A review of 140 Octopus off-pump bypass patients over the age of seventy: procedure of choice?

BACKGROUND

Many studies have demonstrated that patients of advanced age are at increased risk for morbidity and mortality following coronary artery bypass graft (CABG) surgery. When compared to younger age groups, the risks of adverse neurological outcome or mortality have been demonstrated to be higher in septuagenarians and octogenarians. It has been suggested that off-pump coronary artery bypass (OPCAB) surgery, by avoiding the adverse effects of cardiopulmonary bypass (CPB), may improve the risks of morbidity and mortality, particularly in these higher risk elderly patients. Despite the increased rates of adverse events in patients of advanced age, various authors have described these risks to be in the acceptable range, justifying continued recommendations for operative revascularization in properly selected elderly patients. OPCAB theoretically may provide improvements in early outcomes for these patients by avoiding the unwanted sequelae of CPB.

PATIENTS AND METHODS

This report is a study of the potential advantages of OPCAB techniques based on a retrospective analysis of 140 patients aged 70 or more operated on by a single surgeon at a single institution using OPCAB techniques during a 39-month period. In these operations, surgical access was almost exclusively via midline sternotomy. Exposure of target coronary arteries was by means of extended inverted-T pericardiotomy. Local occlusion of coronary arteries was achieved using proximally placed silastic tapes (Quest Medical Inc., Allen, TX). Distal occlusion was rarely needed. Stabilization was obtained exclusively with the suction-based Octopus stabilization system (Medtronic, Inc., Minneapolis, MN). A mean number of 2.36+/-0.95 distal anastomoses were constructed per patient, with a range from one to five. Multivessel OPCAB patients averaged 2.73 grafts per patient.

RESULTS

Of the 142 patients who underwent OPCAB surgery, only two required elective conversion to CABG with CPB. The procedure was safe, with no need for urgent conversion to CPB. Myocardial protection was excellent, with no patient requiring inotropic support leaving the operating room, and no patient developed postoperative stroke. Several patients had evidence of temporary nocturnal confusion but recovered prior to discharge. There were no in-hospital or 30-day post-operative mortalities in this group.

CONCLUSIONS

OPCAB has been demonstrated to be safe and effective, with surgeons from many centers worldwide reporting low rates of morbidity and mortality. Early patency rates appear to be equal to or perhaps even better than CABG with CPB. This report adds to a growing body of literature supporting the use of OPCAB in elderly patients requiring surgical revascularization. If further investigations continue to demonstrate improved outcomes, OPCAB may become the procedure of choice for patients of advanced age.