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Off-Pump Coronary Artery Bypass Grafting in Very High Risk Acute Coronary Syndromes
Lakshmi Srinivasan, Adam Lea, Lognathen Balacumaraswami.
University Hospital of North Staffordshire NHS Trust, Stoke-on-trent, United Kingdom.

OBJECTIVE: Off-pump coronary artery bypass grafting (OPCABG) is associated with reduced early mortality and morbidity in high risk patients with Euroscore >6 (Lemma et al. J Thorac Cardiovasc Surg.) We present clinical outcomes following OPCABG in a very high risk cohort of patients who had presented with preoperative acute coronary syndromes with or without unstable haemodynamics.
OPCABG was offered to all consecutive patients on an all-comers basis. All patients operated by a single surgeon in a cardiothoracic unit in UK between April 2010 - November 2012 were included. Of the 218 patients who underwent OPCABG, 16 patients had acute coronary syndrome preoperatively with or without stable haemodynamics. The coronary disease pattern was deemed unsuitable for PCI or ischaemia was ongoing despite primary PCI. The average age was 62 (range 42-83) and six were obese (BMI >30). All 16 patients were on intravenous nitrates and/or heparin. IABP was placed (12 out of 16 patients) in the cardiac catheterisation laboratory and the patients were transferred for surgery.
Five out of sixteen patients were operated as urgent, ten were operated as an emergency and one was operated under salvage conditions. Three patients had poor ejection fraction (EF< 30%), one was in cardiogenic shock and three had failed primary PCI, two of the latter had dissected coronary arteries. The patients tolerated OPCABG well
and made an excellent recovery with no mortality or any major adverse cardiac, renal or cerebrovascular events. Only two patients needed inotropic support postoperatively and there were no reoperations.
OPCABG has less incidence of major adverse events in high risk patients in acute settings when a specific high risk strategy is tailored to suit the individual patient haemodynamics.

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