Improving neurologic outcome in off-pump surgery: the "no touch" technique.
BACKGROUND
As patients referred for cardiac surgery include increasingly older individuals, the prevalence of comorbid factors, such as previous cerebrovascular disease, carotid disease, aortic atherosclerosis, and reoperations, is on the rise. Avoiding manipulation of the ascending aorta in this high-risk subgroup may become a necessity to perform safe coronary artery bypass grafting (CABG) surgery.


METHODS
We retrospectively reviewed our database of 640 off-pump CABG patients and identified 84 patients in whom we adopted the "no touch" technique (NTT). Revascularization was carried out with single or bilateral internal thoracic arteries (ITA) and by connecting additional coronary grafts (saphenous vein, radial artery) in a T or Y configuration. The right gastroepiploic artery was used as a conduit in 2 patients. The brachiocephalic artery was used as an alternative inflow site in 3 patients (reoperation).


RESULTS
Age, sex, risk factors, functional class, and history of congestive heart failure were comparable in the two groups. In the NTT group, the frequencies were higher for severe atherosclerosis of the aorta (13% versus 0%; P =.00), carotid disease (25% versus 16%; P =.02), and history of previous cerebrovascular accidents (17% versus 8%; P =.04). Complete revascularization was achieved in 96% of the patients in the off-pump CABG group, compared with 90% in the NTT group (P =.17). No differences in the prevalence of postoperative low cardiac output syndrome, intra-aortic balloon pump use, perioperative myocardial infarction, or operative mortality at 30 days were observed between the two groups. In the NTT group, weak trends toward a lower incidence of postoperative delirium (8% versus 15%; P =.12), a lower incidence of stroke (0% versus 1%; P =.85), and a shorter intensive care unit stay (P =.07) were observed. Hospital stay was also shorter in the NTT group (P =.04).


CONCLUSIONS
Avoiding aortic manipulations in patients with severe atherosclerosis of the aorta, carotid disease, and a previous history of cerebrovascular accidents is technically feasible and is associated with a low risk of mortality and good shortterm results. Adopting this practice may reduce the incidence of stroke and improve early outcome in this subset of patients.
Leacche
Marzia
M
Department of Cardiac Surgery and Research Center, Montreal Heart Institute, Montreal, Quebec, Canada. rc2910@aol.com
Carrier
Michel
M
Bouchard
Denis
D
Pellerin
Michel
M
Perrault
Louis P
LP
Pagá
Pierre
P
Hebert
Yves
Y
Cartier
Raymond
R
D002303:Cardiac Output, Low / Q000453:epidemiology; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000379:methods*; D003693:Delirium / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D015994:Incidence; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000009:adverse effects / Q000379:methods; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D017534:Radial Artery / Q000637:transplantation; D012189:Retrospective Studies; D012501:Saphenous Vein / Q000637:transplantation; D020521:Stroke / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome