A review of 140 Octopus off-pump bypass patients over the age of seventy: Procedure of choice?

Background: Many studies have demonstrated that patients of advanced age ar e at increased risk for morbidity and mortality following coronary artery b ypass graft (CABG) surgery. When compared to younger age groups, the risks of adverse neurological outcome or mortality have been demonstrated to be h igher in septuagenarians and octogenarians. It has been suggested that off- pump coronary artery bypass (OPCAB) surgery, by avoiding the adverse effect s of cardiopulmonary bypass (CPB), may improve the risks of morbidity and m ortality, particularly in these higher risk elderly patients. Despite the i ncreased rates of adverse events in patients of advanced age, various autho rs have described these risks to be in the acceptable range, justifying con tinued recommendations for operative revascularization in properly selected elderly patients. OPCAB theoretically may provide improvements in early ou tcomes for these patients by avoiding the unwanted sequelae of CPB. Patients and Methods: This report is a study of the potential advantages of OPCAB techniques based on a retrospective analysis of 140 patients aged 70 or more operated on by a single surgeon at a single institution using OPCA B techniques during a 39-month period. In these operations, surgical access was almost exclusively via midline sternotomy. Exposure of target coronary arteries was by means of extended inverted-T pericardiotomy. Local occlusi on of coronary arteries was achieved using proximally placed silastic tapes (Quest Medical Inc., Allen, TX). Distal occlusion was rarely needed. Stabi lization was obtained exclusively with the suction-based Octopus(TM) stabil ization system (Medtronic, Inc., Minneapolis, MN). A mean number of 2.36 +/ -0.95 distal anastomoses were constructed per patient, with a range from on e to five. Multivessel OPCAB patients averaged 2.73 grafts per patient. Results: Of the 142 patients who underwent OPCAB surgery, only two required elective conversion to CABG with CPB. The procedure was safe, with no need for urgent conversion to CPB. Myocardial protection was excellent, with no patient requiring inotropic support leaving the operating room, and no pat ient developed postoperative stroke. Several patients had evidence of tempo rary nocturnal confusion but recovered prior to discharge. There were no in -hospital or 30-day post-operative mortalities in this group. Conclusions: OPCAB has been demonstrated to be safe and effective, with sur geons from many centers worldwide reporting low rates of morbidity and mort ality. Early patency rates appear to be equal to or perhaps even better tha n CABG with CPB. This report adds to a growing body of literature supportin g the use of OPCAB in elderly patients requiring surgical revascularization . If further investigations continue to demonstrate improved outcomes, OPCA B may become the procedure of choice for patients of advanced age.