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• W2165143360 abstract "Coronary artery bypass graft (CABG) surgery on a beating heart was introduced with suture techniques and local stabilization by Kolessov in 1967.1Kolessov V.I. Mammary artery-coronary artery anastomosis as a method of treatment for angina pectoris.J Thorac Cardiovasc Surg. 1967; 54: 535-544PubMed Google Scholar However, cardiopulmonary bypass and cardioplegic arrest, with their ability to provide a quiet bloodless field for the construction of precise and delicate surgical anastomoses, offered compelling advantages compared with the off-pump approach and rapidly became more widely accepted.2Favaloro R.G. Effler D.B. Groves L.K. Shelton W.C. Sones Jr, F.M. Direct myocardial revascularization by saphenous vein graft. Present operative techniques and indications.Ann Thorac Surg. 1970; 10: 97-111Abstract Full Text PDF PubMed Scopus (87) Google Scholar With the dramatic reduction of operative mortality throughout the ensuing decades, surgeons began to focus their attention on decreasing operative morbidity, especially conditions associated with neurologic and systemic inflammatory influences after CABG surgery. Traditionally, many of these sequelae have been ascribed to the use of cardiopulmonary bypass. During the past decade, there has been a dramatic resurgence in the application of off-pump technology in CABG surgery. This has inspired remarkable advances in the techniques of localized tissue stabilization and a greater understanding of the physiology of beating heart mobilization and exposure. An avalanche of reports in the literature has demonstrated the early safety and efficacy of the procedure.3Hart J.C. Puskas J.D. Sabik 3rd, J.F. Off-pump coronary revascularization current state of the art.Semin Thorac Cardiovasc Surg. 2002; 14: 70-81Abstract Full Text PDF PubMed Scopus (32) Google Scholar More than 20% of CABG procedures performed nationwide apply off-pump technology. However, considerable controversy remains regarding the relative merits and long-term outcomes of this approach to coronary revascularization.4Gardner TJ. Off-pump CABG safer for the brain. Presented at 81st Annual Meeting of The American Association for Thoracic Surgery, May 9, 2001, San Diego, CaliforniaGoogle Scholar One area of concern, and even greater uncertainty, surrounds the issue of the existence of a hypercoagulable state after off-pump CABG surgery. Are patients undergoing off-pump CABG surgery relatively more hypercoagulable postoperatively than their counterparts undergoing on-pump CABG surgery? Such a hypothesis is indeed reasonable in view of the acute phase activation of clotting factors that follow off-pump CABG surgery (as well as surgery in general) and the lack of platelet, fibrinolytic, and other abnormalities related to the heart-lung machine. However, there was no evidence to indicate a clinical problem associated with the procedure until Mariani and colleagues5Mariani A.M. Gu J. Boonstra P.W. et al.Procoagulant activity after off-pump coronary operation is the current anticoagulation adequate?.Ann Thorac Surg. 1999; 67: 1370-1375Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar awakened our concern with their report in 1999. They reviewed 22 consecutive off-pump cases and found a postoperative increase in procoagulant activity, represented by prothrombin factor 1 and 2, which was also accompanied by an increase in von Willebrand factor (endothelial activation) and fibrinolysis. Although Mariani and colleagues5Mariani A.M. Gu J. Boonstra P.W. et al.Procoagulant activity after off-pump coronary operation is the current anticoagulation adequate?.Ann Thorac Surg. 1999; 67: 1370-1375Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar demonstrated no clinical sequelae during their brief follow-up of this limited series of patients with internal thoracic artery (ITA) grafts, they recommended the institution of an aggressive perioperative anticoagulant regimen in all off-pump CABG