Ten year experience of using a novel metabolic protocol in 'off pump' coronary artery bypass revascularization.

PURPOSE: Assessment of both short- and long-term outcomes in patients undergoing off-pump coronary artery bypass using a perioperative metabolic protocol. METHODS: A total of 975 of 995 adult patients underwent coronary artery bypass 'off-pump' from 1997 through 2006. Patients presenting in cardiogenic shock were excluded from this assessment. A perioperative metabolic protocol, which included the implementation of allopurinol, insulin supplementation, magnesium sulfate, supplemental corticosteroids, milrinone, norepinephrine (prn), aspirin, clopidogrel, statins and ß-blockers, was used in these patients. RESULTS: The mean age at the time of surgery was 70.5 years and the average number of bypass grafts was 4 per procedure; 18% (n = 176) of the cases had a preoperative intra-aortic balloon pump inserted for hemodynamic instability, tight left main coronary artery stenosis or angina. The 30-day mortality was 1.8% versus a Society of Thoracic Surgeons (STS) predicted mortality of 4.8%. Left main coronary artery disease was present in 38% (n = 371) of the patients. No strokes occurred intra-operatively and the postoperative incidence of stroke was 0.9% (n = 9). Incidence of renal failure requiring dialysis was 0.8% (n = 8). There was a single sternal infection. Mean follow up was 65 months with a survival rate of 90% (n = 955). Re-intervention, which commonly involved PTCA ± stent placement or re-do coronary artery bypass grafting (CABG), was 4% at 1 year and 11.6% (n = 113) during the 65-month follow-up period. CONCLUSIONS: Off-pump coronary artery bypass coupled with this novel metabolic protocol was associated with a low operative mortality and acceptable perioperative morbidities, including patients with left main coronary artery disease. These benefits are apparent at both short- and medium-term follow up.

A targeted metabolic protocol with D-ribose for off-pump coronary artery bypass procedures: a retrospective analysis.

OBJECTIVES: Coronary revascularization using cardiopulmonary bypass is an effective surgical procedure for ischemic coronary artery disease. Complications associated with cardiopulmonary bypass have included cerebral vascular accidents, neurocognitive disorders, renal dysfunction, and acute systemic inflammatory responses. Within the last two decades off-pump coronary artery bypass has emerged as an approach to reduce the incidence of these complications, as well as shorten hospital stays and recovery times. Many patients with coronary artery disease have insulin resistance and altered energy metabolism, which can exacerbate around the time of coronary revascularization. D-ribose has been shown to enhance the recovery of high-energy phosphates following myocardial ischemia. We hypothesized that patient outcomes could improve using a perioperative metabolic protocol with D-ribose. METHODS: A perioperative metabolic protocol was used in 366 patients undergoing off-pump coronary artery bypass during 2004-2008. D-ribose was added in 308 of these 366 patients. Data were collected prospectively as part of the Society of Thoracic Surgeons database and retrospectively analyzed. RESULTS: D-ribose patients were generally similar to those who did not receive D-ribose. There was one death, two patients suffered strokes and renal failure requiring dialysis occurred in two patients postoperatively among the entire group of patients. D-ribose patients enjoyed a greater improvement in cardiac index postrevascularization compared with non-D-ribose patients (37% vs. 17%, respectively, p < 0.001). CONCLUSIONS: This metabolic protocol was associated with very low mortality and morbidity with a significant early postoperative improvement in cardiac index using D-ribose supplementation. These preliminary results support a prospective randomized trial using this protocol and D-ribose.