Off-pump arterial grafting: 125 cases using the Medtronic-Utrecht Octopus

Objectives: The use of arterial grafts in coronary bypass surgery requites a high degree of cardiac stabilization, traditionally achieved with cardiop ulmonary bypass and cardioplegic arrest. The Medtronic-Utrecht Octopus has recently been developed as an advanced cardiac stabilization device, based on its unique suction method for regional epicardial immobilization and ret raction. The objective of this study was to investigate the feasibility of using this device to enable total arterial revascularization on the beating , working heart. Methods: From May 1997 to November 1998, off-pump coronary artery bypass using exclusively arterial grafts was performed in 125 selec ted patients (108 males), aged 26-82 years (mean 61.1 +/- 10.5 years). Coro nary artery immobilization was achieved with the Octopus, which uses local epicardial suction and avoids cardiac compression. Aortic anastomoses were avoided: both internal thoracic arteries and the right gatstroepiploic arte ry were used as pedicle grafts in all but one case. All radial artery graft s and one right internal thoracic artery were used as Y-grafts from the lef t internal thoracic artery. There were four surgical approaches: sternotomy (98 patients), left anterior small thoracotomy (20 patients), anterolatera l thoracotomy (six patients) and a subxiphoid approach in one patient. Resu lts: Sternotomy: 187 grafts were performed in 98 patients (mean 1.9 grafts per patient). There were 99 grafts to anterior wall vessels, 47 grafts to p osterior wall vessels and 41 grafts to lateral wall vessels. Left anterior thoracotomy: 20 patients had a single graft to the left anterior descending artery (LAD). Left anterolateral thoracotomy: three patients had a single graft to a circumflex branch, while three had composite grafts to the LAD a nd circumflex systems. Subxiphoid: one patient had a single graft to the po sterior descending branch of the right coronary artery. There were no peri- operative deaths in any group. No patient required conversion to cardiopulm onary bypass. Three patients required conversion from a limited-access appr oach to sternotomy. There was one re-operation for bleeding. Postoperative stay was 27 days (mean 3.6 +/- 1.1; median 3 days) for anterior thoracotomy , 3-4 days (mean 3.5 +/- 0.6) for anterolateral thoracotomy, and 378 days ( mean 6.6 +/- 8.7; median 4 days) for sternotomy. There were two late deaths in salvage patients; no patient has required cardiac intervention or re-op eration. Conclusions: The Octopus maintains excellent local cardiac immobil ization - enabling the routine use of arterial grafts in off-pump coronary surgery. It allows easy access to anterior wall vessels on the heart, and-r elatively straightforward access to the posterior wall. Circumflex branches are graftable with careful case selection and adjunctive technical maneuve rs. (C) 1999 Elsevier Science B.V. All rights reserved.