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J Thorac Cardiovasc Surg 2005;130:951-952
© 2005 The American Association for Thoracic Surgery

Letters to the Editor

Reply to the Editor:

Fukushima Medical University, Fukushima, Japan

We thank Dr Takagi and associates for raising important questions on our recent proposal of the introduction of off-pump coronary artery bypass (OPCAB) into the combined operation of coronary revascularization and aortic arch repair (AAR) using antegrade selective cerebral perfusion. ¹

The first question is, "Does the introduction of off-pump coronary artery bypass into aortic arch aneurysm repair minimize the period of myocardial ischemia and cardiopulmonary bypass?" The answer is, "Yes." Recently, we reviewed our experience on the patients who underwent the simultaneous operation of total arch replacement (TAR) for atherosclerotic aortic aneurysm and coronary artery bypass grafting (CABG) between 1992 and 2004 (unpublished data). In the conventional coronary artery bypass (CCAB) group, distal coronary artery anastomosis (CABG distal) was constructed using the CCAB technique. Since 1998, CABG distal has been constructed on the beating heart before the cardiopulmonary bypass (CPB) period (OPCAB group). The demographics were similar in both groups; however, the surgical outcomes were dissimilar (Table 1). These preliminary data showed a decreased period of myocardial ischemia and CPB with fewer postoperative adverse effects in the OPCAB group.

In this simultaneous operation, there are several options; CABG distal can be constructed on the beating, arrested, or fibrillating heart; CABG proximal can be constructed before or after AAR, with aortic crossclamping or lateral clamping. As long as the entire procedure is performed, either way, with appropriate myocardial protection and coronary revascularization within a tolerable CPB period, the outcome is expected to be satisfactory. Recently, a CPB period longer than 300 minutes in AAR was demonstrated as an independent risk factor for in-hospital mortality by a multivariate analysis. ² Reduction of the period for each procedure, as seen in the shorter "CABG proximal" bar in Dr Takagi and associates' strategy, seems to reduce the CPB period. We are, however, afraid that the "CABG distal" bar during the CPB period in their strategy would become much longer, depending on the number of diseased coronary arteries. Recently, cardiac surgeons are seeing more and more elderly patients with aortic aneurysm and multivessel coronary artery disease in civilized countries like Japan where the senior population is growing rapidly. We recommend our strategy especially for elderly patients with comorbidities who can poorly tolerate an elongated CPB time and still require multiple coronary revascularization.

For surgeons who are not fully familiar with the OPCAB technique, here is a tip: The patient is heparinized and cannulated for CPB; OPCAB on the anterior cardiac wall (the left anterior descending and diagonal artery) is performed first; the surgeon, faced with some difficulties in OPCAB on the other wall, initiates CPB to decompress the beating heart and maintain the hemodynamics. The patient has already avoided an unnecessary CPB period.

References

1. Yokoyama H, Sato Y, Takase S, Takahashi K, Wakamatsu H, Sato Y. Introduction of off-pump coronary artery bypass into aortic arch repair. a new solution for the surgical treatment of multiorgan arteriosclerosis. J Thorac Cardiovasc Surg 2005;129:935-936.[Free Full Text]
   
2. Kazui T, Washiyama N, Muhhamad BAH, Terada H, Yamashita K, Takinami M, et al. Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion. Ann Thorac Surg 2000;70:3-9.[Abstract/Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hitoshi Yokoyama Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Yokoyama, H. Search for Related Content PubMed Articles by Yokoyama, H. Related Collections Coronary disease Great vessels Related Article