenosis of the proximal LAD, MIDCAB is associated with a longer in-hospital recovery period127 and higher costs than is direct stenting,128 but that MIDCAB produces similar or better short- and long-term outcomes.30,129 However, in the U.S., only a few centers regularly perform MIDCAB. Early in the MIDCAB experience, many U.S. centers mobilized the LIMA using direct visualization through the thoracotomy (Figs. 46.21 and 46.22). This method was often technically demanding, and the forceful retraction of the chest wall necessary to expose the LIMA could cause substantial early postoperative pain. Furthermore, LIMA grafts produced by this technique may be too short. Nevertheless, U.S. centers that perform MIDCAB frequently report excellent results.130–132 More recently, there has been resurgent interest in videoscopic LIMA mobilization (Figs. 46.23 to 46.25). With this technique, the left lung is collapsed while right lung ventilation is maintained, the left pleural space is insufflated with CO2, and the LIMA is harvested from the back of the chest 11/24/2006 12:09:34 PM su rgic a l t r e atm e n t of corona ry a rt e ry dise a se 10 6 5 FIGURE 46.21. When minimally invasive direct coronary artery bypass was fi rst being used, surgeons harvested the left internal mammary artery through a small anterior thoracotomy by aggressively retracting the anterior chest wall. This technique caused a great deal of postoperative discomfort for the patient and was sometimes technically challenging for the surgeon. For patients with multivessel CAD, combining a LIMA-toLAD bypass (MIDCAB) with endovascular intervention in the circumflex and right coronary arteries may be a good alternative to standard CABG. A multicenter series136 and a small, single-center series137 have shown that videoscopic mobilization of the LIMA and opening of the pericardium, using a voice-operated robotic arm to manipulate the scope, enables the surgeon to place the chest wall incision more accurately. This permits construction of the LIMA-to-LAD anastomosis without a rib spreader; instead, only soft tissue retractors and a specially designed, bed-mounted stabilizer are used to expose the anastomotic site through the natural intercostal space.135 Patients are subsequently taken to the catheterization lab where stents are placed in the circumflex and right coronary arteries. This approach significantly reduces postoperative pain.138 FIGURE 46.22. Diagram of the minimally invasive direct coronary artery bypass (MIDCAB) operation, showing the typical size and location of the incision and its position relative to the IMA-to-LAD graft. FIGURE 46.23. When videoscopic mammary harvest is combined with off-pump bypass during anterior thoracotomy, the patient experiences only modest postoperative discomfort and a favorable cosmetic result. wall using 5-mm videoscopic instruments. This technique avoids the aggressive chest wall retraction required for direct LIMA harvest and allows the entire length of the artery to be safely mobilized. Although this technique is associated with a significant learning curve, its success has been well documented.133–135 Hybrid Minimally Invasive Direct Coronary Artery Bypass/Endovascular Procedures CAR046.indd 1065 11/24/2006 12:09:34 PM 10 6 6 chapter 46 FIGURE 46.24. When a conventional thoracoscope is coupled to a video camera and thoracoscopic instrumentation, the internal mammary artery can be harvested without aggressive chest wall retraction. Single rightlung ventilation and insufflation of the left chest with low-pressure CO2 facilitates this technique. Robot-Assisted Endoscopic Coronary Artery Bypass Grafting Several reports document totally videoscopic LIMA-to-LAD procedures in which surgical robots were used to mobilize the LIMA and perform the sutured anastomosis, both onpump139–141 and off-pump (Fig. 46.26).139,142,143 These robots use master–slave servomotors and microprocessor control to precisely emulate and miniaturize the surgeon’s movements, enabling the surgeon to manipulate videoscopic instruments with multiple degrees of freedom (Fig. 46.27). A highresolution, three-dimensional display provides stereopsis with a high degree of magnification (Fig. 46.28). Tremor filtering and motion scaling can be adjusted to the surgeon’s preferences, enabling tremendous precision, which compensates somewhat for the lack of tactile feedback (although tactile feedback systems are under development144). Although intriguing, surgical robots are not likely to be in widespread use for CABG in the near future, mainly because of the expense of the robots and the challenges involved in learning