Prospective evaluation of patency and early experience utilizing an automated distal anastomosis device (C-port).

BACKGROUND: : In November 2005, a new automated distal anastomotic device (C-Port) for coronary artery bypass grafting (CABG) was cleared by the FDA for use in the United States. This study represents a prospective evaluation of our early experience using the device with graft patency assessment determined by 64 slice multidetector row computed tomography angiography (64CT). MATERIALS AND METHODS: : Patients undergoing coronary artery bypass were evaluated preoperatively by cine angiography for possible use of the C-Port system. A final decision for its use was made clinically at operation based on target vessel and vein graft specifications. Patency of the grafts was evaluated at 1 to 7 months (average 91 days) by 64CT with IRB approval and signed informed consent. RESULTS: : The C-Port device was used to form 69 distal anastomoses in 50 patients (46 CABG were performed off pump). There were eight misfires with no adverse effects for an immediate success rate of 88.4%. Thirty-five of 41 patients were available postoperatively for evaluation by 64CT (85.4% follow-up). There was one postoperative death. Seventeen sequential anastomoses were excluded because of inability to reliably evaluate patency by 64CT. Four 64CT scans were uninterpretable. For the remaining 31 patients, 64CT scans were used to evaluate for graft patency. The overall patency rate for all anastomoses was 94.5% (86/91) with selected patency for internal mammary artery of 100% (28/28), for C-Port connectors of 93.3% (42/45), and for hand-sewn venous end-to-side anastomosis of 88.9% (16/18). The difference in patency between C-Port anastomoses and hand sewn was not statistically significant (P = 0.62). CONCLUSIONS: : The C-Port system provides reliable and reproducible compliant automated distal venous anastomoses, which results in acceptable patency at intermediate follow-up. With proper training, the learning curve for using this connector system is relatively short and the need to abandon the procedure is low. 64CT is an excellent noninvasive method for cardiac surgeons and their institutions to accurately evaluate their actual surgical results.

Elimination of cardiopulmonary bypass improves early survival for multivessel coronary artery bypass patients.

BACKGROUND: Coronary artery bypass graft (CABG) surgery performed without cardiopulmonary bypass (CPB) is currently increasing in clinical practice. Decreased morbidity associated with off-pump (OP) CABG in selected risk groups examined in relatively small, single institution groups has been the focus of most recent studies. The purpose of this study was to determine the independent impact of CPB on early survival in all isolated multivessel CABG patients undergoing surgery in two large institutions with established experience in OPCABG techniques. METHODS: A review of two large databases employed by multiple surgeons in the hospitals of two institutions identified 8,758 multivessel CABG procedures performed from January 1998 through July 2000. In all, 8,449 procedures were included in a multivariate logistic regression analysis to determine the relative impact of CPB on mortality independent of known risk factors for mortality. Procedures were also divided into two treatment groups based on the use of CPB: 6,466 had CABG with CPB (CABG-CPB), 1,983 had CABG without CPB (OPCABG). Disparities between groups were identified by univariate analysis of 17 preoperative risk factors and treatment groups were compared by Parsonnet's risk stratification model. Finally, computer-matched groups based on propensity score for institution selection for OPCABG were combined and analyzed by a logistic regression model predicting risk for mortality. RESULTS: CABG-CPB was associated with increased mortality compared with OPCABG by univariate analysis, 3.5% versus 1.8%, despite a lower predicted risk in the CABG-CPB group. CPB was associated with increased mortality by multiple logistic regression analysis with an odds ratio of 1.79 (95% confidence interval = 1.24 to 2.67). An increased risk of mortality associated with CPB was also determined by logistic regression analysis of the combined computer-matched groups based on OPCABG-selection propensity scores with an odds ratio of 1.9 (95% confidence interval = 1.2 to 3.1). CONCLUSIONS: Elimination of CPB improves early survival in multivessel CABG patients. Rigorous attempts to statistically account for selection bias maintained a clear association between CPB and increased mortality. Larger multiinstitutional studies are needed to confirm these findings and determine the most appropriate application of OPCABG.

Influence of Old Age, Gender, and Internal Mammary Artery Grafting on Operative Mortality and Morbidity in Coronary Artery Bypass Grafting.

Operative risk may change its pattern from time to time. To investigate determinants for operative mortality in patients undergoing CABG since the mid 1980s and the influence of age, gender, and IMAG on mortality, the data of 6,360 patients who underwent CABG from January 1986 through June 1993 were analyzed. Of these patients, 2,153 had SVG alone and 4,207 had IMAG including UIMAG (3,957) and BIMAG (250). Overall mortality was 4.34%. OM (in hospital death) for IMAG (2.69%) was lower than for SVG (7.57%, p is less than 0.0001). There was no difference in mortality between BIMAG (3.2%) and UIMAG patients (2.65%, p equals 0.6) or UIMAG/SVG patients (4.29%, p equals 0.36). Fewer IMAG patients had postoperative complications (LCO, insertion of IABP, prolonged ventilation, reoperation for bleeding, neurological complications, perioperative MI, and infection of legs) than SVG patients. There was no difference in the incidence of sternal infection. To determine risk factors for mortality and the influence of IMAG on the outcome, 82 variables (31 preoperative, 17 intraoperative, and 34 postoperative) were analyzed by univariate analysis. Significant variables or the variables having a trend (p is less than 0.2) to be associated with mortality were included in stepwise multiple logistic regression analyses. Two regression analyses were separately performed. Regression 1 only included pre- and intraoperative variables whereas regression 2 included postoperative variables as well. The logistic regressions demonstrate that preoperative (low EF, age at or above 70, female gender, history of CHF or arrhythmia, and functional Class), intraoperative (emergency operation, reoperation, long perfusion time, and lack of IMAG), and postoperative (complications) variables are independently associated with higher mortality. Female gender is an independent determinant for mortality and not dependent on small body surface area. Neither use of BIMAG or right IMAG, nor number of grafts is associated with the OM. The identification of these risk factors may have important implications in further improvement of the results for CABG.