title: Awake coronary artery bypass grafting: utopia or reality?
abstract: BACKGROUND
  Off-pump coronary artery bypass grafting (OPCAB) was implemented to reduce trauma during surgical coronary revascularization. High thoracic epidural anesthesia further reduced intraoperative stress and postoperative pain. This technique also supports awake coronary artery bypass (ACAB), completely avoiding the drawbacks of mechanical ventilation and general anesthesia in high-risk patients. We compared our first results of the ACAB procedure with the conventional OPCAB operation.
  
  
  METHODS
  Thirty-five patients underwent ACAB (group A) with left internal mammary artery to left anterior descending coronary artery grafting using a partial lower ministernotomy (n = 25) or double bypass grafting (n = 9) and even triple vessel coronary artery revascularization (n = 1) through complete median sternotomy. Thirty-four patients (group B), matched for age, sex, and comorbidity with group A, underwent either partial lower ministernotomy (n = 24) or OPCAB by complete sternotomy (n = 10). We recorded clinical outcomes and postoperative visual analog scale pain scores.
  
  
  RESULTS
  In group A, 32 patients remained awake throughout the entire procedure. Three patients required secondary intubation because of incomplete analgesia (n = 1) or pneumothorax (n = 2). Patients in group A had a recovery room stay of 6.0 +/- 3.2 hours. In group B, mechanical ventilation was implemented for 4.8 +/- 3.1 hours and intensive care unit stay lasted 12 +/- 6.8 hours. Group A had no in-hospital deaths, compared with 1 death in the conventional OPCAB group. Each group had 1 patient with graft stenosis detected on the predischarge angiogram. Early postoperative pain was significantly less in group A than in group B (visual analog scale of 32 +/- 8 compared with 58 +/- 11, p < 0.0001).
  
  
  CONCLUSIONS
  The present data demonstrate the feasibility and safety of surgical coronary revascularization without general anesthesia. Continuation of thoracic epidural analgesia provides better pain control and faster mobilization after such procedures. Surprisingly, the ACAB procedure was well accepted by the patients.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany. t.aybek@em.uni-frankfurt.de
authors.forename: Tayfun
authors.initials: T
authors.lastname: Aybek
authors.forename: Paul
authors.initials: P
authors.lastname: Kessler
authors.forename: Selami
authors.initials: S
authors.lastname: Dogan
authors.forename: Gerd
authors.initials: G
authors.lastname: Neidhart
authors.forename: Mohammad Fawad
authors.initials: MF
authors.lastname: Khan
authors.forename: Gerhard
authors.initials: G
authors.lastname: Wimmer-Greinecker
authors.forename: Anton
authors.initials: A
authors.lastname: Moritz
mesh_terms: D000767:Anesthesia, Epidural; D001026:Coronary Artery Bypass / Q000379:methods* / Q000401:mortality; D004434:Early Ambulation; D006801:Humans; D007902:Length of Stay; D010147:Pain Measurement; D010149:Postoperative Pain; D010342:Patient Acceptance of Health Care; D011183:Postoperative Complications; D013249:Sternum / Q000601:surgery; D016896:Treatment Outcome; D014851:Wakefulness