to use them for robotic totally endoscopic CABG (TECAB), especially TECAB without CPB. Even surgeons experienced with TECAB can perform only one in three of them off-pump; the majority of cases require a small MIDCAB incision in order to perform the anastomosis. Part of the difficulty of performing closed-chest robotic CABG lies in the technical demands of constructing a precise anastomosis in a confined space without the use of sutures. (The robots’ manipulators cannot tie knots.) A number of new tools, however, are on the horizon that may ameliorate this problem. Several novel anastomotic devices, currently in clinical trials, can create a precise, sutureless anastomosis between the graft and the coronary artery (Figs. 46.29 and 46.30). If, ultimately, these produce acceptable results and are approved for widespread use, they could make closedchest robotic CABG a practical option for the treatment of CAD. Port-Access Coronary Artery Bypass Grafting FIGURE 46.25. Thoracoscopic view of the left internal mammary artery from inside the left chest. Generally, any segment of the left internal mammary artery can be harvested using this technique, but there is a significant learning curve. CAR046.indd 1066 Port-access cardiac surgery was introduced by Heartport, Inc. (Redwood City, CA) in 1996 as a means of reducing surgical trauma. Multifunctional catheters inserted into the femoral artery and vein are used for CPB, balloon endoclamping of the ascending aorta, antegrade cardioplegia, and venting the ascending aorta. Additional catheters threaded into the left jugular vein deliver retrograde cardioplegia into 11/24/2006 12:09:35 PM su rgic a l t r e atm e n t of corona ry a rt e ry dise a se 10 67 FIGURE 46.26. The Intuitive robot (Intuitive Surgical, Inc., Sunnyvale, CA) has a remote console that provides the surgeon with excellent three-dimensional stereopsis and effectors for manipulating the robotic instruments in a very intuitive environment. The bedside robotic component is connected to the console by cables. the coronary sinus and vent the pulmonary artery. This enables the surgeon to make only a small chest incision suitable to the desired procedure. Although port-access CPB has been used successfully in multivessel CABG performed through small fifth intercostal space thoracotomies,145–147 this procedure has fallen out of favor, partly because of the difficulty of constructing grafts of appropriate length and lie. Nonetheless, port access is still used in some TECAB procedures and is helpful in limitedaccess mitral and atrial septal defect repairs. FIGURE 46.27. The Intuitive robot uses sophisticated microprocessor control and master–slave servos to emulate the motion of a human hand. This ingenious mechanism provides seven degrees of freedom, enabling surgeons to learn quickly to manipulate the effectors. CAR046.indd 1067 FIGURE 46.28. Closed-chest bypass without an incision, using robotic telemanipulation instruments, has been performed at only select centers, mostly outside the United States. Although this approach is currently considered technically demanding, new developments in anastomotic devices, closed-chest stabilization, and robotic technology may one day increase its applicability. 11/24/2006 12:09:36 PM 10 6 8 chapter 46 gests that OPCAB has advantages for at least some patients. As CABG technology is refined further, less invasive techniques of LIMA-to-LAD grafting may become practical, perhaps paving the way for new hybrid approaches to the treatment of CAD. References FIGURE 46.29. The Converge anastomotic device (Converge Medical, Sunnyvale, CA) allows a graft to be attached to a coronary artery in an end-to-side fashion with an automated mechanism. Anastomotic devices of this type may prove essential in the evolution of less invasive variants of coronary artery bypass grafting. Summary The excellent results provided by CABG, especially when the LIMA is used to graft the LAD, are well documented. Although there have been significant advances in the field of catheter-based intervention, to date none has matched the long-term patency of the LIMA graft. Moreover, there are not yet long-term data (i.e., 10 or more years of follow-up) on drug-eluting stents. Although there is not complete agreement about the relative safety and efficacy of OPCAB and conventional CABG with CPB, considerable evidence sug- FIGURE 46.30. Postoperative angiogram showing a widely patent saphenous vein graft to the obtuse marginal coronary artery constructed with the Converge anastomotic device (Converge Medical). CAR046.indd 1068 1. American Heart Association. Heart Disease and Stroke Statistics—2005 Update. Dallas, TX: American Heart Association, 2005. 