Off-pump redo coronary artery bypass grafting: technical aspects and early results.

BACKGROUND Redo coronary artery bypass grafting (CABG) represents an high-risk surgical procedure, because of an increased incidence of perioperative death, myocardial infarction and stroke. Theoretically, the avoidance of cardiopulmonary bypass may reduce surgical traumatism and ameliorate early results. MATERIALS AND METHODS From January 1995 to May 2001, we performed 123 redo CABGs, of which 53 (44%) off-pump. Off-pump procedure represented respectively 90% of redo CABG in the period 2000-2001 versus 30% in the 1995-1999 period. The mean age was 66.4 years, males were 39 (73%). The mean 2D-echo ejection fraction was 56% and in 9 cases (17%) was less than 40%. Three operations (5.6%) were performed on an urgent base. The access was median sternotomy in all cases. The mean number of grafts per patient was 1.9 (1.7 in the period 1995-99 vs. 2.3 in the period 2000-01, p=0.01). In 20 cases (38%) we grafted the circumflex artery branches (19% in the period 1995-99 vs. 55.5% in the period 2000-01, p=0.015). Improvements in surgical techniques were achieved over time. The current operative strategy includes the use of deep traction stitches in the posterior pericardium and wall stabilizers to expose target vessels, coronary intraluminal shunts during construction of the anastomoses and continuous trans-esophageal echocardiographic monitoring. Urgent conversion to on-pump procedure was not required in any case. RESULTS We recorded no in-hospital death, one perioperative myocardial infarction (1.9%), one fifth postoperative day-stroke (1.9%) and 9 atrial fibrillations (17%). Mediastinal re-exploration for bleeding was performed in no one patient; 13 patients (24.5%) required postoperative blood transfusion. The mean length of postoperative stay was 7.5 days, ranging from 6 to 18 days. CONCLUSIONS In our experience off-pump redo CABG is a safe and effective alternative to on-pump procedure and now off-pump is our first choice-technique in redo CABG. A complete revascularization is technically feasible with a low incidence of perioperative complications.