ObjectiveTo evaluate the safety and efficacy of total arterial off-pump coronary artery bypass grafting (OPCABG) using a left internal thoracic artery (LITA) combined with bilateral radial arteries (RAs). MethodsWe retrospectively analyzed the clinical data of patients with severe multi-vessel coronary artery disease who underwent total arterial OPCABG with a LITA and bilateral RAs at Sichuan Provincial People’s Hospital from November 2020 to April 2023. Results A total of 24 patients were included, comprising 23 males and 1 female, with a mean age of (53.63±4.33) years. The New York Heart Association (NYHA) functional class was Ⅱ to Ⅲ. The mean number of distal anastomoses was 3.17±0.38. A Y-graft was constructed in 12 patients and sequential grafting was performed in 4 patients. Concomitant procedures included coronary endarterectomy in 1 patient, intra-aortic balloon pump (IABP) implantation in 10 patients, and thymoma resection in 1 patient. The mean operative time was (308.13±30.39) min, mechanical ventilation time was (15.42±7.42) h, ICU stay was (46.08±27.32) h, and postoperative hospital stay was (11.71±1.90) d. There were no in-hospital deaths. Postoperative complications included one patient of acute renal failure and one patient of cerebral infarction. Pre-discharge color Doppler echocardiography revealed that the left ventricular end-diastolic diameter was significantly smaller than before surgery (P<0.05), while the left ventricular ejection fraction and fractional shortening were significantly higher (P<0.05). Coronary computed tomography angiography (CTA) showed that all arterial grafts were patent. During a mean follow-up of (14.58±8.75) months, no patients experienced angina recurrence or mortality. Repeat coronary CTA or angiography in 16 patients one year postoperatively confirmed that all arterial grafts remained patent. Conclusion Total arterial OPCABG using a LITA and bilateral RAs is a safe and effective treatment for patients with severe multi-vessel coronary artery disease. For high-risk patients, intraoperative IABP support is recommended.
ObjectiveTo investigate the early clinical efficacy of minimally invasive cardiac surgery coronary artery bypass grafting (MICS CABG) via left intercostal small incision for multivessel coronary artery disease. MethodsThe patients who received off-pump CABG in the Central China Fuwai Hospital of Zhengzhou University from June 2021 to June 2023 were enrolled. Patients were divided into two groups according to the operative technique used, including a traditional midline sternotomy group and a left intercostal small incision group. The clinical data of the two groups were compared. ResultsA total of 143 patients were enrolled, including 70 patients in the traditional midline sternotomy group and 73 patients in the left intercostal small incision group. The age of the patients in the left intercostal small incision group and the traditional midline sternotomy group was (63.8±8.0) years and (63.0±7.8) years, respectively; the proportions of males were 69.9% and 74.3%, respectively. The differences were not statistically significant (all P>0.05). All patients in the two groups successfully completed the operation, and no patients in the left intercostal small incision group were converted to thoracotomy. The patients in the left intercostal small incision group showed less postoperative drainage within postoperative 24 hours [(239.4±177.7) mL vs. (338.0±151.9) mL, P<0.001], lower perioperative blood transfusion rate [32.9% (24/73) vs. 51.4% (36/70), P=0.028], higher postoperative myoglobin level within postoperative 24 hours [366.1 (247.9, 513.0) ng/mL vs. 220.8 (147.2, 314.9) ng/mL, P<0.001], shorter intensive care unit stay [45.5 (31.5, 67.5) h vs. 68.0 (46.0, 78.5) h, P=0.001] and postoperative hospital stay [(10.8±4.0) d vs. (13.1±5.3) d, P=0.028] compared to the traditional midline sternotomy group. There was no significant difference in the incidence of major adverse cardiac and cerebrovascular event between the two groups [2.7% (2/73) vs. 2.9% (2/70), P=1.000]. ConclusionCompared to the full median sternotomy, MICS CABG leads to a good clinical result with smaller trauma, faster overall recovery, and less perioperative blood transfusion.
