Recuperación de autores

Palma de Mallorca, España (especial para SIIC):
Dados los avances en el tratamiento de la cardiopatía isquémica, el paciente referido para cirugía de revascularización miocárdica es cada vez mayor y con múltiples factores de riesgo asociados. Con la finalidad de reducir la morbilidad asociada con la circulación extracorpórea (CEC) y el clampeo aórtico, se desarrolló la revascularización coronaria con doble arteria mamaria interna sin CEC.
Objetivo: Describir la experiencia de nuestro servicio con esta técnica y sus resultados.
Pacientes y métodos: Desde enero de 1998 hasta diciembre de 2002 se revascularizaron sin CEC, mediante esternotomía media, un total de 743 pacientes, de los cuales 621 eran varones (83.5%), con una edad media de 65.3 años (23-90), siendo el 35.3% mayores de 70 años. Los enfermos presentaban un Euroscore medio de 2.9 ± 2.43 y un Parsonnet 95 medio de 3.4 ± 3.42. Como factores de riesgo preoperatorios destacamos que 41.5% eran fumadores, 29.5% eran diabéticos, 15.9% eran obesos, 14.7% tenían arteriopatía periférica y 8.1% padecían enfermedad pulmonar obstructiva crónica (EPOC). En esta serie, el 51.8% de los pacientes presentaba antecedentes de infarto de miocardio (IAM), estando 95.8% sintomáticos, de los cuales el 66.2% con angina inestable. En la angiografía 25.6% presentaban lesión de tronco común; 50.3% lesión de triple vaso, y 18.1% enfermedad de dos vasos con función ventricular media de 60% ± 13.2 (23-88), siendo en 18.2% de pacientes menor del 50%. En la mayoría de los pacientes ambas arterias mamarias fueron disecadas con técnica de “esqueletización” para preservar la vascularización esternal y anastomosadas como injerto en “Y” o “T” para alcanzar todos los territorios lesionados mediante el uso de diferentes “estabilizadores epicárdicos”. La permeabilidad de las anastomosis se evaluó mediante Doppler intraoperatorio y en los 31 primeros casos de revascularización sobre cara lateral, además se realizó angiografía de control.
Resultados: Se realizaron un total de 2 028 anastomosis distales, siendo la media de 2.7 (1-5) por paciente, recibiendo 3 o más puentes el 62% de los enfermos. En más del 98% de los casos no se realizó ninguna anastomosis proximal evitando así cualquier tipo de clampeo aórtico. La mayoría de los pacientes fueron extubados en quirófano o a las pocas horas de la intervención. En cuanto a la morbilidad quirúrgica, 40 (5.4%) pacientes presentaron fibrilación auricular posoperatoria, 24 (3.2%) IAM perioperatorio, 7 (0.9%) mediastinitis, 7 (0.9%) reoperación por sangrado y 3 (0.4%) accidente vascular cerebral permanente (ACV). La mortalidad hospitalaria fue de 3.2%, la estancia media posoperatoria fue de 6.9 ± 5.3 días, de los cuales 2.1 ± 2.9 fueron en cuidados intensivos.

Rubén Fernández Tarrio *
Referencias bibliográficas
1. Cameron A, Davis KB, Green GE. Coronary bypass surgery with internal-mammary-artery grafts. Effects on survival over a 15-year period. N Engl J Med 1996;334:216-9. 2. Cosgrove DM, Lytle BW, Loop FD et al. Does bilateral internal mammary artery grafting increase surgical risk? Journal of Thoracic and Cardiovascular Surgery 1988;95:850-6. 3. Fiore AC, Naunheim KS, Dean P et al. Results of internal thoracic artery grafting over 15 years: single versus double grafts. Annals of Thoracic Surgery 1990;49:202-9. 4. Morris JJ, Smith LR, Glower DD et al. Clinical evaluation of single versus multiple mammary artery bypass. Circulation 1990;82(Suppl 4):IV-214-23. 5. Schmidt SE, Jones JW, Thornby JI, Miller C, Beall AC. Improved survival with multiple left-sided bilateral internal thoracic artery grafts. Ann Thorac Surg 1997;64:9-15. 6. Pick AW, OrszulaK TA, Anderson BJ, Schaff HV. Single versus bilateral internal Mammary artery grafts: 10-year outcome analysis. Ann Thorac Surg 1997;64:599-605. 7. Buxton BF, Komeda M, Fuller JA, Gordon I. Bilateral Internal Thoracic Artery grafting may improve outcome of coronary artery surgery. Risk-adjusted survival. Circulation 1998;98:II-1-II-6. 8. Lytle BW, Blackstone, Loop FD et al. