• Journal of Chest Surgery
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• v.37 no.9
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• pp.762-767
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• 2004

With the developement of non-invasive surgical techeniques, coronary artery bypass graft without cardiopulmonary bypass has become popular. We compared the preoperative risk factors and in-hospital outcomes of patients having off-pump CABG with these having on-pump CABG. Material and Method： From January 2001 to June 2003, 87 patients underwent CABG. Thirty-sin patients underwent on-pump CABG, fifty-one patients under-went off-pump CABG. Preoperative risk factors, extent of coronary disease, operative time, postoperative endotracheal intubation time, duration of ICU stay & hospital stay, the amount of bleeding and postoperative levels of cardiac enzymes were compared in both groups, Result: The were no differences in their sex ratios, ages, preoperative risk factors, preoperative Ml, Canadian classes, extent of coronary artery diseases and, echocardio-graphic ejection fraction between Off-pump CABG and On-pump CABG groups. Off-pump CABG group had significantly lower mean operative time (270$\pm$79.3 min vs 372$\pm$142.2 min, p＜0.001), mean ventilation time (17.1$\pm$13.4 hr vs 24.3$\pm$17.8 hr) and CK-MB level (8,9$\pm$18.7 IU/L vs 25.7$\pm$8.4 IU/L) than on-pump CABG groups, On-pump CABG group had more distal grafts (2.2$\pm$0.5 vs 1.7$\pm$0.71 than Off-pump CABG groups did. There were no differences in their postoperative complications and outcomes including amount of postoperative bleeding for 24 hrs, reoperation for bleeding control, mean in-hospital days, postoperative infection, renal failure and neurologic complications between Off-pump CABG and On-pump CABG groups. Conclusion: This study showed that patients who underwent Off-pump CABG had less operation time & intubation time and lower CK-MB level; however, they also have less distal graft. Even though CABG without CPB provided satisfactory results, more clinical experience & longer follow-up is required.

• Journal of Chest Surgery
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• v.39 no.5 s.262
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• pp.354-358
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• 2006

Background: Pulsatile pumps for extracorporeal circulation have been known to be better for tissue perfusion than non-pulsatile pumps but be detrimental to blood corpuscles. This study is intended to examine the risks and benefits of $T-PLS^{TM}$ through the comparison of clinical effects of $T-PLS^{TM}$ (pulsatile pump) and $Bio-pump^{TM}$ (non-pulsatile pump) used for coronary bypass surgery. Material and Method: The comparison was made on 40 patients who had coronary bypass using $T-PLS^{TM}\;and\;Bio-pump^{TM}$ (20 patients for each) from April 2003 to June 2005. All of the surgeries were operated on pump beating coronary artery bypass graft using cardiopulmonary extra-corporeal circulation. Risk factors before surgery and the condition during surgery and the results were compared. Result: There was no significant difference in age, gender ratio, and risk factors before surgery such as history of diabetes, hypertension, smoking, obstructive pulmonary disease, coronary infarction, and renal failure between the two groups. Surgery duration, hours of heart-lung machine operation, used shunt and grafted coronary branch were little different between the two groups. The two groups had a similar level of systolic arterial pressure, diastolic arterial pressure and mean arterial pressure, but pulse pressure was measured higher in the group with $T-PLS^{TM}\;(46{\pm}15\;mmHg\;in\;T-PLS^{TM}\;vs\;35{\pm}13\;mmHg\;in\;Bio-pump^{TM},\;p<0.05)$. The $T-PLS^{TM}$-operated patients tended to produce more urine volume during surgery, but the difference was not statistically significant $(9.7{\pm}3.9\;cc/min\;in\;T-PLS^{TM}\;vs\;8.9{\pm}3.6\;cc/min\;in\;Bio-pump^{TM},\;p=0.20)$. There was no significant difference in mean duration of respirator usage and 24-hour blood loss after surgery between the two groups. Plasma free Hb was measured lower in the group with $T-PLS^{TM}\;(24.5{\pm}21.7\;mg/dL\;in\;T-PLS^{TM}\;versus\;46.8{\pm}23.0mg/dL\;in\;Bio-pump^{TM},\;p<0.05)$. There was no significant difference in coronary infarction, arrhythmia, renal failure and morbidity rate of cerebrovascular disease. There was a case of death after surgery (death rate of 5%) in the group tested with $T-PLS^{TM}$, but the death rate was not statistically significant. Conclusion: Coronary bypass was operated with $T-PLS^{TM}$ (Pulsatile flow pump) using a heart-lung machine. There was no unexpected event caused by mechanical error during surgery, and the clinical process of the surgery was the same as the surgery for which $Bio-pump^{TM}$ was used. In addition, $T-PLS^{TM}$ used surgery was found to be less detrimental to blood corpuscles than the pulsatile flow has been known to be. Authors of this study could confirm the safety of $T-PLS^{TM}$.

• Journal of Chest Surgery
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• v.38 no.5 s.250
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• pp.349-356
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• 2005

Background: Arterial conduits using in coronary artery bypass grafting (CABG) have been known a great long term patency rates, and improved short and long term clinical outcomes. It has been reported that Off pump CABG has better clinical results than CABG using cardiopulmonary bypass. To evaluate the advantage of arterial conduits over venous conduits and to avoid the adverse effects of cardiopulmonary bypass, we performed total arterial Off pump CABG. Material and Method: From January 2001 to October 2004, Off pump CABG using only arterial conduits was performed on 325 patients with a mean age of $59.3\pm11.9$ years ($36\~83$). Mean ejection fraction was $55.4\pm14.0\%\;(15\~86).$ Angiography showed left main disease or triple-vessel disease in $81.9\%$ of the patients. Indications of using arterial conduits was stenosis $\ge50\%$ of left anterior descending artery, stenosis $\ge80\%$ of branches of left circumflex artery, and stenosis $\ge90\%$ of right coronary artery and its branches. Multi-slice computed tomography was performed on 194 patients to evaluate the short term patency rates. Result: A total of 928 distal anastomoses were performed and the average anastomoses per a patient were $2.86\pm0.78$. There was 1 operative mortality. Postoperative complications were mediastinitis in 6 patients ($1.8\%$), renal failure in 4 patients ($1.2\%$), perioperative myocardial infarction in 3 patients ($0.9\%$), reoperation for bleeding in 3 patients ($0.9\%$). There was no postoperative stroke. Patency rate of arterial conduits was $99.3\%$ (581/585). There were 4 stenoses or competitive flows in 2 radial arteries and 2 right internal mammary arteries. Conclusion: Total arterial Off pump CABG appears to be safe, showing a low surgical mortality and morbidity and excellent short term patency rates of arterial conduits.

• Journal of Chest Surgery
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• v.41 no.3
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• pp.366-368
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• 2008

We report there on a 46-year-old male patient whose angina recurred after a coronary bypass graft (CABG). Occlusion of the first diagonal branch was found on performing a coronary angiogram (CAG), and this occlusion had not previously been present. So, a redo-off pump CABG was performed via a left posterolateral thoracotomy. The anastomosis was made between the descending thoracic aorta and the diagonal branch by using the right radial artery. On the Multi-detector computerized tomography (MDCT) coronary angiogram conducted after the operation, it was confirmed that there was no abnormality in the anastomosis site. A Redo-CABG was successfully performed via left posterolateral thoracotomy in the patient whose disease was only at the diagonal branch.

• Journal of Chest Surgery
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• v.41 no.5
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• pp.605-609
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• 2008

Background: It is well known that preoperative administration of combined antiplatelet agents can have an impact on the postoperative bleeding, the requirement for transfusion and the need for reexploration during on-pump coronary artery bypass surgery. Yet its effects have not been well evaluated in the case of off-pump coronary artery bypass surgery. Material and Method: We performed a retrospective study of nineteen patients who underwent OPCAB from March 2003 to December 2004. All the patients had taken antiplatelet agents until 12 hours before operation. The patients were divided into bo groups as an aspirin group and a combined (aspirin+clopidogrel) group. The perioperative platelet count, the hemoglobin level, the hematocrit, the prothrombin time and the aPTT were compared between both groups. The amount of postoperative bleeding, the transfusion requirement and the need for re-exploration to control bleeding were also compared between both groups. Result: There was no difference of operation time and the intraoperative ACT between the aspirin group and the combined group. The amount of blood loss through the chest tube for 24 hours was not different between the aspirin group $(697{\pm}271mL)$ and the combined group $(944{\pm}432mL)$. The number of patients who received blood transfusion was also not different between both groups. There was no patient who required reexploration for bleeding control in both groups. The perioperative hemoglobin level and hematocrit were also not different between both groups, but the postoperative hemoglobin level and hematocrit were decreased significantly in the group. Conclusion: The Preoperative combined antiplatelet (aspirin+clopidogrel) therapy group was not different from the aspirin group for the amount of postoperative bleeding, the amount of blood transfusion and the need for reexploration during off-pump coronary artery bypass grafting. This subject needs further evaluation because of small population in our study.