ObjectiveTo explore the clinical efficacy of robot-assisted coronary artery bypass grafting through a small incision in the left intercostal space in the treatment of multivessel coronary disease. MethodsA retrospective analysis was conducted on the clinical data of patients who underwent coronary artery bypass grafting through a small incision in the left intercostal space at Central China Fuwai Hospital of Zhengzhou University from January 1, 2023 to October 15, 2024. Patients were divided into a robotic group and a minimally invasive group based on whether the surgery was assisted by the Da Vinci robot. ResultsA total of 81 patients were included, with 57 in the minimally invasive group, including 41 males and 16 females, with a median age of 65.0 (57.5, 69.5) years; and 24 in the robotic group, including 17 males and 7 females, with a median age of 61.0 (56.0, 69.0) years. There was no statistically significant difference in baseline data between the two groups (P>0.05). The robotic group had less intraoperative bleeding [300 (200, 438) mL vs. 500 (375, 600) mL, P=0.006], shorter postoperative mechanical ventilation time [15.0 (13.3, 23.5) h vs. 22.0 (15.5, 39.5) h, P=0.037], and lower incidence of postoperative pain [8 (33.3%) vs. 33 (57.9%), P=0.043]. The hospitalization cost in the robotic group was higher than that in the minimally invasive group [130491 (123298, 135691) yuan vs. 123892 (115543, 133449) yuan, P=0.023]. There was no statistical difference in postoperative laboratory indicators between the two groups (P>0.05). There was also no statistical difference in the duration of surgery, postoperative 24 h drainage volume, ICU stay time, postoperative hospital stay or incidences of perioperative compications including pleural effusion, transfusion, new-onset atrial fibrillation, acute kidney injury, non-union of incision, major cardiovascular and cerebrovascular adverse events, and reoperation between the two groups (P>0.05). ConclusionCompared with the minimally invasive group, the robotic group shows satisfactory efficacy and can effectively reduce postoperative pain and intraoperative bleeding, and shorten postoperative mechanical ventilation time.
Objective To investigate the efficacy and safety of tranexamic acid in patients with the age>70 years during off-pump coronary artery bypass grafting (OPCABG). Methods From June 2014 to August 2016, 340 patients undergoing elective OPCABG were included in this study. All the patients were more than 70 years old, among whom 282 were males and 58 were females. According to the random number generation method, the patients were randomly assigned to receive either tranexamic acid (30 mg/kg, infusion time was longer than 30 min after anesthesia induction; n=170) or a placebo (infusion equivalent volume of saline solution; n=170). The primary end point was chest tube drainage 6 h and 24 h postoperatively. The secondary end points were blood transfusion volumes, incidence of various thrombotic events, duration of mechanical ventilation, length of ICU and hospital stay. Results Compared with patients in the placebo group, the patients receiving tranexamic acid had a significant reduction in chest tube drainage at postoperative 6 h (275.6±105.1 ml vs. 459.6±110.2 ml, P<0.001) and 24 h (685.3±202.5 ml vs. 915.9±223.6 ml, P<0.001). There was also a significant reduction in allogeneic red blood cell transfusion (0.80±0.66 U vs. 1.60±1.30 U, P<0.001) and fresh frozen plasma transfusion (166±25 ml vs. 257±30 ml, P<0.001). There were no significant differences in incidence of various thrombotic events, duration of mechanical ventilation, length of ICU and hospital stay between the two groups. Conclusion Tranexamic acid can significantly reduce blood loss and transfusion in elderly patients 6 h and 24 h after OPCABG and the incidence of thrombotic events will not increase.
ObjectiveTo investigate the role of preoperative peripheral blood CD4/CD8 ratio in predicting the prognosis of patients with coronary atherosclerotic heart disease (CAD) after off-pump coronary artery bypass grafting (OPCABG).MethodsA total of 118 patients with CAD who underwent OPCABG in our hospital from September 2016 to April 2017 were included in the study, including 82 males and 36 females aged 62.74±4.50 years. The primary end point was the incidence of major adverse cardiovascular events (MACE). Patients were divided into a high CD4/CD8 group (≥1.40, 62 patients) and a low CD4/CD8 group (<1.40, 56 patients) according to the results of flow cytometry. The correlation between CD4/CD8 ratio and prognosis of patients after OPCABG and the value of CD4/CD8 ratio for predicting postoperative MACE were evaluated.ResultsMedian duration of follow-up was 23.25 (20.91, 24.70) months, during which 21 patients (17.80%) experienced MACE and 4 patients (3.39%) were lost to follow-up. Kaplan-Meier analysis revealed that high CD4/CD8 group had a significantly higher MACE rate than the low CD4/CD8 group did (log-rank χ2=5.797, P=0.02). The results of adjusted Cox proportional hazards model showed that CD4/CD8 ratio (HR=3.103, 95%CI 1.557-6.187, P<0.01) was an independent risk factor of MACE in patients with CAD after OPCABG. The receiver operating characteristic curve showed that area under curve was 0.778 (95%CI 0.661-0.894, P<0.01), the optimal cut off value was 2.24, the sensitivity was 57.1%, and the specificity was 87.6%.ConclusionPreoperative peripheral blood CD4/CD8 ratio is an independent predictor of MACE after OPCABG in patients with CAD.
