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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 1, January/February 2020
16
AFRICA
OPCAB surgery with an alternative retraction method:
a single-centre experience
Erdem Cetin, Tolga Can, Celal Selcuk Unal, Aydin Keskin, Emre Kubat
Abstract
Background:
The off-pump coronary artery bypass (OPCAB)
technique, which is used in order to avoid the side effects of
cardiopulmonary bypass, is often questioned in terms of its
efficacy and safety. Also, in this technique, surgeon experi-
ence plays a very important role. In this study, we share the
results of our 606 OPCAB cases with an alternative retraction
technique.
Methods:
This study was a retrospective analysis of OPCAB
operations performed between January 2014 and December
2018. Patients were evaluated and operated on by a surgical
team led by an experienced OPCAB surgeon with over 200
prior OPCAB surgeries.
Results:
The study included 606 OPCAB cases, and 21.8%
(132) were female and 78.2% (474) were male. Our mortality
rate was 1.7% (
n
= 10) and only two patients suffered a cere-
brovascular incident. A statistically significant difference was
found between pre-operative and six-month postoperative left
ventricular ejection fraction values (
p
<
0.01).
Conclusion:
The OPCAB technique can be performed with
similar results to on-pump surgery when conducted by an
experienced surgeon, as in our study.
Keywords:
on-pump coronary artery bypass, alternative method
Submitted 1/3/19, accepted 21/6/19
Published online 15/7/19
Cardiovasc J Afr
2020;
31
: 16–20
www.cvja.co.zaDOI: 10.5830/CVJA-2019-038
Coronary artery bypass graft surgery (CABG) is a treatment
that improves survival in advanced coronary artery disease. The
off-pump coronary artery bypass (OPCAB) technique, which
is used in order to avoid the side effects of cardiopulmonary
bypass (CPB), is often questioned in terms of its efficacy and
safety. Although there are over 100 randomised controlled trials
and 60 meta-analyses, the superiority of one technique over the
other has not been clearly demonstrated.
1
While some studies
did not show any difference between the two techniques,
2,3
one
study showed that OPCAB resulted in decreased mortality and
morbidity rates and hospitalisation time.
4
In these studies, another important criterion in determining
the effectiveness of OPCAB was the case volume of the
institution and the surgeon. In a study by Benedetto
et al
.,
5
five-year follow-up results of 1 260 OPCAB and 1 700 on-pump
coronary artery bypass (ONCAB) operations were published.
The experience of the surgeons who performed the cases was
also evaluated. Surgeons performing sporadic (one to five
cases) OPCAB operations had a high conversion rate, low graft
count and high mortality rate. OPCAB results of high-volume
surgeons were found to be similar to ONCAB surgery.
In our centre, CABG operations are routinely performed by
a single team using the off-pump technique. In this study, we
share the results of our 606 OPCAB cases and the alternative
technique we used for retraction and positioning of the heart.
Methods
This descriptive study is a retrospective analysis of OPCAB
operations performed between January 2014 and December 2018.
For all patients the OPCAB technique was routinely chosen, and
there were no exclusion criteria. Patients were evaluated and
operated on by a surgical team led by an experienced OPCAB
surgeon (over 200 prior OPCAB surgeries).
All patients were sedated with 2 mg IV midazolam and
anaesthesia induction was done with fentanyl 10 µg/kg,
midazolam 0.1 mg/kg and rocuronium 1 mg/kg. In order to
prevent possible cardiac oedema during the positioning of the
heart, 1 mg/kg methylprednisolone was routinely given to all
of our patients as well as pheniramine IV in order to prevent
possible reactions during protamine administration. Following
100–200 IU/kg heparinisation, the activated clotting time (ACT)
was kept between 200 and 400 seconds. In order to benefit from
its anti-arrhythmic effects, 1 mg/kg lidocaine 2.5% IV and 10
ml 15% magnesium sulfate were administered during internal
thoracic artery harvest. Potassium levels were closely monitored
and kept above 4.0 mEq/ml.
After left internal mammary artery (LIMA) harvesting,
the pericardium was opened and a deep pericardial suture was
placed to elevate the heart. The right pleura was opened in all
patients if the circumflex (Cx) coronary artery and its branches
were targeted for bypass, thereby preventing haemodynamic
deterioration during retraction of the heart. In addition,
moistened gauzes were placed through transfer and oblique
sinuses. With the placement of these gauzes, the heart could be
retracted more efficiently. The retraction gauzes were used to
hold the heart until the anastomosis area was determined, as
if the operation was done with CPB, and thereafter, the tissue
stabilisation system (Octopus
®
Evolution, Medtronic) was used.
During anastomosis of the left anterior descending (LAD)
artery to the LIMA, the gauzes were loosened in order to avoid
Department of Cardiovascular Surgery, Karabuk University
Training and Research Hospital, Karabuk, Turkey
Erdem Cetin, MD,
Tolga Can, MD
Celal Selcuk Unal, MD
Aydin Keskin, MD
Department of Cardiovascular Surgery, Gülhane Training
and Research Hospital, Ankara, Turkey
Emre Kubat, MD