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Journal of Cardiothoracic Surgery

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Open Access 01-12-2010 | Research article

Minimizing the risk of perioperative stroke by clampless off-pump bypass surgery: a retrospective observational analysis

Authors: Michael Hilker, Mathias Arlt, Andreas Keyser, Simon Schopka, Alexander Klose, Claudius Diez, Christof Schmid

Published in: Journal of Cardiothoracic Surgery | Issue 1/2010

Abstract

Objectives

Stroke is a devastating complication after coronary artery bypass grafting, occurring in 1.4% to 4.3% of patients. A major cause of stroke is cerebral embolization of aortic atheromatous debris or calcified plaques. This report analyzes the incidence of stroke in patients treated according to the clampless concept, i.e. avoiding side-clamping of the aorta, by means of off-pump coronary artery bypass surgery (OPCAB) in combination with the HEARTSTRING device.

Methods

During a period of 43 months (2005-2008), 412 consecutive patients were treated with the above-mentioned method by one single surgeon. A minimum of one proximal aortal anastomosis was performed in each patient. Altogether, 542 proximal anastomosis were applied, each created by means of the HEARTSTRING device.

Results

The mean age of patients was 67+9.7 years, the predicted mortality 5.2% (logistic EuroSCORE) and the observed mortality 1.9%. Histories of preoperative neurological disorders or cerebrovascular diseases were documented in 15% of patients. The overall incidence of postoperative stroke was 0.48% in contrast to 1.3% according to the stroke risk score.

Conclusions

In accordance to previously published data, our results show that avoiding aortic side-clamping during OPCAB reduces postoperative stroke rates. The HEARTSTRING device is a safe option for creating proximal aortic anastomosis.

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Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ: 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 (14): e340-437.PubMed

Cheng W, Denton TA, Fontana GP, Raissi S, Blanche C, Kass RM: Off-pump coronary surgery: effect on early mortality and stroke. J Thorac Cardiovasc Surg. 2002, 124 (2): 313-20. 10.1067/mtc.2002.122304.CrossRefPubMed

Puskas JD, Winston AD, Wright CE, Gott JP, Brown WM, Craver JM: Stroke after coronary artery operation: incidence, correlates, outcome, and cost. Ann Thorac Surg. 2000, 69 (4): 1053-6. 10.1016/S0003-4975(99)01569-6.CrossRefPubMed

Bucerius J, Gummert JF, Borger MA, Walther T, Doll N, Onnasch JF: Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. Ann Thorac Surg. 2003, 75 (2): 472-8. 10.1016/S0003-4975(02)04370-9.CrossRefPubMed

Charlesworth DC, Likosky DS, Marrin CA, Maloney CT, Quinton HB, Morton JR: Development and validation of a prediction model for strokes after coronary artery bypass grafting. Ann Thorac Surg. 2003, 76 (2): 436-43. 10.1016/S0003-4975(03)00528-9.CrossRefPubMed

Likosky DS, Leavitt BJ, Marrin CA, Malenka DJ, Reeves AG, Weintraub RM: Intra- and postoperative predictors of stroke after coronary artery bypass grafting. Ann Thorac Surg. 2003, 76 (2): 428-34. 10.1016/S0003-4975(03)00490-9. discussion 435CrossRefPubMed

Guerrieri Wolf L, Abu-Omar Y, Choudhary BP, Pigott D, Taggart DP: Gaseous and solid cerebral microembolization during proximal aortic anastomosis in off-pump coronary surgery: the effect of an aortic side-biting clamp and two clampless devices. J Thorac Cardiovasc Surg. 2007, 133 (2): 485-93. 10.1016/j.jtcvs.2006.10.002.CrossRefPubMed

Bergman P, Hadjinikolaou L, Dellgren G, Linden van der J: A policy to reduce stroke in patients with extensive atherosclerosis of the ascending aorta undergoing coronary surgery. Interact Cardiovasc Thorac Surg. 2004, 3 (1): 28-32. 10.1016/S1569-9293(03)00219-6.CrossRefPubMed

Lev-Ran O, Braunstein R, Sharony R, Kramer A, Paz Y, Mohr R: No-touch aorta off-pump coronary surgery: the effect on stroke. J Thorac Cardiovasc Surg. 2005, 129 (2): 307-13. 10.1016/j.jtcvs.2004.06.013.CrossRefPubMed

10.

Biancari F, Mosorin M, Lahtinen J, Heikkinen J, Rasinaho E, Anttila V: Results with the Heartstring anastomotic device in patients with diseased ascending aorta. Scand Cardiovasc J. 2006, 40 (4): 238-9. 10.1080/14017430600849211.CrossRefPubMed

11.