2. Sabiston DC Jr. Direct surgical management of congenital and acquired lesions of the coronary circulation. Prog Cardiovasc Dis 1963;24:299–316. 3. Garrett HE, Cartmill TB, Thiele JP, Howell JF, DeBakey ME. Experimental evaluation of venous autografts as aorta to left ventricular myocardial shunts in revascularization of the heart: a preliminary report. Cardiovasc Res Cent Bull 1964;24: 15–20. 4. Garrett HE, Dennis EW, DeBakey ME. Aortocoronary bypass with saphenous vein graft: seven-year follow-up. JAMA 1996; 276:1517–1520. 5. Favaloro RG. Direct myocardial revascularization. Surg Clin North Am 1971;51:1035–1042. 6. Olearchyk AS. Vasilii I. Kolesov: a pioneer of coronary revascularization by internal mammary-coronary artery grafting. J Thorac Cardiovasc Surg 1988;96:13–18. 7. Favaloro RG, Effler DB, Groves LK, Sheldon WC, Shirey EK, Sones FM Jr. Severe segmental obstruction of the left main coronary artery and its divisions: surgical treatment by the saphenous vein graft technique. J Thorac Cardiovasc Surg 1970; 60:469–482. 8. Johnson WD, Flemma RJ, Lepley D, Jr, Ellison EH. Extended treatment of severe coronary artery disease: a total surgical approach. Ann Surg 1969;170:460–470. 9. Yusuf S, Zucker D, Peduzzi P, et al. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 1994;344:563–570. 10. Rihal CS, Raco DL, Gersh BJ, Yusuf S. Indications for coronary artery bypass surgery and percutaneous coronary intervention in chronic stable angina: review of the evidence and methodological considerations. Circulation 2003;108:2439–2445. 11. Caines AE, Massad MG, Kpodonu J, Rebeiz AG, Evans A, Geha AS. Outcomes of coronary artery bypass grafting versus percutaneous coronary intervention and medical therapy for multivessel disease with and without left ventricular dysfunction. Cardiology 2004;101:21–28. 12. Hueb W, Soares PR, Gersh BJ, et al. The medicine, angioplasty, or surgery study (MASS-II): a randomized, controlled clinical trial of three therapeutic strategies for multivessel coronary artery disease: one-year results. J Am Coll Cardiol 2004;43: 1743–1751. 13. Serruys PW, Unger F, Sousa JE, et al. Comparison of coronaryartery bypass surgery and stenting for the treatment of multivessel disease. N Engl J Med 2001;344:1117–1124. 14. The SoS Investigators. Coronary artery bypass surgery versus percutaneous coronary intervention with stent implantation in patients with multivessel coronary artery disease (the Stent or Surgery trial): a randomised controlled trial. Lancet 2002;360: 965–970. 15. Delacretaz E, Meier B. Therapeutic strategy with total coronary artery occlusions. Am J Cardiol 1997;79:185–187. 16. RITA Trial Participants. Coronary angioplasty versus coronary artery bypass surgery: the Randomized Intervention Treatment of Angina (RITA) trial. Lancet 1993;341:573–580. 11/24/2006 12:09:38 PM su rgic a l t r e atm e n t of corona ry a rt e ry dise a se 17. CABRI Trial Participants. First-year results of CABRI (Coronary Angioplasty versus Bypass Revascularisation Investigation). Lancet 1995;346:1179–1184. 18. Kurbaan AS, Bowker TJ, Rickards AF. Differential restenosis rate of individual coronary artery sites after multivessel angioplasty: implications for revascularization strategy. Coronary Angioplasty versus Bypass Revascularisation Investigation. Am Heart J 1998;135:703–708. 19. The BARI Investigators. Influence of diabetes on 5-year mortality and morbidity in a randomized trial comparing CABG and PTCA in patients with multivessel disease: the Bypass Angioplasty Revascularization Investigation (BARI). Circulation 1997;96:1761–1769. 20. Nalysnyk L, Fahrbach K, Reynolds MW, Zhao SZ, Ross S. Adverse events in coronary artery bypass graft (CABG) trials: a systematic review and analysis. Heart 2003;89:767–772. 21. Cheng DC, Bainbridge D, Martin JE, Novick RJ. EvidenceBased Perioperative Clinical Outcomes Research Group. Does off-pump coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with conventional coronary artery bypass? A meta-analysis of randomized trials. Anesthesiology 2005;102:188–203. 22. Tevaearai HT, Mueller XM, von Segesser LK. Minimally invasive harvest of the saphenous vein for coronary artery bypass grafting. Ann Thorac Surg 1997;63:S119–S121. 23. Souza DS, Dashwood MR, Tsui JC, et al. Improved patency in vein grafts harvested with surrounding tissue: results of a randomized study using three harvesting techniques. Ann Thorac Surg 2002;73:1189–1195. 24. Yun KL, Wu Y, Aharonian V, et al. Randomized trial of endoscopic versus open vein harvest for coronary artery bypass grafting: six-month patency rates. J Thorac Cardiovasc Surg 2005;129:496–503. 25. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986;314:1–6. 26. Zeff RH, Kongtahworn C, Iannone LA, et al. Internal mammary artery versus saphenous vein graft to the left anterior descending coronary artery: prospective randomized study with 10year follow-up. Ann Thorac Surg 1988;45:533–536. 27. Edwards FH, Clark RE, Schwartz M. Impact of internal mammary artery conduits on operative mortality in coronary revascularization. Ann Thorac Surg 1994;57:27–32. 28. Fournial G, Fourcade J, Roux D, Garcia O, Sauer M, Glock Y. Cardiac factors predictive of 10-year survival after coronary surgery [in French]. Arch Mal Coeur Vaiss 1999;92:851–858. 29. Tatoulis J, Buxton BF, Fuller JA. Patencies of 2127 arterial to coronary conduits over 15 years. Ann Thorac Surg 2004;77: 93–101. 30. Cisowski M, Drzewiecki J, Drzewiecka-Gerber A, et al. Primary stenting versus MIDCAB: preliminary report-comparison of two methods of revascularization in single left anterior descending coronary artery stenosis. Ann Thorac Surg 2002;74:S1334– S1339. 31. Royse AG, Royse CF, Tatoulis J. Total arterial coronary revascularization and factors influencing in-hospital mortality. Eur J Cardiothorac Surg 1999;16:499–505. 32. Zacharias A, Habib RH, Schwann TA, Riordan CJ, Durham SJ, Shah A. Improved survival with radial artery versus vein conduits in coronary bypass surgery with left internal thoracic artery to left anterior descending artery grafting. Circulation 2004;109:1489–1496. 33. Desai ND, Cohen EA, Naylor CD, Fremes SE. A randomized comparison of radial-artery and saphenous-vein coronary bypass grafts. N Engl J Med 2004;351:2302–2309. 34. Sethi GK, Copeland JG, Moritz T, Henderson W, Zadina K, Goldman S. Comparison of postoperative complications CAR046.indd 1069 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 10 6 9 between saphenous vein and IMA grafts to left anterior descending coronary artery. Ann Thorac Surg 1991;51:733–738. van der Meer J, Hillege HL, van Gilst WH, et al. A comparison of internal mammary artery and saphenous vein grafts after coronary artery bypass surgery: no difference in 1-year occlusion rates and clinical outcome. CABADAS Research Group of the Interuniversity Cardiology Institute of The Netherlands. Circulation 1994;90:2367–2374. Myers WO, Berg R, Ray JF, et al. All-artery multigraft coronary artery bypass grafting with only internal thoracic arteries possible and safe: a randomized trial. Surgery 2000;128:650–659. Miles RH, Kollpainter RE, Riveron FA, Johnkoski JA. The pneumatic tourniquet technique for endoscopic radial artery harvest. J Card Surg 2004;19:495–498. Patel AN, Henry AC, Hunnicutt C, Cockerham CA, Willey B, Urschel HC Jr. Endoscopic radial artery harvesting is better than the open technique. Ann Thorac Surg 2004;78:149–153. Newman RV, Lammle WG. Radial artery harvest using endoscopic techniques. Heart Surg Forum 2003;6:E194–E195. Possati G, Gaudino M, Alessandrini F, et al. Midterm clinical and angiographic results of radial artery grafts used for myocardial revascularization. J Thorac Cardiovasc Surg 1998;116: 1015–1021. Maniar H, Sundt T, Barner H, et al. Effect of target stenosis and location on radial artery graft patency. J Thorac Cardiovasc Surg 2002;123:45–52. Cameron J, Trivedi S, Stafford G, Bett JH. Five-year angiographic patency of radial artery bypass grafts. Circulation 2004;110:II23–II26. Wan S, LeClerc JL, Vincent JL. Inflammatory response to cardiopulmonary bypass: mechanisms involved and possible therapeutic strategies. Chest 1997;112:676–692. Hsu LC. Heparin-coated cardiopulmonary bypass circuits: current status. Perfusion 2001;16:417–428. Ueyama K, Nishimura K, Nishina T, Nakamura T, Ikeda T, Komeda M. PMEA coating of pump circuit and oxygenator may attenuate the early systemic inflammatory response in cardiopulmonary bypass surgery. ASAIO J 2004;50:369–372. Vocelka C, Lindley G. Improving cardiopulmonary bypass: heparin-coated circuits. J Extra Corpor Technol 2003;35:312– 316. von Segesser LK, Tozzi P, Mallbiabrrena I, Jegger D, Horisberger J, Corno A. Miniaturization in cardiopulmonary bypass. Perfusion 2003;18:219–224. Journois D. Hemofi ltration during cardiopulmonary bypass. Kidney Int Suppl 1998;66:S174–S177. Whitaker DC, Stygall JA, Newman SP, Harrison MJ. The use of leucocyte-depleting and conventional arterial line fi lters in cardiac surgery: a systematic review of clinical studies. Perfusion 2001;16:433–446. Anic D, Gasparovic H, Ivancan V, Batinic D. Effects of corticosteroids on inflammatory response following cardiopulmonary