• Journal of Chest Surgery
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• v.46 no.6
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• pp.444-448
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• 2013

Background: We aimed to investigate the preoperative, operative, and postoperative factors affecting intra-aortic balloon pump (IABP) insertion in patients undergoing isolated on-pump coronary artery bypass grafting (CABG). We also investigated factors affecting morbidity, mortality, and survival in patients with IABP support. Methods: Between January 2002 and December 2009, 1,657 patients underwent isolated CABG in Izmir Katip Celebi University Ataturk Training and Research Hospital. The number of patients requiring support with IABP was 134 (8.1%). Results: In a multivariate logistic regression analysis, prolonged cardiopulmonary bypass time and prolonged operation time were independent predictive factors of IABP insertion. The postoperative mortality rate was 35.8% and 1% in patients with and without IABP support, respectively (p=0.000). Postoperative renal insufficiency, prolonged ventilatory support, and postoperative atrial fibrillation were independent predictive factors of postoperative mortality in patients with IABP support. The mean follow-up time was $38.55{\pm}22.70$ months and $48.78{\pm}25.20$ months in patients with and without IABP support, respectively. The follow-up mortality rate was 3% (n=4) and 5.3% (n=78) in patients with and without IABP support, respectively. Conclusion: The patients with IABP support had a higher postoperative mortality rate and a longer length of intensive care unit and hospital stay. The mid-term survival was good for patients surviving the early postoperative period.

• Journal of Chest Surgery
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• v.37 no.5
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• pp.416-422
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• 2004

Acute renal failure (ARF) is a common postoperative complication after the cardiac surgery. Postoperative ARF have various causes, and are combined with other complications rather than being the only a complication. It deteriorates the general condition of the patient, and makes it difficult to manage the combined complications by disturbing the adequate medication and fluid therapy. We have planned this study to evaluate the effects of postoperative ARF after the on-pump coronary artery bypass surgery (CABG) on the recovery of patients and identify the risk factors. Method and Material: We reviewed the medical records of patients who underwent CABG with cardiopulmonary bypass by a single surgeon from Jan. 2000 to Dec. 2002, We checked the preoperative factors; sex, age, history of previous serum creationism over 2.0 mg/㎗, preoperatively last checked serum creatinine, diabetes, hypertension, left ventricular ejection fraction, intraoperative factors; whether the operation is an emergent case or not, cardiopulmonary bypass time, aortic cross clamp time, the number of distal anastomosis, postoperative factors: IABP. Then we have studied the relations of these factors and the cases of postoperative peak serum creatinine over 2.0 mg/㎗. Result: There were 19 cases with postoperative peak serum creatinine over 2.0 mg/㎗ in a total 97 cases. Dialysis were done in 3 cases for ARF with pulmonary edema and severely reduced urine output. There were 8 cases (42.1%) with combined complications among the 19 patients. This finding showed a significant difference from the 5 cases (6,4%) in the patients whose creatinine level have not increased over 2.0 mg/㎗. The mortalities are different as 1.3% to 10.5%. The risk factors that are related with postoperative serum creatinine increment over 2.0 mg/㎗ are diabetes, the history of previous serum creatinine over 2.0 mg/㎗ and left ventricular ejection fraction. Conclusion: Postoperative ARF after the on-pump CABG is related with preoperative diabetes, the history of previous serum creatinine over 2,0 mg/㎗ and left ventricular ejection fraction. Postoperative ARF could De the reason for increased rate of complications and mortality after on-pump CABG. Therefore, in the patients with these risk factors, the efforts to prevent postoperative ARF like off-pump CABG should be considered.

