COMPARATIVE ANALYSIS OF CORONARY ARTERY BYPASS GRAFTING ON A BEATING HEART USING THE HEARTSTRING DEVICE AND THE NO-TOUCH AORTA TECHNIQUE: SINGLE-CENTER EXPERIENCE

Highlights

• Coronary artery bypass grafting (CABG) on a functioning heart using a Heartstring device and a non-aortic touch technique demonstrates comparable results in postoperative complications, including the incidence of strokes, perioperative myocardial infarction, acute kidney injury, and hospital mortality.
• The use of the Heartstring device is associated with a longer duration of surgery and a more frequent need for hemotransfusion, which may be due to a higher revascularization index in this group.
• Both techniques are safe and effective, and the choice of approach should be based on the individual characteristics of the patient, the anatomy of the coronary arteries and the technical capabilities of the surgical team.

Abstract

Aim. To compare the immediate outcomes of off-pump coronary artery bypass grafting (CABG) using the Heartstring device and the no-touch aorta technique.

Methods. This retrospective study included data from 2 550 patients who underwent off-pump CABG using either the Heartstring device or the no-touch aorta technique at the Federal Center for Cardiovascular Surgery (Astrakhan, Russia) between April 2009 and December 2022. Inclusion criteria: age ≥ 18 years, off-pump CABG using the Heartstring device or the no-touch aorta technique. Exclusion criteria: conversion to on-pump CABG, combined procedures with carotid artery surgery, minimally invasive access, or use of a side clamp. After propensity score matching (nearest neighbor method, 1:1), two comparable groups were formed: the Heartstring group (n = 742) and the no-touch aorta group (n = 742). Outcomes assessed included perioperative myocardial infarction, stroke, acute kidney injury, wound infection, postoperative atrial fibrillation, re-exploration for bleeding, blood transfusions, and in-hospital mortality.

Results. The median age of patients was 61 years (56–65 years; p = 0.296). The proportion of males was 76.1% in the Heartstring group and 83.4% in the no-touch aorta group (p < 0.001). The incidence of atrial fibrillation was 8.2% vs. 11.2% (p = 0.054), history of stroke was 8.6% vs. 7.3% (p = 0.337), and prior percutaneous coronary intervention was 7.8% vs. 8% (p = 0.923), respectively. The median left ventricular ejection fraction was 55% (50–59%) in both groups (p = 0.175). Operative time was longer in the Heartstring group (155 (130–180) minutes vs. 140 (110–170) minutes; p < 0.001), likely due to a higher revascularization index (3 (2–4) vs. 2 (1–3); p < 0.001). Bilateral internal mammary artery grafting and complete arterial revascularization were more frequent in the no-touch aorta group (29.9% vs. 3.1%; p < 0.001 and 68.6% vs. 2%; p < 0.001, respectively). Postoperative complications and in-hospital mortality did not differ significantly between the groups, except for a higher rate of blood transfusions in the Heartstring group (23.2% vs. 15.6%; p < 0.001). The incidence of perioperative myocardial infarction was 1.5% vs. 0.5% (p = 0.117), stroke was 0.7% vs. 0.8% (p = 1.0), acute kidney injury was 1.5% vs. 0.8% (p = 0.329), wound infection was 1.6% vs. 0.5% (p = 0.07), postoperative atrial fibrillation was 10.8% vs. 9.8% (p = 0.377), and re-exploration for bleeding was 0.7% vs. 1.2% (p = 0.422). In-hospital mortality was 0.5% vs. 1.1% (p = 0.386).

Conclusions. Both techniques demonstrated comparable results in terms of postoperative complications and in-hospital mortality. The use of the Heartstring device was associated with longer operative times and a higher need for blood transfusions, likely due to a higher revascularization index.

1. Neumann F.-J., Sousa-Uva M., Ahlsson A., Alfonso F., Banning A.P., Benedetto U., et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019;40:87–165. https://doi.org/10.1093/eurheartj/ehy394.

2. Feldman T.E., Brand M. Van Den, Bass E.J., Dyck N. Van, Leadley K., Dawkins K.D., et al. new england journal 2009:961–72.

3. Goel S.S., Shishehbor M.H. Strategies for multivessel revascularization in patients with diabetes. Cardiol Rev 2013;29:2375–84. https://doi.org/10.1056/nejmoa1211585.

4. Mohr F.W., Morice M.-C., Kappetein A.P., Feldman T.E., Ståhle E., Colombo A., et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 2013;381:629–38. https://doi.org/https://doi.org/10.1016/S0140-6736(13)60141-5.

5. Puskas J.D., Winston A.D., Wright C.E., Gott J.P., Brown W.M. 3rd, Craver J.M., et al. Stroke after coronary artery operation: incidence, correlates, outcome, and cost. Ann Thorac Surg 2000;69:1053–6. https://doi.org/10.1016/s0003-4975(99)01569-6.

6. Vallely M.P., Yan T.D., Edelman J.J.B., Hayman M., Brereton R.J.L., Ross D.E. Anaortic, Total-arterial, Off-pump Coronary Artery Bypass Surgery: How To Do It. Hear Lung Circ 2010;19:555–60. https://doi.org/https://doi.org/10.1016/j.hlc.2010.04.078.

