title: Combined use of off-pump techniques and a sutureless proximal aortic anastomotic device reduces cerebral microemboli generation during coronary artery bypass grafting.
abstract: OBJECTIVE
  Intraoperative cerebral microemboli are associated with the development of postoperative stroke and neurocognitive decline in patients undergoing coronary artery bypass grafting. Although cardiopulmonary bypass is responsible for the generation of a significant number of such emboli, the elimination of cardiopulmonary bypass alone has not been conclusively shown to improve neurocognitive outcome. The current study was performed to determine the effects of combined off-pump coronary artery bypass grafting and sutureless proximal aortic anastomotic techniques on the generation of intraoperative cerebral microemboli compared with standard coronary artery bypass grafting techniques of cardiopulmonary bypass and hand-sewn proximal anastomoses.
  
  
  METHODS
  Fifty-three patients underwent off-pump coronary artery bypass grafting by using the sutureless Symmetry aortic connector device (St Jude Medical, St Paul, Minn) for all proximal anastomoses. Eighteen of these patients received intraoperative transcranial Doppler ultrasonography to determine right- and left-sided cerebral microembolic counts. These results were compared with those obtained from a similar group of 17 patients undergoing standard coronary artery bypass grafting, in whom cardiopulmonary bypass and hand-sewn proximal anastomoses were used.
  
  
  RESULTS
  Our use of the proximal anastomotic device in patients undergoing coronary artery bypass grafting was safe, with no aortic complications, postoperative strokes, or in-hospital deaths. Microembolic counts to both the right and left cerebral circulation were significantly reduced in the patients undergoing off-pump coronary artery bypass grafting (right = 21.9 +/- 20.7 emboli, left = 24.9 +/- 19.2 emboli) compared with those in patients undergoing standard coronary artery bypass grafting (right = 181.6 +/- 85.3, left = 189.9 +/- 60.401, P <.0001).
  
  
  CONCLUSIONS
  Our use of a sutureless proximal anastomotic device during off-pump coronary artery bypass grafting is safe and significantly decreases cerebral microembolism when compared with standard coronary artery bypass grafting with cardiopulmonary bypass and hand-sewn anastomoses. Long-term follow-up is needed to determine the effects of this technical strategy on neurocognitive outcome.
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
authors.forename: John E
authors.initials: JE
authors.lastname: Scarborough
authors.forename: William
authors.initials: W
authors.lastname: White
authors.forename: Frantz E
authors.initials: FE
authors.lastname: Derilus
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Mathew
authors.forename: Mark F
authors.initials: MF
authors.lastname: Newman
authors.forename: Kevin P
authors.initials: KP
authors.lastname: Landolfo
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical / Q000295:instrumentation; D002315:Cardiopulmonary Bypass; D003131:Combined Modality Therapy; D001026:Coronary Artery Bypass / Q000295:instrumentation* / Q000379:methods / Q000401:mortality; D003327:Coronary Disease / Q000401:mortality / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D020766:Intracranial Embolism / Q000000981:diagnostic imaging / Q000517:prevention & control*; D007431:Intraoperative Complications / Q000000981:diagnostic imaging / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation; D011336:Probability; D011446:Prospective Studies; D012016:Reference Values; D018570:Risk Assessment; D012494:Sampling Studies; D016019:Survival Analysis; D013536:Suture Techniques; D016896:Treatment Outcome; D017585:Ultrasonography, Doppler, Transcranial