ObjectiveTo study the learning curve of minimal invasive coronary artery bypass grafting (MICS CABG) and the influence on the perioperative clinical effects by analyzing operation time.MethodsFrom March 2012 to November 2020, 212 patients underwent MICS CABG by the same surgeon. Among them, 59 patients (52 males and average age of 62.89±8.27 years) with single vessel bypass grafting were as a single-vessel group and 153 patients (138 males, average age of 59.80±9.22 years) with multi-vessel bypass grafting were as a multi-vessel group. Two sets of operation time-operation sequence scatter plots were made and learning curve was analyzed by cumulative summation (CUSUM) and regression method of operation time. The surgical data of each group before and after the inflection point of the learning curve were compared with the main clinical outcome events within 30 days after surgery.ResultsThere was no death, perioperative myocardial infarction and stroke in 212 MICS CABG patients and no transfer to cardiopulmonary bypass or redo thoracotomy. The learning curve conformed to the cubic fitting formula. In the single-vessel group, CUSUM (x operation number)=–1.93+93.45×x–2.33×x2+0.01×x3, P=0.000, R2=0.986, the tipping point was 27 patients. In the multi-vessel group, CUSUM (x)=y=2.87+1.15×x–1.29× x2+3.463×x3, P=0.000, R2=0.993, and the tipping point was 59 patients. The two sets of case data were compared before and after the learning curve and there was no statistical difference in main clinical outcomes within 30 days (mortality, acute myocardial infarction, stroke, perioperative blood transfusion rate), ventilator tube, and intensive care unit retention.ConclusionThe learning curve of MICS CABG conforms to the cubic formula, and the process transitions from single to multiple vessels bypass. To enter the mature stage of the learning phase, a certain number of patients need to be done. Reasonable surgical procedures and quality control measures can ensure the safety during the learning phase.
ObjectiveTo describe our experiences of application of off-pump coronary artery bypass grafting surgery (OPCABG) in coronary artery disease (CAD) patients with dilated left ventricle.MethodsA retrospective analysis of 303 patients with dilated left ventricle [left ventricular end-diastolic diameter (LVEDD)> 60 mm] who underwent OPCABG from January 2008 to December 2018 at a single center was conducted. There were 205 males and 98 females at age of 45-87 (66.9±9.3) years.ResultsThe mean pulmonary artery pressure in 90 patients was more than 25 mm Hg. Sixteen patients underwent OPCABG with emergent transition of extracorporeal circulation (CPB). Twenty-one patients underwent OPCABG with CPB at the beginning of CABG. Thirty-five patients underwent intra-aortic balloon counterpulsation (IABP). Four patients died during in-hospital time with the experience of emergent transition of CPB. Six months after operation, LVEDD and left ventricular ejection fraction (LVEF) were improved.ConclusionOPCABG is a safe and effective alternative for CAD patients with dilated left ventricle. However, for patients with higher pulmonary pressure and a spherical left ventricle after cardiac reshaping, there is a high risk of emergent transition of CPB during OPCABG; for this kind of patients, it is necessary to start CPB at the beginning of OPCABG.
ObjectiveTo compare and analyze the postoperative quality of life in patients after minimally invasive coronary artery bypass grafting (MICABG) and conventional median thoracotomy off-pump coronary artery bypass grafting surgery (OPCABG). MethodsFrom November 2015 to January 2018, 94 patients who underwent MICABG in the Peking University Third Hospital were included in the MICABG group. During the same period 441 patients who received OPCABG were included in the OPCABG group. The patients were matched by using propensity score matching method with a ratio of 1∶1. The quality of life was compared between two groups at 1 month, 6 months and 12 months after the surgery using SF-36 scale. ResultsA total of 82 patients were matched for each group. In the MICABG group, there were 66 males and 16 females with a mean age of 62.6±8.2 years. In the OPCABG group, there were 67 males and 15 females with a mean age of 63.2±13.2 years. One month after the operation, the physical health assessment (PCS) and mental health assessment (MCS) of the MICABG group were higher than those of the OPCABG group (50.3±10.6 points vs. 46.1±10.3 points, P=0.011; 59.5±9.3 points vs. 54.2±11.0 points, P=0.002). Scores of these following five dimensions: general health, physical functioning (PF), role-physical, social functioning (SF), role-emotion in the MICABG group were higher than those in the OPCABG group, while the score of body pain was inferior to that in the OPCABG group, and the differences were statistically significant (P<0.05). Six months after the surgery, the PCS and MCS of the two groups were not statistically different (80.0±13.1 points vs. 77.8±12.4 points, P=0.271; 81.6±13.5 points vs. 80.4±11.2 points, P=0.537). However, the scores of PF and SF in the MICABG group were still higher than those in the OPCABG group (P<0.05). Twelve months after the surgery, there was no statistical difference in the score of each dimension between the two groups (P>0.05). ConclusionThe improvement of quality of life within 6 months after MICABG is better than that of OPCABG, and it is similar between the two groups at 12 months after the surgery, indicating that MICABG has a certain effect of improving the short-term quality of life after the surgery, and the long-term quality of life is comparable to conventional surgery.
