Off-Pump Cardiac Surgery
Source: Khan NE, et al. N Engl J Med. 2004;350:21-28.
Despite the effectiveness of coronary artery bypass surgery for anginal symptom relief, many believe the use of cardiopulmonary bypass (CPB) is the major cause of postoperative morbidity, including neuropsychological impairment. Thus, Kahn and colleagues preformed a randomized trial of CPB vs off-pump coronary artery surgery in 104 patients with multivessel disease. Repeat coronary angiography was performed at 3 months post-op. Troponin T levels were higher post-op in the CPB vs the off-pump patients, but at 3 months 98% of the grafts were open in the CPB group vs 88% of the off-pump group (P = .002). There were no deaths.
Despite evidence of more early myocardial damage, 3-month graft potency rates were significantly less in the off-pump group. These results have implications for the long-term results of off-pump surgery and dampen enthusiasm for this technique in patients with multivessel disease.
Sutureless Bypass Graft Connector
Source: Cavendish JJ, et al. J Am Coll Cardiol. 2004;43:133-139.
Off-pump coronary artery bypass surgery has resulted in a need for devices to speed attachment of the grafts to the aorta and coronary arteries. The Symmetry Bypass Connector (St. Jude Medical, St. Paul, Minn) was the first device approved for this use. This device is used to attach saphenous vein grafts to the aortic wall via a star-shaped nitinol connector, without suturing. Early implantation results are excellent, but few long-term data exist. Cavendish and associates report on 5 cases at their institution out of 121 where the device was used, who developed acute coronary syndromes 2-5 months after surgery. In all 5 cases, the saphenous vein grafts placed were either occluded (n = 6) or had severe ostial stenosis (n = 5). One patient had repeat surgery. The other 4 were stented percutaneously. Two patients presented later with ostial in-stent restenosis, one of whom was treated with brachy therapy but then had another recurrence. Cavendish et al suggest that until more long-term data are available, this device should only be used in cases where the risk of stroke during aortic cross-clamping is unacceptably high.