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Elective Implementation of Pump Assisted CABG With 0r Without Arrested Heart as an Alternative to OPCABG Reduces Complications and the Incidence of Emergency Conversions: A Retrospective Review Of 1319 Consecutive Cases.
Alex Zapolanski1, Christopher K. Johnson1, Giovanni Ferrari2, Mariano E. Brizzio1, Richard E. Shaw1, Jason S. Sperling1, Juan B. Grau1.
1Valley-Columbia Heart Center, Ridgewood, NJ, USA, 2University of Pennsylvania School of Medicine, Glenolden, PA, USA.

OBJECTIVE: Off-pump cardiopulmonary bypass surgery (OPCABG) has not been widely adopted, due to its technical demands and heavy reliance on practitioner experience. In some situations, emergency conversion (EC) from off-pump to on-pump becomes unavoidable. Several series have demonstrated an increase in morbidity and mortality when conversions occur. No established algorithms exist to guide surgeons through the decision to utilize cardiopulmonary bypass in order to reduce the risk for EC. The purpose of the current study was to analyze the influence of implementing a flexible approach in decision making to CABG. This includes all alternatives available to the surgeon in order minimize EC. Additionally, we also assessed the extent of perioperative complications associated with EC.
METHODS: Using our STS database, we retrospectively analyzed our most recent series of coronary revascularization procedures from 1/2006-12/2011. 1319 patients were scheduled for isolated CABG. We divided them into three groups: off-pump (Group A; N=1087, 82%), on-pump with cardioplegic arrest (Group B; N=195, 15%), and on-pump beating (Group C; N=37, 3%). We analyzed the in-hospital and 30-day complications for each group, as well as for those patients who underwent EC.
RESULTS: In-hospital and 30-day mortality was 0.65% for Group A, 1.5% for Group B, and 0% for Group C. Overall mortality for the entire series was 0.76%. Five patients (0.46%) were converted emergently from off- to on-pump. The mortality in this group was 0% without any perioperative complications. Indications for conversion were inadequate size and/or diffuse disease of distal vessels, hemodynamic instability, and/or inadequate visualization/exposure.
CONCLUSIONS: Appropriate decision-making following pericardiotomy at the time of CABG prevents unnecessary ECs. When EC becomes unavoidable, CPB should be instituted expeditiously without persistence to finish the operation off pump in order to avoid prolonged hemodynamic instability and/or ischemia. Implementing elective on pump beating as a viable and safe alternative to some challenging OPCABG cases reduces complications and may reduce the need for EC. Our flexible approach to CABG does not compromise a high percentage of off pump cases. Contrary to other published results, this series had a low complication rate associated with ECs.

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