7. Ramponi F., Seco M., Brereton R.J.L., Gaudino M.F.L., Puskas J.D., Calafiore A.M., et al. Toward stroke-free coronary surgery: The role of the anaortic off-pump bypass technique. J Card Surg 2021;36:1499–510. https://doi.org/10.1111/jocs.15372.

8. Edelman J.J., Reddel C.J., Kritharides L., Bannon P.G., Fraser J.F., Curnow J.L., et al. Natural history of hypercoagulability in patients undergoing coronary revascularization and effect of preoperative myocardial infarction. J Thorac Cardiovasc Surg 2014;148:536–43. https://doi.org/https://doi.org/10.1016/j.jtcvs.2013.10.028.

9. Cooper E.A., Edelman J.J.B, Black D., Brereton R.J., Ross D.E., Bannon P.G., et al. Anaortic Off-Pump Coronary Artery Bypass Grafting in the Elderly and Very Elderly. Hear Lung Circ 2013;22:989–95. https://doi.org/https://doi.org/10.1016/j.hlc.2013.05.650.

10. Deutsch M.-A., Zittermann A., Renner A., Schramm R., Götte J., Börgermann J., et al. Risk-adjusted analysis of long-term outcomes after on- versus off-pump coronary artery bypass grafting. Interact Cardiovasc Thorac Surg 2021;33:857–65. https://doi.org/10.1093/icvts/ivab179.

11. Chernov I.I., Enginoev S.T., Kondrat’ev D.A., Ziankou A.A., Ekimov S.S., Motreva A.P., Magomedov G.M., Tsaroev B.S., Tarasov D.G., Komarov R.N. Long-term results of the off-pump coronary artery bypass. Clinical and Experimental Surgery. Petrovsky Journal. 2020; 8 (4): 49–54. DOI: https://doi.org/10.33029/2308-1198-2020-8-4-49-54 (in Russ).

12. Amano Yoshiyuki, Maekawa, Atsuo, Yamana, Koji; Akita, Kiyotoshi; Matsuhashi, Kazuki; Niwa, Wakana; Takagi, Yasushi KT. Outcomes of 881 Consecutive Coronary Artery Bypass Graft Patients Using Heartstring Device. Thorac Cardiovasc Surg 2024. https://doi.org/10.1055/s-0044-1786986.

13. Moss E., Puskas J.D., Thourani V.H., Kilgo P., Chen E.P., Leshnower B.G., et al. Avoiding aortic clamping during coronary artery bypass grafting reduces postoperative stroke. J Thorac Cardiovasc Surg 2015;149:175–80. https://doi.org/10.1016/j.jtcvs.2014.09.011.

14. Manabe S., Fukui T., Miyajima K., Watanabe Y., Matsuyama S., Shimokawa T., et al. Impact of proximal anastomosis procedures on stroke in off-pump coronary artery bypass grafting. J Card Surg 2009;24:644–9. https://doi.org/10.1111/j.1540-8191.2009.00911.x.

15. Seco M., Edelman J.J.B., Boxtel B. Van, Forrest P., Byrom M.J., Wilson M.K., et al. Neurologic Injury and Protection in Adult Cardiac and Aortic Surgery. J Cardiothorac Vasc Anesth 2015;29:185–95. https://doi.org/https://doi.org/10.1053/j.jvca.2014.07.026.

16. Edelman J.J., Yan T.D., Bannon P.G., Wilson M.K., Vallely M.P. Coronary Artery Bypass Grafting With and Without Manipulation of the Ascending Aorta – A Meta-Analysis. Hear Lung Circ 2011;20:318–24. https://doi.org/https://doi.org/10.1016/j.hlc.2011.02.003.

17. Pawliszak W., Kowalewski M., Raffa G.M., Malvindi P.G., Kowalkowska M.E., Szwed K.A., et al. Cerebrovascular events after no-touch off-pump coronary artery bypass grafting, conventional side-clamp off-pump coronary artery bypass, and proximal anastomotic devices: A meta-analysis. J Am Heart Assoc 2016;5:1–13. https://doi.org/10.1161/JAHA.115.002802.

18. Misfeld M., Brereton R.J.L., Sweetman E.A., Doig G.S. Neurologic complications after off-pump coronary artery bypass grafting with and without aortic manipulation: meta-analysis of 11,398 cases from 8 studies. J Thorac Cardiovasc Surg 2011;142:e11-7. https://doi.org/10.1016/j.jtcvs.2010.11.034.

19. Zhao D.F., Edelman J.J., Seco M., Bannon P.G., Wilson M.K., Byrom M.J., et al. Coronary Artery Bypass Grafting With and Without Manipulation of the Ascending Aorta: A Network Meta-Analysis. J Am Coll Cardiol 2017;69:924–36. https://doi.org/10.1016/j.jacc.2016.11.071.

20. Torregrossa G., Amabile A., Williams E.E., Fonceva A., Hosseinian L., Balkhy H.H. Multi-arterial and total-arterial coronary revascularization: Past, present, and future perspective. J Card Surg 2020;35:1072–81. https://doi.org/10.1111/jocs.14537.