The Effectiveness of Left Side Pericardiotomy in Off-Pump Coronary Artery Bypass Grafting / 日本心臓血管外科学会雑誌

ABSTRACT

In off-pump coronary artery bypass grafting (OPCAB), adequate exposure under stable hemodynamic condition is mandatory. We introduced left side pericardiotomy to expose the left anterior descending artery without lifting up the ventricle in 2008. With this pericardiotomy approach, the exposure of the circumflex and right coronary artery territory became easier and OPCAB with left side pericardiotomy was compared with OPCAB with midline pericardiotomy. From 2004 to 2011, 194 elective first time coronary artery bypass grafting (CABG) were performed in our hospital. Before 2008, 62 patients underwent OPCAB with midline pericardiotomy which constituted 61% of the CABG in that period. After 2008, the pericardium was dissected on the left side and a small pericadiotomy was made on the left side of the main pulmonary artery. This incision was then extended to the apex. With this pericardiotomy, only two patients underwent CABG with cardiopulmonary bypass (one patient with 15% left ventricle ejection fraction and one more patient who developed acute coronary syndrome during anesthesia induction). Thus 91 out of 93 patients underwent OPCAB (98%) (Group L). In Group L, old myocardial infarction and unstable angina patients were frequent. The frequency of the patients with left ventricular ejection fraction less than 40% tended to be more in Group L. The operation time was significantly shorter in Group L (Group M 305±71 min, Group L 223±54, <i>p</i><0.0001) and the number of distal anastomoses number was significantly more in Group L (Group M 2.3±0.7, Group L 2.8±1.0, <i>p</i><0.0001). Blood pressure during left circumflex coronary artery and right coronary artery anastomosis was significantly higher in Group L, and even continuous dopamine infusion requirement was significantly less in Group L (92% in Group M, 13% in Group L, <i>p</i><0.001) among the patients with left ventricle ejection fraction less than 60%. There was only 1 hospital death in Group M. Postoperative maximum CK-MB was significantly lower in Group L (Group M 48±107 IU/<i>l</i>, Group L 13±16 IU/<i>l</i>, <i>p</i>=0.005) and the patients with CK-MB more than 12 IU/<i>l </i>was significantly frequent in Group M (Group M 73%, Group L 33%, <i>p</i><0.0001). Postoperative ICU and hospital stay period was significantly shorter in Group L (ICU stay Group M 3.4±2.3 days, Group L 2.0±1.4 days, <i>p</i><0.0001, hospital stay Group M 27±21 days, Group L 16±7 days, <i>p</i><0.0001). The patency of the graft to the left anterior descending artery did not differ significantly (Group M 94%, Group L 99%), however the patencies of the grafts to left circumflex artery and right coronary artery were significantly better in Group L (left circumflex artery Group M 75%, Group L 98%, <i>p</i>=0.001, right coronary artery Group M 81%, Group L 98%, <i>p</i>=0.014). Left side pericardiotomy seemed to be useful because OPCAB with left side pericardiotomy yielded shorter operation time, less myocardial enzyme release, improved postoperative recovery and better patency of graft to the left circumflex and right coronary artery.