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J Thorac Cardiovasc Surg 2005;130:950-951
© 2005 The American Association for Thoracic Surgery

Letters to the Editor

Does the introduction of off-pump coronary artery bypass into aortic arch aneurysm repair minimize the period of myocardial ischemia and cardiopulmonary bypass?

Hisato Takagi, MD, PhD, Takuya Umemoto, MD, PhD

Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan

To the Editor:

We read with interest the brief communication by Yokoyama and associates 1 Go regarding the introduction of off-pump coronary artery bypass (OPCAB) into the simultaneous operation of aortic arch repair and coronary revascularization to minimize the period of aortic crossclamping (myocardial ischemic time) and cardiopulmonary bypass (CPB), but we disagree with the new solution for the surgical treatment of multiorgan arteriosclerosis by reason of the following.

Our strategy, which most cardiovascular surgeons may prefer, and Yokoyama and colleagues' procedure are shown in Figure 1. After the initiation of CPB, we perform distal anastomoses of coronary artery bypass grafting (CABG) during the core cooling under on-pump beating heart surgery. After the completion of arch and branch repair under hypothermia and antegrade cerebral perfusion, proximal anastomoses of CABG are undertaken during the rewarming under partial clamping of the proximal ascending aorta or the replaced prosthetic graft (when the proximal ascending aorta is inappropriate for partial clamping). The period of distal or proximal anastomoses of CABG presented in the figure of Yokoyama and colleagues' article (reconstructed in Figure 1) might be exaggerated to be as long as that of arch or branch repair. Because the period of distal or proximal anastomoses of CABG (only 1.5 ± 0.8 anastomoses in Yokoyama and colleagues' study) must be far shorter than that of arch or branch repair, the period of CPB is not prolonged even though distal anastomoses of CABG are performed during CPB. Aortic crossclamping (myocardial ischemia) in our strategy is required only during arch repair and is far shorter than that in Yokoyama and colleagues' procedure (during both proximal anastomoses of CABG and arch repair). Even though distal anastomoses of CABG are undertaken during aortic crossclamping (dotted column in Figure 1) in our strategy when the anastomoses are technically complicated and cannot be performed under on-pump beating heart surgery, the period of aortic crossclamping is as long as that in Yokoyama and colleagues' procedure.


Figure 1
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  		Figure 1. Time course in the combined procedure of coronary artery revascularization and aortic arch repair. A, OPCAB and aortic arch repair in Yokoyama and associates' procedure.1 B, CABG and aortic arch repair with our strategy. Note the period of cardiopulmonary bypass (CPB) in B is as long as that in A, and the period of aortic crossclamping (myocardial ischemic time) in B is shorter than that in A. Even though distal anastomoses of CABG are undertaken during aortic crossclamping (dotted column) in our strategy, the period of aortic crossclamping is as long as that in Yokoyama's procedure. OPCAB, Off-pump coronary artery bypass; CABG, coronary artery bypass grafting.

 
Yokoyama and colleagues' combined procedure of OPCAB grafting and aortic arch repair prolongs total operation time, because the extra period of distal anastomoses of OPCAB grafting is indispensable in addition to the period of CPB. Distal coronary artery anastomoses under on-pump beating heart surgery with sufficient decompression of the heart and without hemodynamic deterioration must be technically easier than that under off-pump beating heart surgery. Moreover, the period of aortic crossclamping (myocardial ischemic time), including proximal anastomoses of CABG, in Yokoyama and colleagues' procedure is longer than that in our strategy. Which strategy do you prefer?

References

  1. Yokoyama H, Sato Y, Takase S, Takahashi K, Wakamatsu H, Sato Y. Introduction of off-pump coronary artery bypass into aortic arch aneurysm repair. a new solution for the surgical treatment of multiorgan arteriosclerosis. J Thorac Cardiovasc Surg 2005;129:935-936.[Free Full Text]

Related Article

Reply to the Editor:
Hitoshi Yokoyama
J. Thorac. Cardiovasc. Surg. 2005 130: 951-952. [Extract] [Full Text] [PDF]




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Takuya Umemoto
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