IJTCVS 2002; 18: 1 IJTCVS, Jan–Mar, 2002 Prevention of Phrenic Nerve Palsy During CABG "OP-CAB" Surgery – An Initial Experience of Puri D, Puri N, Dhaliwal RS, Gupta PK 1 22 Cases with Indigenous Equipments 3 CTV Surgery PGIMER, Chandigarh & Anatomy Srivastava CP, Devgarha S, Singh R, Nathani V, Sharma A, IGMC Shimla Kushwaha KK, Mathur BM Department of CTVS, SMS Medical College and Hospital, Jaipur Introduction: Close proximity of phrenic nerves to internal mammary arteries and pericardium makes them liable to injury during Introduction: Minimal invasive CABG is getting more popular CABG. Injury can occur directly due to transection or secondary to all over the world. It has the advantage of decreased blood loss, rapid compromised vascularity or hypothermia. recovery and short hospital stay. Thus if offer chances for CABG in Methods: We studied in detail the intra thoracic course of IMA sick and elderly patients. and phrenic nerves in 100 cadavers. This information was utilized Methods: "OP-CAB" was performed in 22 cases of CAD admitted while harvesting IMA during CABG. The pericardiophrenic branch in department of CTVS, SMS Hospital, Jaipur from October 1998 to of IMA, a major source of blood supply to the phrenic nerves was October 2001. Out of the 22 cases 15 cases had 1 graft and 7 cases had preserved. Intermittent cooled saline (4°C) was used for topical cooling 2 grafts with average of 1.5. instead of ice slush. Elevation of hemidiaphragm on postoperative Results: Mean age of patients for "OP-CAB" has been 55±10 years. chest roentgenogram and paradoxical movements of diaphragm on All patients had significantly shorter post-op length of stay in hospital fluoroscopy were taken as evidence of phrenic nerve palsy. (7±3) and lower transfusion requirement (2±1). Only 1 patients who Results: Large no of variations were observed in relations between already had documented carotid artery disease died in post-op period phrenic nerve and proximal IMA and in the origin of pericardiophrenic due to stroke. branch of IMA. Incidence of unilateral phrenic nerve injury among Conclusion: Our initial experience with "OP-CAB" has been patients who had CABG during this study was 2%. encouraging we conclude that it is a safe & efficacious method of Conclusion: A thorough knowledge of anatomical variation in the revascularisation & should preferentially be done wherever applicable. course of phrenic nerves, preservation of pericardiophrenic branch of IMA and use of cooled saline instead of ice slush for topical cooling helps in avoiding phrenic nerve palsy during CABG. Does Low Ejection Fraction Alter Outcome in off Pump Coronary Artery Bypass 4 Mani GK, Sharma PK, Agarwal M, Das A, Gara A, Jain AP, Mani M Indraprastha Apollo Hospitals, New Delhi Background: It has almost been established that OPCAB provides equally good, short and intermediate term results in patients with LVEF> 0.3 when compared to a comparable group of patients done Total Arterial Revascularisation on Beating Heart– by conventional (on CP Bypass) technniques. Our Experience in 822 cases 2 Many authors have noticed that posterior vessel grafting (Cx branches, PD and PLV branches of RCA) causes serious hemodynamic Sinha SK, Singh SK, Mishra SK, Kumar D, Kaur C, Gupta S compromise with adverse outcomes. Prolonged myocardial stunning Batra Hospital & Medical Research Centre, 1, Tughlakabad Institutional Area, MB Road, New Delhi which occurs during these manouveres were often blamed for post operative low cardiac output. Introduction: In an attempt to avoid the deleterious effect of Methods: We have compared our 579 patients done by OFF PUMP cardiopulmonary bypass, off pump CABG has been rediscovered and (Group A) techniques who had preoperative LVEF of >0.3 with 208 refined particularly with the advent of better stablizing devices patients done by similar OFF PUMP techniques who had LEEF of (Medtronic Octopus, Guidant Suction Device). To achieve total arterial <0.3 (Group B; between 1st Mar 2000 to 31st Oct 2001). Operative revascularisation, we hanged radial artery/RIMA on LIMA in 'Y' variables were not significantly different, as the same surgical team fashion. and techniques were applied in both subsets. Preoperative TEE Methods: Total arterial revascularisation on beating heart was assessment was used more in Group B. Associated recent infarction, performed in 822 cases (age range 32-88 years) without any selection number of grafts, intraoperative blood loss, CKMB rise, usage of IABP bias. Triple vessel disease was present in 562 patients and ejection support, inotropes, morbidity and mortality were compared in the fraction less than 30 was present in 128 patients. Pre-operative IABP two subsets. was present in 23 cases. Beating heart CABG was performed in these Results: Though patients with LVEF=0.3 were predicted to have a cases with the average number of grafts (3.36 graft/patient) check higher mortality, we noted that acutal mortality was not significantly angiogram was done in 292 