Vicol C, Oberhoffer M, Nollert G, Eifert S, Boekstegers P, Wintersperger B: First clinical experience with the HEARTSTRING, a device for proximal anastomosis in coronary surgery. Ann Thorac Surg. 2005, 79 (5): 1732-7. 10.1016/j.athoracsur.2004.05.080. discussion 1737CrossRefPubMed

12.

Weber A, Reuthebuch O, Turina M: Guidant Heartstring: initial experience in OPCAB surgery. Heart Surg Forum. 2005, 8 (1): E4-8.PubMed

13.

Kazui T, Doi H, Suzuki M, Okamoto T, Koshima R, Sugiki K: Initial clinical experience with the Heartstring. Jpn J Thorac Cardiovasc Surg. 2006, 54 (10): 424-8. 10.1007/s11748-006-0033-2.CrossRefPubMed

14.

Grunkemeier GL, Jin R, Wu Y: Cumulative sum curves and their prediction limits. Ann Thorac Surg. 2009, 87 (2): 361-4. 10.1016/j.athoracsur.2008.10.053.CrossRefPubMed

15.

Grossi EA, Bizekis CS, Sharony R, Saunders PC, Galloway AC, Lapietra A: Routine intraoperative transesophageal echocardiography identifies patients with atheromatous aortas: impact on "off-pump" coronary artery bypass and perioperative stroke. J Am Soc Echocardiogr. 2003, 16 (7): 751-5. 10.1016/S0894-7317(03)00284-0.CrossRefPubMed

16.

Bittner HB, Savitt MA, Ching PV, Ward HB: Off-pump coronary artery revascularization: ideal indication for patients with porcelain aorta and calcification of great vessels. J Cardiovasc Surg (Torino). 2003, 44 (2): 217-21.

17.

Kim WS, Lee J, Lee YT, Sung K, Yang JH, Jun TG: Total arterial revascularization in triple-vessel disease with off-pump and aortic no-touch technique. Ann Thorac Surg. 2008, 86 (6): 1861-5. 10.1016/j.athoracsur.2008.06.025.CrossRefPubMed

18.

Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ: Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009, 360 (10): 961-72. 10.1056/NEJMoa0804626.CrossRefPubMed

19.

Motallebzadeh R, Bland JM, Markus HS, Kaski JC, Jahangiri M: Neurocognitive function and cerebral emboli: randomized study of on-pump versus off-pump coronary artery bypass surgery. Ann Thorac Surg. 2007, 83 (2): 475-82. 10.1016/j.athoracsur.2006.09.024.CrossRefPubMed

20.

Goldman S, Sutter F, Ferdinand F, Trace C: Optimizing intraoperative cerebral oxygen delivery using noninvasive cerebral oximetry decreases the incidence of stroke for cardiac surgical patients. Heart Surg Forum. 2004, 7 (5): E376-81. 10.1532/HSF98.20041062.CrossRefPubMed

21.

Nakamura M, Okamoto F, Nakanishi K, Maruyama R, Yamada A, Ushikoshi S: Does intensive management of cerebral hemodynamics and atheromatous aorta reduce stroke after coronary artery surgery?. Ann Thorac Surg. 2008, 85 (2): 513-9. 10.1016/j.athoracsur.2007.08.056.CrossRefPubMed

22.

Trehan N, Mishra M, Kasliwal RR, Mishra A: Surgical strategies in patients at high risk for stroke undergoing coronary artery bypass grafting. Ann Thorac Surg. 2000, 70 (3): 1037-45. 10.1016/S0003-4975(00)01764-1.CrossRefPubMed

23.

Rosenberger P, Shernan SK, Loffler M, Shekar PS, Fox JA, Tuli JK: The influence of epiaortic ultrasonography on intraoperative surgical management in 6051 cardiac surgical patients. Ann Thorac Surg. 2008, 85 (2): 548-53. 10.1016/j.athoracsur.2007.08.061.CrossRefPubMed

Title: Minimizing the risk of perioperative stroke by clampless off-pump bypass surgery: a retrospective observational analysis
Authors: Michael Hilker
Mathias Arlt
Andreas Keyser
Simon Schopka
Alexander Klose
Claudius Diez
Christof Schmid
Publication date: 01-12-2010
Publisher: BioMed Central
Published in: Journal of Cardiothoracic Surgery / Issue 1/2010
Electronic ISSN: 1749-8090
DOI: https://doi.org/10.1186/1749-8090-5-14

At a glance: The STEP trials

Springer Medicine

Minimizing the risk of perioperative stroke by clampless off-pump bypass surgery: a retrospective observational analysis

Abstract

Objectives

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Objectives

Methods

Results

Conclusions

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