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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 1, January/February 2020
AFRICA
19
that is placed during proximal anastomosis. To avoid this,
proximal anastomosis devices were developed, but the patency
of these grafts was found to be decreased.
7
The 2018 European Society of Cardiology guideline for
myocardial revascularisation recommends OPCAB by experienced
operators and preferably no-touch techniques on the ascending
aorta.
14
In our study, although we used lateral clamps during
proximal anastomosis, CVI was seen in only two patients (0.3%).
We speculate that palpation of the aorta and avoiding any palpable
plaques before clamp positioning contributed to this result.
In their study, Mack
et al
.
15
initially selected patients for
OPCAB surgery who required three or fewer bypasses to
the anterior surface of the heart. In the case of unstable
patients, re-operations, and the need for bypass to the coronary
arteries on the lateral side of the heart, the on-pump technique
was preferred. However, as surgical experience increased and
stabilisation techniques developed, OPCAB was preferred for
all patients. Gauzes, sponges, traction sutures and stabilisation
systems are combined to achieve good exploration of the target
vessels.
16-18
In our study, with high surgical experience and the
support of an alternative retraction method, the anastomoses
are performed in a more stable state without haemodynamic
impairment. Thus anastomoses could easily be performed to the
coronary arteries, especially on the posterior and posterolateral
(Cx and RCA field) areas of the heart, and our success rate in
revascularising the target vessels increased.
The LVEF, evaluated by two-dimensional echocardiography
pre-operatively and at six months after surgery, was analysed
in 596 patients and statistically analysed. These data show a
statistically significant improvement in LVEF, particularly at six
months after surgery. Capuani
et al
.
19
showed a similar result
with the comparison of pre- and postoperative LVEF.
In their study, Benedetto
et al.
5
showed conversion rates
around 10%, and this outcome negatively affected five-year
follow up. In the same study, the rate of conversion was 12.9%
by OPCAB surgeons doing sporadic surgery (one to five cases)
and 1.0% by experienced surgeons (> 60 cases). In their study,
Angelini
et al
.
20
emphasised that OPCAB results, performed by
experienced surgeons who adopted all aspects of the OPCAB
technique, were similar to on-pump surgery results. The low
conversion rate in our study was attributed to the alternative
method of retraction we used and the greater OPCAB experience
of the surgeon. In addition, the conversion decision in these cases
was done in a timely manner, therefore there was no morbidity or
mortality in these patients (data not shown).
Although the ROOBY study showed that OPCAB was
associated with increased mortality rates, many other studies do
not mention increased mortality rates associated with OPCAB.
7
Kowalewski
et al.
21
found a mortality rate of 2.04% with no
significant difference between the two techniques. Our mortality
rate was 1.7% (
n
= 10), which is similar to the mortality rates of
OPCAB surgeries in the literature.
Since only the OPCAB technique is preferred in our centre,
this study is presented as a descriptive one.
Conclusion
The OPCAB technique can be performed with similar results to
on-pump surgery when performed by experienced surgeons, as
in our study. The alternative retraction technique in conjunction
with a stabiliser enables good exposure and stability in OPCAB
surgery and contributes to the quality of coronary anastomoses,
especially of the circumflex and right territory arteries.
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