cases. different 4/208 Vs 6/579. However if mortality is excluded and Results: Conversion to CPB was required in 3 cases (in our initial morbidity is compared, the patients in the subset of < 0.3 LVEF had phase). Post-operative blood loss, ionotropic requirement and ICU longer ICU stay and increased incidence of IABP and inotropic support stay was significantly less in our group of patients in comparison to Even with in the subset of LVEF >0.3 there was a noticeable the CABG done on CPB. The incidence of post-operative arrhythmias differnece in the out come of patients who were operated earlier vis a and development of new renal impairment were also significant less. vis patients who were operated later chronologically (dividing before There was no neurological complication and operative mortality was and after 1.1.2001). <1.0%. Grafting strategy, generous opening of Right pericardio-pleural Conclusion: Total arterial revascularisation on beating heart is a space,usage of intraluminal shunts, optimal compression with the safe, effective and reproducible means of revascularization in almost suction stabilizer and vertical displacement rather than lateral all the patients with excellent patency rate and minimal morbidity. displacement of the left ventricle apex, more frequent usage of IJTCVS-A1.p65 1 2/20/02, 10:04 AM IJTCVS 2002; 18: 2 IJTCVS, Jan–Mar, 2002 milrinone infusion contributed to better outcomes in the later 108 Conclusion: Off pump Redo coronary artery is a suitable option cases. Optimization of volume loading and intraoperative diuresis for quite a number of patients. There is no difference in the results of have had a favorable impact. On pump and Off pump redo surgery. Contrary to the belief it may Conclusion: We conclude that except for patients who are on CPR be advantageous to the patients. or moribund because of dangerous arrhythmias and patients whose mitral regurgitation is organic than ischemic, OFF PUMP CABG is an effective therapeutic modality both in subset of LVEF >0.3 as well as Minimally Invasive Coronary Artery Surgery– subset of LVEF <0.3. A Simple and Effective Approach 7 Mandke NV, Nalladaru Z, Choughule A, Mandke AN Lilavati Hospital and Research Centre,Mumbai OPCAB-In patients with Diabetes Mellitus Aim: This study is done to show the feasibility of doing more than Kumar P, Reddy S, Thakur DN, Kulkarni, Raghavendra, 5 90% of coronary artery bypass surgery patients off pump with good Pranav, Jadhav U, Tendolkar AG CVTS Department, College building, I floor, LTMM College and results. General Hospital, Sion, Mumbai Material & Methods: Off pump Coronary artery surgery was started by us in 1995. Between 1st January 1996 till 31st August 2001, Background: Popularized by Kolesov (1) in the early 1960s, off 1787 patients underwent offpump coronary artery surgery. Cardiac pump coronary artery bypass grafting (OPCAB) is now accepted as stabilizers became available to us from January 2000. We analyzed the procedure of choice for performing coronary artery bypass our data from 1st January 2000 till 31st August 2001. Total number of grafting. Various studies have shown the superiority of an OPCAB Bypass surgeries performed were 1025 our of which 955 (93.17%) were over on pump CABG. done offpump. Seventy patients those who were done on CP Bypass, Methods & Results: Consecutive 150 patients were operated at 40 were intended to be done off pump but had to be converted to CP our institute between October 1999 and July 2001 using the off pump Bypass due to haemodynamic instability. One hundred and fourteen technique. 8 patients had an ejection fraction of less than 30%. 5 patients were not suitable for off pump surgery were still done off patients suffered an intra operative myocardial infarction of which 3 pump with no mortality in this group. Three hundred and thirty three patients had an EF less than 30%. Haemodynamic instability. out of 955 patients (34%) had composit 'Y' grafts using various Requiring conversion to CPB, was seen in 9 patients, 7 of these having conduits. In 955 patients, 3372 anastomoses were performed (3.53 an ejection fraction less than 30%. Of the 5 cases of intra operative grafts/patient). mortality, 4 were in the group of low ejection fraction. Results: Five patients were re-explored for bleeding, 2 patients Conclusion: Patients with low ejection fraction, <30% can be developed CVA and 8 patients died (0.83%). Immediate post-operative managed comfortably using OPCAB, with few cases requiring graft angiography was performed in 167 patients. All arterial grafts ionotropic support. The conversion rate to CPB is higher with low were patent either individual or composits (100% patency rate). One ejection fraction heart and the associated mortality is also high. saphenous vein out of 18 got blocked (94.4% patency rate). Conclusion: This is a small series over a period of 20 months which suggest to us that large number of patients can be done off pump Off Pump Redo CoronaryArtery Surgery- with good results.