Universidade Federal de São Paulo (UNIFESP)UNIFESPSciEL

Buffolo, Enio

Arquivos Brasileiros de Cardiologia

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Myocardial revascularization without extracorporeal circulation

Enio Buffolo

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Revascularização do miocárdio sem circulação extracorpórea Myocardial revascularization without extracorporeal circulation

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Arquivos Brasileiros de Cardiologia - Volume 85, Nº 4, October 2005Point of ViewPoin  of ViewMyocardial Revascularization withoutExtracorporeal CirculationMailing Address:  E n i o  B u f f o l o  •  R :  B o r g e s  L a g o a ,  1 0 8 0  –  7 º  a n d a r  –  0 4 0 3 8 - 0 3 0  -  S ã o  P a u l o ,  S P  - BrazilE-mail: ebuffolo@cardiol.br  or  enio.buffolo@terra.com.br               Received on 04/19/05 • Accepted on 04/22/05Enio BuffoloUniversidade Federal de São Paulo - UNIFESP - São Paulo, SP - BrazilThe myocardial revascularization withoutextracorporeal circulation (ECC) is not new, and the firstreports of consecutive series date back from the beginningof the 80’s1-5.Due to the comfort of performing saphenous-coronaryanastomoses in cardioplegia, cardiovascular surgeons didnot accept this alternative initially, even considering that thecoronary approach is achieved on the heart surface, whichwould not require cardiac arrest in extracorporeal circulation.After a long period of skepticism, there was anextraordinary and increasing interest in the mid-90’s forthis revascularization alternative, with the appearance ofthe “minimal invasion” concepts6.The man points for such acceptance to occur were theintroduction of stabilizers, the recognition of less morbidityand mortality, especially for high-risk patients, and theconsistent results observed in the original series.With the increase of experience in other centers, itwas observed that the myocardial revascularization couldbe complete and show superior results when comparedto the conventional technique.In the registry of the Society of Thoracic Surgeons(STS), the revascularization without ECC (off-pump) offersbetter results than the conventional technique regardingmortality and morbidity, and these data have beenconfirmed in other literature studies7-10.If the differences are not significant for low-risk patients,the difference in post-operative complications isnoteworthy for those with important co-morbidities.Among other advantages, it is worth mentioning thepossibility of extubation in the operating room, shorterIntensive Care Unit (ICU) and hospital stay, decreasedneed for blood transfusion and advantages regardinghospital costs.Among the debatable points it is worth mentioningthe decrease of the inflammatory response, of apoptosis,and the quality of the anastomoses.The preferential candidates to revascularizationwithout ECC are elderly patients with previous stroke;chronic obstructive pulmonary disease; chronic renalfailure; carotid pathology; poor ventricular function; andaorta calcification12-14.Initially, the technique was used solely for anteriordescending coronary, right coronary and diagonal coronarylesions, but exposing the marginals with Lima stitchesand the introduction of suction (Octopus®) or compressionstabilizers (Guidant® - Millennium®), associated to aheart positioner (Starfish®) increased the indications andpossibilities of revascularization without ECC.The applicability has varied along the years, fromsporadic indications to 100% for different surgical groups.During 23 years of our experience, out totalapplicability was 21% in 3,727 cases, reaching 49% inthe last five years.The variations found in literature can be attributed tothe surgeon’s determination and training in thetechnique, to the concept of functional more thananatomical revascularization, and the demography ofpatients referred to surgery.Nevertheless, there is no doubt that the anastomosesperformed with the heart beating is not an indication forall patients, and much less for all surgeons. Only experienceand training can assign the patients to either technique.Finally, the revascularization without ECC, the use ofarterial grafts and the surgical ventricular remodeling inischemic cardiomyopathy are considered some of thegreatest contributions of surgery to the treatment ofcoronary affections, and the comparisons of the medicalpercutaneous treatment with the surgical approach mustbe reconsidered in the light of such contributions.Arquivos Brasileiros de Cardiologia - Volume 85, Nº 4, October 2005MYOCARDIAL REVASCULARIZATION WITHOUT EXTRACORPOREAL CIRCULATION1. Buffolo E, Andrade JCS, Succi JE et al. Revascularização direta domiocárdio sem circulação extracorpórea. Descrição da técnica eresultados iniciais. Arq Bras Cardiol 1982; 38: 365-373.2. Benetti FJ. Direct coronary surgery with saphenous vein bypasswithout either cardiopulmonary bypass or cardiac arrest. JCardiovasc Surg 1985; 26: 217-22.3. Buffolo E, Andrade JCS, Branco JNR et al. Myocardialrevascularization without extracorporeal circulation. Seven-yearsexperience in 593 cases. Eur J Cardiothorac Surg 1990; 4: 504-7.4. Buffolo E, Andrade JCS, Branco JNR et al. Coronary artery bypasswithout cardiopulmonary bypass. Ann Thorac Surg 1996; 61: 63-6.5. Rivetti LA, Gandra SMA, Initial experience using an intraluminalshunt during revascularization of the beating heart. Ann Thorac Surg1997; 63: 1742-47.6. Calafiore AM, Gianmarco GD, Teodori G et al. Lef t anteriordescending coronary ar tery graf ting via lef t anterior smallthoracotomy without cardiopulmonary bypass. Ann Thorac Surg1996; 61: 1658-657. Jasinski MJ, Wos S, Olszowka P et al. Dysfunction of left ventricle asan indication for off-pump coronary artery bypass grafting. Heart SurgForum 2003; 6(6): E85-8.8. Van Dijk D, Nierich AP, Jansen EW et al. Early outcome after off-pumpversus on-pump coronary bypass surgery: results from a randomizedstudy. Circulation 2001; 104: 1761-66.REFERENCES9. Angelini GD, Taylor FC, Reeves BC et al.  Early and midterm outcomeafter off-pump and on-pump surgery in a beating heart againstcardioplegic arrest  studies (BHACAS 1 and 2): a pooled analysis oftwo randomizes controlled trials. Lancet 2002; 359: 1194-9.10. Cleveland JC, Shroyer ALW, Chen AY et al. Off-pump coronary arterybypass grafting decrease risk-adjusted mortality and morbidity. AnnThorac Surg 2001; 72: 1282-9.11. Gerola LR, Buffolo E, Jasbik W et al. Off-pump versus on-pumpmyocardial revascularization in low-risk patients with one or twovessel disease: Perioperative results in a multicenter randomizedcontrolled trial. Ann Thorac Surg 2004; 77: 569-73.12. Kilo J, Baumer H, Czerny M et al. Target vessel revascularizationwithout cardiopulmonary bypass in elderly high-risk patients. AnnThorac Surg 2001; 71: 537-42.13. Kshettry VR, Flavin TF, Emery RW et al. Does multivessel off-pumpcoronary artery bypass reduce postoperative morbidity. Ann ThoracSurg 2000; 69: 1725-30.14. Al-Ruzzeh S, Nakamura K, Athanasiou T et al.  Does off-pumpcoronary artery bypass (OPCAB) surgery improve the outcome inhigh-risk patients?: a comparative study of 1,398 high-risk patients.Eur J Cardiothorac Surg 2003; 23(1): 50-5.15. Lima RC. Padronização técnica da revascularização do miocárdio daartéria circunflexa e seus ramos sem circulação extracorpórea. Tesede Doutorado. São Paulo – Universidade Federal de São Paulo/EscolaPaulista de Medicina.

http://dx.doi.org/10.1590/S0066-782X2005001700011

Myocardial revascularization without extracorporeal circulation

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Scientific Electronic Library Online - Brazil

Directory of Open Access Journals

Repositório Institucional UNIFESP