cases. What is the major concern? Clearly, a pattern of deep venous thrombosis, pulmonary embolism, or arterial thrombosis would be a source of serious concern to the cardiac surgeon. However, the already extensive clinical experience fails to demonstrate such a pattern. Perhaps a less apparent concern would be the occurrence of acute graft closure. Careful evaluation of the current body of knowledge would indicate just the opposite, with acute graft patency rates exceeding 90% in virtually all cases reviewed. The information in Table 1 summarizes the results of a series of angiographic patency studies after off-pump CABG surgery.6Mack J.M. Magovern J.A. Acuff T.A. et al.Results of graft patency by immediate angiography in minimally invasive coronary artery surgery.Ann Thorac Surg. 1999; 68: 383-390Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 7Izzat M.B. Khaw K.S. Atassi W. Yim A.P. Wan S. El-Zufari M.H. Routine intraoperative angiography improves the early patency of coronary grafts performed on the beating heart.Chest. 1999; 115: 987-990Crossref PubMed Scopus (24) Google Scholar, 8Diegeler A. Matin M. Kayser S. et al.Angiographic results after minimally invasive bypass grafting using the minimally invasive direct coronary bypass grafting (MIDCAB) approach.Eur J Cardiothorac Surg. 1999; 15: 680-684Crossref PubMed Scopus (50) Google Scholar, 9Akpinar B. Guden M. Sagbas E. Sanisoglu I. Aytekin V. Bayindir O. Off-pump coronary artery bypass grafting with use of the octopus 2 stabilization system.Heart Surg Forum. 2000; 3: 282-286PubMed Google Scholar, 10Omeroglu S.N. Kirali K. Guler M. et al.Midterm angiographic assessment of coronary artery bypass grafting without cardiopulmonary bypass.Ann Thorac Surg. 2000; 70: 844-850Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar, 11Zehr K.J. Handa N. Bonilla L.F. Abel M.D. Holmes Jr, D.R. Pitfalls and results of immediate angiography after off-pump coronary artery bypass grafting.Heart Surg Forum. 2000; 3: 293-299PubMed Google Scholar, 12Amano A. Hirose H. Takahashi A. Nagano N. Off-pump coronary artery bypass. Mid-term results.Jpn J Thorac Cardiovasc Surg. 2001; 49: 67-78Crossref PubMed Scopus (41) Google Scholar, 13Bull D.A. Neumayer L.A. Stringham J.C. et al.Coronary artery bypass grafting with cardiopulmonary bypass versus off-pump cardiopulmonary bypass grafting does eliminating the pump reduce morbidity and cost?.Ann Thorac Surg. 2001; 71: 170-175Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 14Kim K.B. Lim C. Lee C. et al.Off-pump coronary artery bypass may decrease the patency of saphenous vein grafts.Ann Thorac Surg. 2001; 72: S1033-1037Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar, 15Puskas J.D. Thourani V.H. Marshall J.J. et al.Clinical outcomes, angiographic patency, and resource utilization in 200 consecutive off-pump coronary bypass patients.Ann Thorac Surg. 2001; 71: 1477-1484Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar Even accounting for extensive variability in patient selection, operative technique, and heparin and antiplatelet regimens in these studies, it does not seem that acute graft closure secondary to a hypercoagulable state is a valid clinical concern.TABLE 1Angiographic patency after off-pump coronary bypass surgeryAuthorYearOperationPatientsAngio timingConduitPatencyMack and colleagues6Mack J.M. Magovern J.A. Acuff T.A. et al.Results of graft patency by immediate angiography in minimally invasive coronary artery surgery.Ann Thorac Surg. 1999; 68: 383-390Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar1999MIDCAB100/103 (97)96 hLITA99/100 (99)A*91/100 (91)Izzat and colleagues7Izzat M.B. Khaw K.S. Atassi W. Yim A.P. Wan S. El-Zufari M.H. Routine intraoperative angiography improves the early patency of coronary grafts performed on the beating heart.Chest. 