bypass. Croat Med J 2004;45:158–161. Kilger E, Weis F, Briegel J, et al. Stress doses of hydrocortisone reduce severe systemic inflammatory response syndrome and improve early outcome in a risk group of patients after cardiac surgery. Crit Care Med 2003;31:1068–1074. Bronicki RA, Backer CL, Baden HP, Mavroudis C, Crawford SE, Green TP. Dexamethasone reduces the inflammatory response to cardiopulmonary bypass in children. Ann Thorac Surg 2000;69:1490–1495. Hill GE, Alonso A, Spurzem JR, Stammers AH, Robbins RA. Aprotinin and methylprednisolone equally blunt cardiopulmonary bypass-induced inflammation in humans. J Thorac Cardiovasc Surg 1995;110:1658–1662. Aldea GS, Soltow LO, Chandler WL, et al. Limitation of thrombin generation, platelet activation, and inflammation by elimi- 11/24/2006 12:09:39 PM 10 7 0 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. chapter nation of cardiotomy suction in patients undergoing coronary artery bypass grafting treated with heparin-bonded circuits. J Thorac Cardiovasc Surg 2002;123:742–755. Westerberg M, Bengtsson A, Jeppsson A. Coronary surgery without cardiotomy suction and autotransfusion reduces the postoperative systemic inflammatory response. Ann Thorac Surg 2004;78:54–59. Kincaid EH, Jones TJ, Stump DA, et al. Processing scavenged blood with a cell saver reduces cerebral lipid microembolization. Ann Thorac Surg 2000;70:1296–1300. Borowiec JW, Bozdayi M, Jaramillo A, Nilsson L, Venge P, Henze A. Influence of two blood conservation techniques (cardiotomy reservoir versus cell-saver) on biocompatibility of the heparin coated cardiopulmonary bypass circuit during coronary revascularization surgery. J Card Surg 1997;12:190–197. Lima R. Revascularizacion a o da artèria circunflexa sem auxilio da CEC. Paper presented at XII encontro dos discipulos do Dr. E.J. Zerbini, 1995, Curitiba. Sepic J, Wee JO, Soltesz EG, et al. Cardiac positioning using an apical suction device maintains beating heart hemodynamics. Heart Surg Forum 2002;5:279–284. Chang WI, Kim KB, Kim JH, Ham BM, Kim YL. Hemodynamic changes during posterior vessel off-pump coronary artery bypass: comparison between deep pericardial sutures and vacuum-assisted apical suction device. Ann Thorac Surg 2004; 78:2057–2062. Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation 2004;110:e340–e437. Arom KV, Flavin TF, Emery RW, Kshettry VR, Janey PA, Petersen RJ. Safety and efficacy of off-pump coronary artery bypass grafting. Ann Thorac Surg 2000;69:704–710. Arom KV, Flavin TF, Emery RW, Kshettry VR, Petersen RJ, Janey PA. Is low ejection fraction safe for off-pump coronary bypass operation? Ann Thorac Surg 2000;70:1021–1025. Calafiore AM, Di Mauro M, Contini M, et al. Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease: impact of the strategy on early outcome. Ann Thorac Surg 2001;72:456–462. Cartier R, Brann S, Dagenais F, Martineau R, Couturier A. Systematic off-pump coronary artery revascularization in multivessel disease: experience of three hundred cases. J Thorac Cardiovasc Surg 2000;119:221–229. Cleveland JC, Jr, Shroyer AL, Chen AY, Peterson E, Grover FL. Off-pump coronary artery bypass grafting decreases riskadjusted mortality and morbidity. Ann Thorac Surg 2001;72: 1282–1288. Czerny M, Baumer H, Kilo J, et al. Complete revascularization in coronary artery bypass grafting with and without cardiopulmonary bypass. Ann Thorac Surg 2001;71:165–169. Hart JC, Spooner TH, Pym J, et al. A review of 1582 consecutive Octopus off-pump coronary bypass patients. Ann Thorac Surg 2000;70:1017–1020. Hernandez F, Cohn WE, Baribeau YR, et al. In-hospital outcomes of off-pump versus on-pump coronary artery bypass procedures: a multicenter experience. Ann Thorac Surg 2001;72: 1528–1533. Magee MJ, Dewey TM, Acuff T, et al. Influence of diabetes on mortality and morbidity: off-pump coronary artery bypass grafting versus coronary artery bypass grafting with cardiopulmonary bypass. Ann Thorac Surg 2001;72:776–780. Plomondon ME, Cleveland JC, Jr, Ludwig ST, et al. Off-pump coronary artery bypass is associated with improved riskadjusted outcomes. Ann Thorac Surg 2001;72:114–119. CAR046.indd 1070 46 72. Puskas JD, Thourani VH, Marshall JJ, et al. Clinical outcomes, angiographic patency, and resource utilization in 200 consecutive off-pump coronary bypass patients. Ann Thorac Surg 2001; 71:1477–1483. 73. Puskas JD, Williams WH, Duke PG, et al. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg 2003;125:797–808. 74. Gerola LR, Buffolo E, Jasbik W, et al. Off-pump versus on-pump myocardial revascularization in low-risk patients with one or two vessel disease: perioperative results in a multicenter randomized controlled trial. Ann Thorac Surg 2004;77:569–573. 