• Journal of Chest Surgery
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• v.36 no.5
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• pp.309-315
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• 2003

Background: To avoid the adverse effects of cardiopulmonary bypass and to overcome late vein graft failure we routinely peformed off-pump total arterial coronary revascularization. Material and Method: From July 2000 to August 2001, 104 consecutive patients underwent first elective off-pump total arterial coronary revascularization. Both internal mammary, radial and gastroepiploic arteries were used. Sequential and composite grafts were used to achieve complete revascularization. Perioperative adverse events and postoperative angiograms were analyzed. Result: A total of 252 arterial conduits were used with an average of 2.47 grafts per patient. A total of 326 distal anastomosis were performed with a mean of 3.13 distal anastomosis per patient. Cross over to on-pump occurred in seven patients (6.7%). Of these 4 were due to unstable hemodynamics during lateral or posterior wall stabilization as a result of cardiomegaly and 3 were due to uncontrolled bleeding during dissection of diffusely dimunitive deeply placed intramyocardial coronary arteries. There were no opeartive deaths. Two cases of perioperative myocardial infarction and transient neurologic complications occurred, respectively. Of the 312 distal anastomoses, 308 (98.7%) were compatible with Fitz-Gibboll A or B patency grading. Conclusion: Off-pump total arterial coronary revascularization was technically feasible in most elective cases with satisfactory early results. However, on-pump coronary bypass surgery should be considered in difficult circumstances, such as cardiomegaly or unfavorable anatomy of the target coronary artery.

• Journal of Chest Surgery
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• v.43 no.3
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• pp.246-253
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• 2010

Background: Our objective was to review the long-term prognosis of patients with preoperative mild to moderate ischemic mitral regurgitation who underwent off-pump coronary artery bypass grafting. Material and Method: We prospectively followed 1,000 consecutive and systematic off-pump coronary artery bypass grafting patients who were operated on between September 1996 and March 2004; follow-up was achieved for 97%. Sixty-seven patients (6.7%) had mild to moderate ischemic mitral regurgitation at the time of surgery. Operative mortality, actuarial survival and major adverse cardiac event free survival were compared to assess the effect of ischemic mitral regurgitation. Result: Average follow-up was $66{\pm}22$ months. Patients with ischemic mitral regurgitation were older (p<0.001), had lower ejection fractions (p<0.001) and more comorbidities. Significantly more female patients presented with ischemic mitral regurgitation (p=0.002). There was no significant difference in operative mortality and perioperative myocardial infarction in ischemic mitral regurgitation patients (p=0.25). Eight-year survival was decreased in ischemic mitral regurgitation patients ($39.6{\pm}11.8%$ vs $76.7{\pm}2.2$, p<0.001). However, after correcting for risk factors, mild to moderate ischemic mitral regurgitation was not found to be a significant independent risk factor for long-term mortality (p=0.42). Major adverse cardiac event free survival at 8 years was significantly lower in ischemic mitral regurgitation patients ($53.12{\pm}12%$ vs $77{\pm}2%$, p<0.001). After correction for risk factors, ischemic mitral regurgitation remained a significant independent cause of major adverse cardiac events (HR: 2.31), especially congestive heart failure and recurrent myocardial infarction. Conclusion: In our series, patients with preoperative mild to moderate ischemic mitral regurgitation had a higher prevalence of preoperative risk factors than patients without ischemic mitral regurgitation. They had comparable perioperative mortality and morbidity, but, in the long term, were found to be at elevated risk for recurrent cardiac events.

• Journal of Chest Surgery
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• v.39 no.1 s.258
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• pp.48-55
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• 2006

Background: The benefits of preoperative use of aspirin and plavix in coronary patients have been well documented. Due to their bleeding tendency, there have been many discussions about when to stop the antiplatelet agent before operation. We evaluated the effects of preoperative continuous use of aspirin and plavix in OPCAB patients. Material and Method: 123 patients underwent OPCAB from March, 2004 to Feb., 2005. We divided them into two groups; those who had continuous administration of aspirin and plavix during the preoperative period (n=45, 36.6$\%$) and those who discontinued them at least one day before the operation (n=78, 63.4$\%$). We then compared the platelet count, hemoglobin/hematocrit level, graft patency, postoperative bleeding and related complications, and operation time between the two groups. The patients were also divided into long-term users ($\geq$ 1 month) and short-term users (< 1 month), with the aforementioned factors equally compared. Result: There was no statistical difference between the two groups regarding postoperative bleeding, related complications, graft patency, operation time and mortality. Continuous users showed significantly low platelet levels on immediate post operation (p=0.02), postoperative day (POD) $\sharp$1 (p=0.002) and POD $\sharp$2 (p=0.021), respectively. But there was no difference on POD $\sharp$7. Long-term users showed statistically significant difference in pre- and postoperative platelet count, but none in postoperative bleeding and related complications. Conclusion: Continuous use of aspirin and plavix did not increase postoperative bleeding or related complications. Also graft patency and mortality had no statistical differences in continuous users. We think that there is no need to stop aspirin and plavix before OPCAB.