Improving outcomes for coronary artery bypass surgery

If you have coronary artery disease (CAD), in which one or more of the main blood vessels feeding your heart is blocked, you may be facing coronary artery bypass surgery. A desire to improve outcomes after surgery and advances in technology have led surgeons to perform coronary artery bypass surgery without cardiopulmonary bypass, called off-pump bypass (also called "beating heart") surgery. Off-pump coronary artery bypass surgery differs from traditional coronary artery bypass surgery, because the heart-lung machine is not used. Rather than stopping the heart, technological advances and new kinds of operating equipment now allow the surgeon to hold stabilize portions of the heart during surgery. With a particular area of the heart stabilized, the surgeon can go ahead and bypass the blocked artery in a highly controlled operative environment. Meanwhile, the rest of the heart keeps pumping and circulating blood to the body. Off-pump coronary artery bypass surgery may be performed in certain patients with coronary artery disease. With present technology, all arteries on the heart can be bypassed off-pump. It may be ideal for certain patients who are at increased risk for complications from cardiopulmonary bypass, such as those who have heavy aortic calcification, carotid artery stenosis, prior stroke, or compromised pulmonary or renal function. Not all patients are a candidate. The selection of patients who undergo off-pump surgery is made at the time of surgery when the patient's heart and arteries are evaluated more closely

Off-pump coronary artery bypass surgery is now possible, but is it better?

The aims of off-pump bypass surgery is to decrease the morbidity of coronary artery bypass surgery, such as stroke, renal failure and need for blood transfusion. Also of great interest is the possibility that the off-pump approach may lessen the risk of what are called cognitive changes that have been seen in many patients who underwent CABG with cardiopulmonary bypass. These short-term changes include memory loss, difficulty thinking clearly and problems concentrating for lengthy periods. They usually improve over the months following surgery. But a study in the February 8, 2001 New England Journal of Medicine raised the question of whether these short-term changes may affect long-term cognitive function. 1 Although the reason for these cognitive changes is not yet definitely known, many physicians believe the changes are related to the fact that emboli (tiny particles, most commonly atherosclerotic plaque) are dislodged into the bloodstream when the heart-lung bypass machine is used. As they travel throughout the circulation, the emboli may affect the brain, resulting in cognitive dysfunction. Surgeons at The Cleveland Clinic recently completed a study 2 to date comparing the results of on- and off-pump coronary artery bypass surgery. The researchers matched 406 off -pump and 406 on-pump patients for comparison.

• Medical Therapy: Blood pressure and cholesterol lowering drugs, and treatment to reverse arteriosclerosis

• Endovascular Intervention: This minimally invasive procedure requires small incisions in the groin. Small wire-like, catheter devices called endoluminal stent grafts are threaded to the location of the dissection. These devices have a woven synthetic graft tip, which is deployed at the site of dissection and left in place. This provides a channel for blood to flow freely, repairing arterial leakage, and preventing pressure from rupturing the aorta. This procedure is much less invasive than the traditional open surgery, usually with a hospital stay of about 2-3 days and a recuperation period of a couple of weeks. Please note: This procedure can only be performed on specific patients based on clinical criteria, and no long-term data exists regarding its effectiveness compared to open surgery.

• Open Surgical Repair: The traditional treatment technique involves opening the chest and surgical removing the dissected aorta. A synthetic graft is sewn in its place for blood to flow freely to the rest of the arterial system. This procedure often requires a hospital stay of a week or more, and recuperation can take 6-8 weeks.