75. Straka Z, Widimsky P, Jirasek K, et al. Off-pump versus onpump coronary surgery: fi nal results from a prospective randomized study PRAGUE-4. Ann Thorac Surg 2004;77:789– 793. 76. Khan NE, De Souza A, Mister R, et al. A randomized comparison of off-pump and on-pump multivessel coronary-artery bypass surgery. N Engl J Med 2004;350:21–28. 77. Wehlin L, Vedin J, Vaage J, Lundahl J. Activation of complement and leukocyte receptors during on- and off-pump coronary artery bypass surgery. Eur J Cardiothorac Surg 2004;25: 35–42. 78. Reston JT, Tregear SJ, Turkelson CM. Meta-analysis of shortterm and mid-term outcomes following off-pump coronary artery bypass grafting. Ann Thorac Surg 2003;76:1510–1515. 79. Parolari A, Alamanni F, Cannata A, et al. Off-pump versus on-pump coronary artery bypass: meta-analysis of currently available randomized trials. Ann Thorac Surg 2003;76:37–40. 80. Herz I, Moshkovitz Y, Hendler A, et al. Revascularization of left anterior descending artery with drug-eluting stents: comparison with off-pump surgery. Ann Thorac Surg 2005;79:88– 92. 81. Immer FF, Berdat PA, Immer-Bansi AS, et al. Benefit to quality of life after off-pump versus on-pump coronary bypass surgery. Ann Thorac Surg 2003;76:27–31. 82. Magee MJ, Jablonski KA, Stamou SC, et al. Elimination of cardiopulmonary bypass improves early survival for multivessel coronary artery bypass patients. Ann Thorac Surg 2002;73: 1196–1202. 83. Muneretto C, Bisleri G, Negri A, et al. Off-pump coronary artery bypass surgery technique for total arterial myocardial revascularization: a prospective randomized study. Ann Thorac Surg 2003;76:778–782. 84. Omeroglu SN, Kirali K, Guler M, et al. Midterm angiographic assessment of coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 2000;70:844–849. 85. Puskas JD, Williams WH, Mahoney EM, et al. Off-pump vs conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial. JAMA 2004;291:1841–1849. 86. Stamou SC, Corso PJ. Coronary revascularization without cardiopulmonary bypass in high-risk patients: a route to the future. Ann Thorac Surg 2001;71:1056–1061. 87. Gaudino M, Glieca F, Alessandrini F, et al. High risk coronary artery bypass patient: incidence, surgical strategies, and results. Ann Thorac Surg 2004;77:574–579. 88. Meharwal ZS, Mishra YK, Kohli V, Bapna R, Singh S, Trehan N. Off-pump multivessel coronary artery surgery in high-risk patients. Ann Thorac Surg 2002;74:S1353–S1357. 89. Koutlas TC, Elbeery JR, Williams JM, Moran JF, Francalancia NA, Chitwood WR Jr. Myocardial revascularization in the elderly using beating heart coronary artery bypass surgery. Ann Thorac Surg 2000;69:1042–1047. 11/24/2006 12:09:40 PM su rgic a l t r e atm e n t of corona ry a rt e ry dise a se 90. Stamou SC, Dangas G, Dullum MK, et al. Beating heart surgery in octogenarians: perioperative outcome and comparison with younger age groups. Ann Thorac Surg 2000;69:1140–1145. 91. Shennib H, Endo M, Benhamed O, Morin JF. Surgical revascularization in patients with poor left ventricular function: on- or off-pump? Ann Thorac Surg 2002;74:S1344–S1347. 92. Hoff SJ, Ball SK, Coltharp WH, Glassford DM, Jr, Lea JW, IV, Petracek MR. Coronary artery bypass in patients 80 years and over: is off-pump the operation of choice? Ann Thorac Surg 2002;74:S1340–S1343. 93. Hirose H, Amano A, Takahashi A. Off-pump coronary artery bypass grafting for elderly patients. Ann Thorac Surg 2001;72: 2013–2019. 94. Ascione R, Lloyd CT, Underwood MJ, Lotto AA, Pitsis AA, Angelini GD. Inflammatory response after coronary revascularization with or without cardiopulmonary bypass. Ann Thorac Surg 2000;69:1198–1204. 95. Stamou SC, Pfister AJ, Dullum MK, et al. Late outcome of reoperative coronary revascularization on the beating heart. Heart Surg Forum 2001;4:69–73. 96. Trehan N, Mishra YK, Malhotra R, Sharma KK, Mehta Y, Shrivastava S. Off-pump redo coronary artery bypass grafting. Ann Thorac Surg 2000;70:1026–1029. 97. Al-Ruzzeh S, Athanasiou T, George S, et al. Is the use of cardiopulmonary bypass for multivessel coronary artery bypass surgery an independent predictor of operative mortality in patients with ischemic left ventricular dysfunction? Ann Thorac Surg 2003;76:444–451. 98. Ascione R, Narayan P, Rogers CA, Lim KH, Capoun R, Angelini GD. Early and midterm clinical outcome in patients with severe left ventricular dysfunction undergoing coronary artery surgery. Ann Thorac Surg 2003;76:793–799. 99. Azoury FM, Gillinov AM, Lytle BW, Smedira NG, Sabik JF. Off-pump reoperative coronary artery bypass grafting by thoracotomy: patient selection and operative technique. Ann Thorac Surg 2001;71:1959–1963. 