title: Ten year experience of using a novel metabolic protocol in 'off pump' coronary artery bypass revascularization.
abstract: OBJECTIVE
  Assessment of both short- and long-term outcomes in patients undergoing off-pump coronary artery bypass using a perioperative metabolic protocol.
  
  
  METHODS
  A total of 975 of 995 adult patients underwent coronary artery bypass 'off-pump' from 1997 through 2006. Patients presenting in cardiogenic shock were excluded from this assessment. A perioperative metabolic protocol, which included the implementation of allopurinol, insulin supplementation, magnesium sulfate, supplemental corticosteroids, milrinone, norepinephrine (prn), aspirin, clopidogrel, statins and β-blockers, was used in these patients.
  
  
  RESULTS
  The mean age at the time of surgery was 70.5 years and the average number of bypass grafts was 4 per procedure; 18% (n = 176) of the cases had a preoperative intra-aortic balloon pump inserted for hemodynamic instability, tight left main coronary artery stenosis or angina. The 30-day mortality was 1.8% versus a Society of Thoracic Surgeons (STS) predicted mortality of 4.8%. Left main coronary artery disease was present in 38% (n = 371) of the patients. No strokes occurred intra-operatively and the postoperative incidence of stroke was 0.9% (n = 9). Incidence of renal failure requiring dialysis was 0.8% (n = 8). There was a single sternal infection. Mean follow up was 65 months with a survival rate of 90% (n = 955). Re-intervention, which commonly involved PTCA ± stent placement or re-do coronary artery bypass grafting (CABG), was 4% at 1 year and 11.6% (n = 113) during the 65-month follow-up period.
  
  
  CONCLUSIONS
  Off-pump coronary artery bypass coupled with this novel metabolic protocol was associated with a low operative mortality and acceptable perioperative morbidities, including patients with left main coronary artery disease. These benefits are apparent at both short- and medium-term follow up.
authors.affiliation: Saddleback Memorial Medical Center, Laguna Hills, CA, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Perkowski
authors.affiliation: Saddleback Memorial Medical Center, Laguna Hills, CA, USA.
authors.forename: Susan
authors.initials: S
authors.lastname: Wagner
authors.affiliation: Saddleback Memorial Medical Center, Laguna Hills, CA, USA.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Muller
authors.affiliation: Northwestern Medicine West Region and Northwestern University Feinberg School of Medicine, Wheaton and Chicago, IL, USA.
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Schneider
authors.affiliation: Jacqmar, Inc., 10965 53rd Ave. No., Minneapolis, MN 55442, USA congenital@aol.com.
authors.forename: J A
authors.initials: JA
authors.lastname: St Cyr
mesh_terms: D000368:Aged; D002140:California; D047549:Coronary Artery Bypass, Off-Pump / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000378:metabolism / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D004734:Energy Metabolism / Q000187:drug effects*; D005260:Female; D006439:Hemodynamics; D006801:Humans; D008297:Male; D011183:Postoperative Complications / Q000401:mortality / Q000601:surgery; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: coronary artery bypass; metabolic; mortality; off-pump; revascularization