ObjectiveThe pleural injury caused by harvesting internal mammary artery (LIMA) can significantly increase the possibility of early pleural effusion after off-pump coronary artery bypass grafting (OPCABG). We compared the differences in pleural effusion, pain severity, and early lung function in different treatments to find the optimal strategy.MethodsA total of 300 patients receiving OPCABG using LIMA with left pleural lesion were selected (176 males and 124 females, mean age of 63.1±8.7 years). After bypass surgery, patients with pleural rupture were randomly divided into three groups: group A (n=100) received a pericardial drainage tube and a left chest tube inserted from the midline (subxyphoid); group B (n=100) had a pericardial drainage tube and a tube placed in the sixth intercostal space at the midaxillary line; group C (n=100) with the broken pleura sutured, had a pericardial drainage tube and a mediastinal drainage tube inserted. All patients underwent pulmonary function testing and arterial blood gas analysis on postoperative days (PODs) 5. The three methods were analyzed and evaluated.ResultsTotal drainage: group B (852±285 ml)>group C (811±272 ml)>group A (703±226 ml); there was no significant difference between the group B and group C, but they were statistically different from the group A (P<0 05="" patients="" with="" pleural="" effusion="" after="" removal="" of="" drainage="" tubes:="" group="" a="" 13="" patients="">group B (7 patients)>group C (3 patients), and there was significant difference among the three groups (P<0 05="" pain="" sensation="" the="" day="" after="" extubation:="" group="" b="" 2="" 4="" 0="" 8="" 3="" 8="" 0="" 9="">group A (1.9±0.7, 3.3±0.8)>group C (1.1±0.6, 2.5±0.8), there was significant difference among the three groups (P<0 05="" pain="" sensationon="" on="" postoperative="" days="" 5:="" group="" b="" 0="" 3="" 0="" 2="" 0="" 6="" 0="" 5="">group A (0.3±0.3, 0.5±0.4)>group C (0.2±0.2, 0.5±0.3), and there was no significant difference among the three groups. Vital capacity on postoperative days 5: there was no significant difference between the group B and group C, and both groups were greater than group A (P<0.05). There was no difference in FEV1 and PCO2 among the three groups. Group C was better than group A in PO2 on postoperative day 5 (P<0.05).ConclusionSuturing the broken pleura during the operation can not only reduce the degree of postoperative pain but also have less pleural effusion and better pulmonary function. It can be used as the preferred method.
ObjectiveTo compare the impact of cardiopulmonary coronary artery bypass grafting (CCABG) and off-pump coronary artery bypass grafting (OPCAB) on the incidence of postoperative acute kidney injury (AKI) in the elderly patients (age≥70 years). MethodsThe clinical data of the isolated coronary artery bypass grafting (CABG) patients (age≥70 years) in our center from January 1, 2009 to December 31, 2017 were collected and retrospectively analyzed. The patients with long-term dialysis, missing serum creatinine data, emergent surgery or CABG combined with other cardiac procedures were excluded. Totally there were 3 346 patients undergoing isolated CABG, and finally 1 405 patients (age≥70 years) entered the study. The elderly patients were divided into a CCABG group (956 patients) and an OPCAB group (449 patients) according to whether they used extracorporeal circulation. The incidence and severity of postoperative AKI in the two groups were compared. Results AKI occurred in 306 (32.0%) patients in the CCABG group and in 138 (30.7%) patients in the OPCAB group with no significant difference (P=0.677). According to the acute kidney injury network (AKIN) criteria, the severity of AKI in the CCABG vs. OPCAB was as followings, AKIN stage Ⅰ: 211 (22.1%) vs. 93 (20.7%); AKIN stage Ⅱ: 51 (5.3%) vs. 23 (5.1%); and AKIN stage Ⅲ: 44 (4.6%) vs. 22 (4.9%) with no significant difference (P=0.579, 1.000 and 0.788). There was no significant difference in the new onset of dialysis between the CCABG group (31 patients, 3.2%) and the OPCAB group (10 patients, 2.2%, P=0.376). Conclusion AKI is a common complication in the elderly CABG patients, with AKIN stage Ⅰ accounting for the most proportion, but rate of postoperative renal replacement therapy is low. Compared with CCABG, OPCAB is not associated with a significantly low rate or reduced severity of AKI in elderly patients.