100. Fonger JD, Doty JR, Sussman MS, Salomon NW. Lateral MIDCAB grafting via limited posterior thoracotomy. Eur J Cardiothorac Surg 1997;12:399–404. 101. Abraham R, Ricci M, Salerno T, Kerr P. A minimally invasive alternative approach for reoperative grafting of the right coronary artery. J Card Surg 2002;17:289–291. 102. Fonger JD, Doty JR, Salazar JD, Walinsky PL, Salomon NW. Initial experience with MIDCAB grafting using the gastroepiploic artery. Ann Thorac Surg 1999;68:431–436. 103. Tector AJ, Amundsen S, Schmahl TM, Kress DC, Peter M. Total revascularization with T grafts. Ann Thorac Surg 1994; 57:33–38. 104. Clark RE, Brillman J, Davis DA, Lovell MR, Price TR, Magovern GJ. Microemboli during coronary artery bypass grafting: genesis and effect on outcome. J Thorac Cardiovasc Surg 1995;109:249–257. 105. Sotaniemi KA, Mononen H, Hokkanen TE. Long-term cerebral outcome after open-heart surgery: a five-year neuropsychological follow-up study. Stroke 1986;17:410–416. 106. Stump DA, Rogers AT, Hammon JW, Newman SP. Cerebral emboli and cognitive outcome after cardiac surgery. J Cardiothorac Vasc Anesth 1996;10:113–118. 107. Diegeler A, Hirsch R, Schneider F, et al. Neuromonitoring and neurocognitive outcome in off-pump versus conventional coronary bypass operation. Ann Thorac Surg 2000;69:1162– 1166. 108. Bendszus M, Reents W, Franke D, et al. Brain damage after coronary artery bypass grafting. Arch Neurol 2002;59:1090– 1095. 109. Restrepo L, Wityk RJ, Grega MA, et al. Diffusion- and perfusion-weighted magnetic resonance imaging of the brain CAR046.indd 1071 10 71 before and after coronary artery bypass grafting surgery. Stroke 2002;33:2909–2915. 110. Knipp SC, Matatko N, Wilhelm H, et al. Evaluation of brain injury after coronary artery bypass grafting. A prospective study using neuropsychological assessment and diffusionweighted magnetic resonance imaging. Eur J Cardiothorac Surg 2004;25:791–800. 111. Shaw PJ, Bates D, Cartlidge NE, et al. Neuro-ophthalmological complications of coronary artery bypass graft surgery. Acta Neurol Scand 1987;76:1–7. 112. Zamvar V, Deglurkar I, Abdullah F, Khan NU. Bleeding from the lung surface: a unique complication of off-pump CABG operation. Heart Surg Forum 2001;4:172–173. 113. Taggart DP, Browne SM, Halligan PW, Wade DT. Is cardiopulmonary bypass still the cause of cognitive dysfunction after cardiac operations? J Thorac Cardiovasc Surg 1999;118:414– 420. 114. Van Dijk D, Jansen EW, Hijman R, et al. Cognitive outcome after off-pump and on-pump coronary artery bypass graft surgery: a randomized trial. JAMA 2002;287:1405–1412. 115. Keizer AM, Hijman R, van Dijk D, Kalkman CJ, Kahn RS. Cognitive self-assessment one year after on-pump and off-pump coronary artery bypass grafting. Ann Thorac Surg 2003;75:835– 838. 116. Matata BM, Sosnowski AW, Galinanes M. Off-pump bypass graft operation significantly reduces oxidative stress and inflammation. Ann Thorac Surg 2000;69:785–791. 117. Okubo N, Hatori N, Ochi M, Tanaka S. Comparison of m-RNA expression for inflammatory mediators in leukocytes between on-pump and off-pump coronary artery bypass grafting. Ann Thorac Cardiovasc Surg 2003;9:43–49. 118. Lund C, Hol PK, Lundblad R, et al. Comparison of cerebral embolization during off-pump and on-pump coronary artery bypass surgery. Ann Thorac Surg 2003;76:765–770. 119. Chavanon O, Durand M, Hacini R, et al. Coronary artery bypass grafting with left internal mammary artery and right gastroepiploic artery, with and without bypass. Ann Thorac Surg 2002;73:499–504. 120. Kobayashi J, Tagusari O, Bando K, et al. Total arterial off-pump coronary revascularization with only internal thoracic artery and composite radial artery grafts. Heart Surg Forum 2002;6: 30–37. 121. Gu YJ, Mariani MA, van Oeveren W, Grandjean JG, Boonstra PW. Reduction of the inflammatory response in patients undergoing minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1998;65:420–424. 122. Gu YJ, Mariani MA, Boonstra PW, Grandjean JG, van Oeveren W. Complement activation in coronary artery bypass grafting patients without cardiopulmonary bypass: the role of tissue injury by surgical incision. Chest 1999;116:892–898. 123. Benetti FJ, Ballester C, Sani G, Doonstra P, Grandjean J. Video assisted coronary bypass surgery. J Card Surg 1995;10:620– 625. 124. Detter C, Reichenspurner H, Boehm DH, et al. Minimally invasive direct coronary artery bypass grafting (MIDCAB) and off-pump coronary artery bypass grafting (OPCAB): two techniques for beating heart surgery. Heart Surg Forum 2002;5:157–162. 