1999; 115: 987-990Crossref PubMed Scopus (24) Google Scholar1999OPCAB24/24 (100)IntraoperativeLITA22/24 (92)Before revisionSVG18/18 (100)Diegler and colleagues8Diegeler A. Matin M. Kayser S. et al.Angiographic results after minimally invasive bypass grafting using the minimally invasive direct coronary bypass grafting (MIDCAB) approach.Eur J Cardiothorac Surg. 1999; 15: 680-684Crossref PubMed Scopus (50) Google Scholar1999MIDCAB221/271 (82)2-6 postoperative daysLITA218/221 (99)195/221 (89)A*23/221 (10)B*3/221 (1)C*Akpinar and colleagues9Akpinar B. Guden M. Sagbas E. Sanisoglu I. Aytekin V. Bayindir O. Off-pump coronary artery bypass grafting with use of the octopus 2 stabilization system.Heart Surg Forum. 2000; 3: 282-286PubMed Google Scholar2000OPCAB71/126 (56)Before dischargeLITA71/71 (100)All types143/150 (95)Omeroglu and colleagues10Omeroglu S.N. Kirali K. Guler M. et al.Midterm angiographic assessment of coronary artery bypass grafting without cardiopulmonary bypass.Ann Thorac Surg. 2000; 70: 844-850Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar2000OPCAB70/696 (10)24-61 moLITA65/68 (96)RITA1/1 (100)RandomSVG82/103 (80)Zehr and colleagues11Zehr K.J. Handa N. Bonilla L.F. Abel M.D. Holmes Jr, D.R. Pitfalls and results of immediate angiography after off-pump coronary artery bypass grafting.Heart Surg Forum. 2000; 3: 293-299PubMed Google Scholar2000OPCAB50/50 (100)<48 hLITA46/51 (90)RA15/17 (88)SVG73/76 (96)Amano and colleagues12Amano A. Hirose H. Takahashi A. Nagano N. Off-pump coronary artery bypass. Mid-term results.Jpn J Thorac Cardiovasc Surg. 2001; 49: 67-78Crossref PubMed Scopus (41) Google Scholar2001MIDCAB/OPCAB80/194 (41)Before dischargeAll types201/203 (99)Bull and colleagues13Bull D.A. Neumayer L.A. Stringham J.C. et al.Coronary artery bypass grafting with cardiopulmonary bypass versus off-pump cardiopulmonary bypass grafting does eliminating the pump reduce morbidity and cost?.Ann Thorac Surg. 2001; 71: 170-175Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar2001OPCAB40/40 (100)<48 hAll types105/108 (97)Kim and colleagues14Kim K.B. Lim C. Lee C. et al.Off-pump coronary artery bypass may decrease the patency of saphenous vein grafts.Ann Thorac Surg. 2001; 72: S1033-1037Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar2001OPCAB112/122 (92)<96 hITA139/145 (96)130/145 (90)RA13/13 (100)RGEA10/10 (100)SVG157/187 (84)A*90/1221 yITA114/117 (97)A*101/117 (86)RA8/8 (100)RGEA7/7 (100)SVG106/156 (68)92/156 (59)A*Puskas and colleagues15Puskas J.D. Thourani V.H. Marshall J.J. et al.Clinical outcomes, angiographic patency, and resource utilization in 200 consecutive off-pump coronary bypass patients.Ann Thorac Surg. 2001; 71: 1477-1484Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar2001OPCAB167/200Before dischargeLITA158/158 (100)143/158 (91)A*RITA4/4 (100)RA24/24 (100)22/24 (92)A*SVG208/213 (98)203/213 (95)A*Numbers in parentheses are percentages. MIDCAB, Minimally invasive direct coronary artery bypass; OPCAB, off-pump coronary artery bypass; LITA, left internal thoracic artery; RITA, right internal thoracic artery; RA, radial artery; RGEA, right gastroepiploic artery; SVG, saphenous vein graft; A,* B,* C,* Fitzgibbon classification. Open table in a new tab Numbers in parentheses are percentages. MIDCAB, Minimally invasive direct coronary artery bypass; OPCAB, off-pump coronary artery bypass; LITA, left internal thoracic artery; RITA, right internal thoracic artery; RA, radial artery; RGEA, right gastroepiploic artery; SVG, saphenous vein graft; A,* B,* C,* Fitzgibbon classification. Careful analysis of the data exposes a more menacing problem. Kim and associates14Kim K.B. Lim C. Lee C. et al.Off-pump coronary artery bypass may decrease the patency of saphenous vein grafts.Ann Thorac Surg. 2001; 72: S1033-1037Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar conducted a 3-group study that compared a cohort of patients undergoing off-pump CABG surgery, a group of patients undergoing on-pump CABG surgery, and a similar group of patients undergoing on-pump CABG surgery whose grafts were constructed on the beating heart during the pre-off–pump CABG learning phase. At 1-year follow-up, ITA patency was similar among the