125. Greenspun HG, Adourian UA, Fonger JD, Fan JS. Minimally invasive direct coronary artery bypass (MIDCAB): surgical techniques and anesthetic considerations. J Cardiothorac Vasc Anesth 1996;10:507–509. 126. Subramanian VA, McCabe JC, Geller CM. Minimally invasive direct coronary artery bypass grafting: two-year clinical experience. Ann Thorac Surg 1997;64:1648–1653. 127. Hong SJ, Lim DS, Seo HS, et al. Percutaneous coronary intervention with drug-eluting stent implantation vs. minimally 11/24/2006 12:09:40 PM 10 7 2 128. 129. 130. 131. 132. 133. 134. 135. 136. 137. chapter invasive direct coronary artery bypass (MIDCAB) in patients with left anterior descending coronary artery stenosis. Catheter Cardiovasc Interv 2005;64:75–81. Reeves BC, Angelini GD, Bryan AJ, et al. A multi-centre randomised controlled trial of minimally invasive direct coronary bypass grafting versus percutaneous transluminal coronary angioplasty with stenting for proximal stenosis of the left anterior descending coronary artery. Health Technol Assess 2004;8:1–43. Cisowski M, Drzewiecka-Gerber A, Ulczok R, et al. Primary direct stenting versus endoscopic atraumatic coronary artery bypass surgery in patients with proximal stenosis of the left anterior descending coronary artery: a prospective, randomised study. Kardiol Pol 2004;61:253–261. Mehran R, Dangas G, Stamou SC, et al. One-year clinical outcome after minimally invasive direct coronary artery bypass. Circulation 2000;102:2799–2802. Subramanian VA, Patel NU. Current status of MIDCAB procedure. Curr Opin Cardiol 2001;16:268–270. Vassiliades TA, Jr, Rogers EW, Nielsen JL, Lonquist JL. Minimally invasive direct coronary artery bypass grafting: intermediateterm results. Ann Thorac Surg 2000;70:1063–1065. Duhaylongsod FG, Mayfield WR, Wolf RK. Thoracoscopic harvest of the internal thoracic artery: a multicenter experience in 218 cases. Ann Thorac Surg 1998;66:1012–1017. Nataf P, Al-Attar N, Ramadan R, et al. Thoracoscopic IMA takedown. J Card Surg 2000;15:278–282. Vassiliades TA Jr. Atraumatic coronary artery bypass (ACAB): techniques and outcome. Heart Surg Forum 2001;4: 331–334. Stahl KD, Boyd WD, Vassiliades TA, Karamanoukian HL. Hybrid robotic coronary artery surgery and angioplasty in multivessel coronary artery disease. Ann Thorac Surg 2002;74: S1358–S1362. Lee MS, Wilentz JR, Makkar RR, et al. Hybrid revascularization using percutaneous coronary intervention and robotically assisted minimally invasive direct coronary artery bypass surgery. J Invasive Cardiol 2004;16:419–425. CAR046.indd 1072 46 138. de Canniere D, Jansens JL, Goldschmidt-Clermont P, Barvais L, Decroly P, Stoupel E. Combination of minimally invasive coronary bypass and percutaneous transluminal coronary angioplasty in the treatment of double-vessel coronary disease: two-year follow-up of a new hybrid procedure compared with “on-pump” double bypass grafting. Am Heart J 2001;142:563– 570. 139. Detter C, Boehm DH, Reichenspurner H, Deuse T, Arnold M, Reichart B. Robotically assisted coronary artery surgery with and without cardiopulmonary bypass: from fi rst clinical use to endoscopic operation. Med Sci Monit 2002;8:MT118–MT123. 140. Dogan S, Aybek T, Andressen E, et al. Totally endoscopic coronary artery bypass grafting on cardiopulmonary bypass with robotically enhanced telemanipulation: report of forty-five cases. J Thorac Cardiovasc Surg 2002;123:1125–1131. 141. Falk V, Diegeler A, Walther T, et al. Total endoscopic computer enhanced coronary artery bypass grafting. Eur J Cardiothorac Surg 2000;17:38–45. 142. Boehm DH, Reichenspurner H, Detter C, et al. Clinical use of a computer-enhanced surgical robotic system for endoscopic coronary artery bypass grafting on the beating heart. Thorac Cardiovasc Surg 2000;48:198–202. 143. Mohr FW, Falk V, Diegeler A, et al. Computer-enhanced “robotic” cardiac surgery: experience in 148 patients. J Thorac Cardiovasc Surg 2001;121:842–853. 144. Kitagawa M, Dokko D, Okamura AM, Yuh DD. Effect of sensory substitution on suture-manipulation forces for robotic surgical systems. J Thorac Cardiovasc Surg 2005;129:151–158. 145. Groh MA, Sutherland SE, Burton HG, III, Johnson AM, Ely SW. Port-access coronary artery bypass grafting: technique and comparative results. Ann Thorac Surg 1999;68:1506–1508. 146. Grossi EA, Groh MA, Lefrak EA, et al. Results of a prospective multicenter study on port-access coronary bypass grafting. Ann Thorac Surg 1999;68:1475–1477. 147. Reichenspurner H, Gulielmos V, Wunderlich J, et al. PortAccess coronary artery bypass grafting with the use of cardiopulmonary bypass and cardioplegic arrest. Ann Thorac Surg 1998;65:413–419. 11/24/2006 12:09:40 PM