groups. Saphenous vein graft (SVG) patency was 88% in patients undergoing CABG surgery, 87% in patients undergoing on-pump beating heart surgery, and 68% in patients undergoing off-pump surgery (P < .01).14Kim K.B. Lim C. Lee C. et al.Off-pump coronary artery bypass may decrease the patency of saphenous vein grafts.Ann Thorac Surg. 2001; 72: S1033-1037Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar There are many questions that can be raised about a retrospective study of nonconcurrent groups of patients who underwent operations at different points during the learning curve and with variable follow-up. The major underlying issue is more subtle and one that must be addressed. It has been learned from multiple pathologic and clinical studies that vein graft disease takes many forms: thrombosis (acute), intimal hyperplasia (subacute), and graft atherosclerosis (chronic).16Motwani J.G. Topol E.J. Aortocoronary saphenous vein graft disease pathogenesis, predisposition and prevention.Circulation. 1998; 97: 916-931Crossref PubMed Scopus (977) Google Scholar Although intimal hyperplasia may take months to occur, and atherosclerosis 1 year or more to develop, the initiating events (intimal injury, platelet activation, thrombus formation, macrophage infiltration, and smooth muscle cell activation) all occur in the acute postoperative period of SVG (but not during ITA) healing. Therefore, during the early postoperative period, even in the absence of any clinically manifest adverse events, the groundwork may be laid for the occurrence of multiple late events, thus adversely impairing long-term graft patency. In short, have we, in our enthusiasm to reduce perioperative morbidity, created a sleeping giant of late graft closure? Casati and colleagues17Casati V. Gerli C. Franco A. et al.Activation of coagulation and fibrinolysis during coronary surgery on-pump versus off-pump techniques.Anesthesiology. 2001; 95: 1103-1109Crossref PubMed Scopus (99) Google Scholar compared multiple hematologic variables in patients undergoing off-pump versus on-pump CABG surgery. They documented that a decrease in platelet count and activation of fibrinolysis were more profound in on-pump surgery, whereas the activation of fibrinogen and other acute phase reactants (consistent with the deposition of thrombus at surgical sites of injury) seemed to be more evident during the first postoperative day in patients undergoing off-pump CABG surgery. Therefore, patients undergoing off-pump coronary artery bypass surgery might well be expected to be more prone to graft closure. As disconcerting as these findings may seem, a comparative analysis of perioperative hemostatic function in patients who did and did not experience SVG occlusion within 3 months of surgery found an increase in plasma plasminogen activator inhibitor-1 activity to be the only postoperative hemostatic measurement predictive of subsequent SVG closure.18Moor E. Blombac M. Silveira A. et al.Haemostatic function in patients undergoing coronary artery bypass grafting perioperative perturbations and relations to saphenous vein graft closure.Thromb Res. 2000; 98: 39-49Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Notably, the classic atherosclerotic risk factors were found to be more powerful predictors than the hemostatic factors, a finding corroborated by the Cleveland Clinic experience.19Lytle B.W. Loop F.D. Cosgrove D.M. et al.Long-term (5 to 12 years) serial studies of internal mammary artery and saphenous vein coronary bypass grafts.J Thorac Cardiovasc Surg. 1985; 89: 248-258PubMed Google Scholar The emergence of long-term comparative studies demonstrating the clinical equivalence of on-pump and off-pump CABG surgery has been most encouraging.20Angelini G.D. Taylor F.C. Reeves B.C. Ascione R. Early and midterm outcome after off-pump and on-pump surgery in beating heart against cardioplegic arrest studies (BHACAS 1 and 2) a pooled analysis of two randomized controlled trials.Lancet. 2002; 359: 1194-1199Abstract Full Text Full Text PDF PubMed Scopus (508) Google Scholar However, in the absence of convincing data, there is currently extreme variability in the management of anticoagulation and antiplatelet agents in off-pump CABG surgery.21D’Ancona G. Donias H.W. Karamanoukian R.L. et al.OPCAB therapy survey off-pump clopidogrel, aspirin or both therapy survey.Heart Surg Forum. 2001; 4: 354-358PubMed Google Scholar In the presence of a well-founded concern for the impact of a relatively hypercoagulable state after off-pump CABG surgery on long-term graft patency, and in the absence of valid data indicating appropriate guidelines, what reasonable recommendations can be offered at this time? First, arterial conduits, especially in situ ITA grafts, have been demonstrated to be less prone to the pathogenesis of late graft closure than SVG grafts and are considered to be the conduit of choice in myocardial revascularization. As a result, off-pump CABG surgery may prove to be an even stronger indication for the use of arterial grafting than conventional on-pump surgery. Second, risk factor modification is known to affect the course of both graft and native coronary disease in all patients undergoing CABG surgery, and patients undergoing off-pump CABG surgery are no exception. Therefore, careful attention to risk factor modification may prove critical in maintaining graft patency and improving long-term clinical results. Third, in view of the lower incidence of bleeding complications after off-pump CABG surgery, consideration should be given to limiting the reversal of heparin intraoperatively.22Nader N.D. Khadra W.Z. Reich N.T. Bacon D.R. Salerno T.A. Panos A.L. Blood product use in cardiac revascularization comparison of on-and off-pump techniques.Ann Thorac Surg. 1999; 68: 1640-1643Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar Fourth, in view of the well-documented and common unresponsiveness to aspirin,23Steinhubl S.R. Antiplatelet agents in cardiology the choice of therapy.Ann Thorac Surg. 2000; 70: S3-8Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar as well as the considerable effectiveness of thienopyridines (ticlopidine and its safer successor clopidogrel) reported in both the cardiology24Schomig A. Neumann F.-J. Kastrati A. et al.A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents.N Engl J Med. 1996; 334: 1084-1089Crossref PubMed Scopus (1911) Google Scholarand cardiac surgical literature,25Bhatt D.L. Chew D.P. Hirsch A.T. Ringleb P.A. Hacke W. Topol E.J. Superiority of clopidogrel versus aspirin in patients with prior cardiac surgery.Circulation. 2001; 103: 363-368Crossref PubMed Scopus (256) Google Scholar serious consideration should be given to the perioperative (and perhaps the prolonged postoperative) use of clopidogrel. Fifth, the recent success of drug-eluting stents26Teirstein P.S. Living the dream of no restenosis.Circulation. 2001; 104: 1996-1998Crossref PubMed Scopus (64) Google Scholar raises serious concerns regarding the use of SVGs in stentable vessels. These data, although still early, pose a theoretical issue in the use of combined procedures for patients unable to receive all-arterial conduits. Sixth, gene therapy may have a dramatic impact on arresting the progression of SVG disease,27Mangi A.A. Dzau V.J. Gene therapy for human bypass grafts.Ann Med. 2001; 33: 153-155Crossref PubMed Scopus (20) Google Scholar and advances in this area may have particular relevance to patients undergoing off-pump coronary artery bypass surgery. Perhaps the most helpful recommendation would be to direct research efforts toward managing the perioperative hypercoagulable state and its long-term impact on graft patency in patients undergoing off-pump coronary revascularization. Paul A. Kurlansky, MD" @default.
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• W2165143360 title "Is there a hypercoagulable state after off-pump coronary artery bypass surgery? What do we know and what can we do?" @default.
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