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg 1999;117:855-72. 9. Sauvage LR, Wu H, Kowalsky TE. Healing basis and surgical techniques for complete revascularization of the left ventricle using only the internal mammary arteries. Ann Thorac Surg 1986;42:449-465. 10. Tector AJ, Kress DC, Downey FX, Schmahl TM. Complete revascularization with internal thoracic artery grafts. Sem Thorac Cardiovasc Surg 1996;8:29-41. 11. Tector AJ, Amundsen S, Schmahl TM, Kress DC, Downey FX. Total revascularization with T-graft. Ann Thorac Surg 1994;57:33-39. 12. Benetti FJ, Naselli G, Wood M, Geffner L. Direct myocardial revascularization without extracorporeal circulation. Experience in 700 patients. Chest 1991;100:312-316. 13. Buffolo E, Silva de Andrade JC, Rodrigues Branco JN, Teles CA, Aguiar LF, Gomes WJ. Coronary artery bypass surgery without cardiopulmonary bypass. Ann Thorac Surg 1996;61:63-6. 14. Odell JA. Coronary artery bypass grafting without cardiopulmonary bypass. Annals of Thoracic Surgery 1996;62:623. 15. Shennib H, Lee AGL, Akin J. Coronary artery bypass grafting on the beating heart. Annals of Thoracic Surgery 1997;63:988-92. 16. Borst C, Jansen EWL, Tulleken CAF et al. Coronary artery bypass grafting without cardiopulmonary bypass and without interruption of native coronary flow using a novel anastomosis site restraining device ("Octopus"). Journal of the American College of Cardiology 1996;27:1356-64. 17. Jansen EW, Borst C, Lahpor JR et al. Coronary artery bypass grafting without cardiopulmonary bypass using the octopus method: results in the first one hundred patients. J Thorac Cardiovasc Surg 1998;116:60-7. 18. Calafiore AM, Teodori G, Di Giammarco G et al. Multiple arterial conduits without cardiopulmonary bypass: early angiographic results. Ann Thorac Surg 1999;67:450-6. 19. Cartier R, Hébert Y, Blain R, Tremblay N, Desjardins J, Leclerc Y. Triple coronary artery revascularization on the stabilized beating heart. Can J Surg 1998;41:283-288 20. Gundry SR, Razzouk AJ, Bailey LL. Coronary artery bypass with and without the heart-lung machine: a case matched 6 year follow-up. Circulation 1996;94(Suppl 1):I-293. 21. Herrera JM, Cuenca J, Campos V, Rodriguez F, Valle JV, Juffé A. Cirugía Coronaria sin circulación extracorpórea: 5 años de experiencia. Rev Esp Cardiol 1998;51(2):136-140. 22. De Jesus RA, Acland RD. Anatomic study of the collateral blood supply of the sternum. Ann Thorac Surg 1995;59:163-8. 23. Parish MA, Asai T, Grossi EA et al. The effects of different techniques of internal mammary artery harvesting on sternal blood flow. J Thorac Cardiovasc Surg 1992;104:1303-7. 24. Choi JB, Lee Sy. Skeletonized and pedicle internal thoracic artery grafts: effect on free flow during bypass. Ann Thorac Surg 1996;61:909-13. 25. Cunningham JM, Gharavi MA, Fardin R, Meek RA. Considerations in the skeletonization technique of internal thoracic artery dissection. Ann Thorac Surg 1992;54:947-51. 26. Galbut DL, Traad EA, Dorman MJ et al. Seventeen-years experience with bilateral internal mammary artery grafts. Ann Thorac Surg 1990;49:195-201. 27. Calafiore AM, Vitolla G, Iaco AL et al. Bilateral internal mammary artery grafting: midterm results of pedicle versus skeletonized conduits. Ann Thorac Surg 1999;67:1637-42. 28. Gurevitch J, Paz J, Shapira I et al. Routine use of bilateral skeletonized internal mammary arteries for myocardial revascularization. Ann Thorac Surg 1999;68:406-12. 29. Baumgartner FJ, Gheissari A, Capouya ER, Panagiotides GP, Katouzian A, Yokoyama T. Technical aspects of total revascularization in off-pump coronary bypass via sternotomy approach. Ann Thorac Surg 1999;67:1653-8. 30. Cartier R, Blain R. Off-pump revascularization of the circumflex artery: technical aspect and short-term results. Ann Thorac Surg 1999;68:94-9. 31. Grundeman PF, Borst C, van Herwaarden JA, Mansvelt Beck HJ, Jansen EW. Hemodynamic changes during displacement of the beating heart by the Utrecht Octopus method. Ann Thorac Surg 1997;63:S88-S92. 32. Do QB, Cartier R. Hemodynamic changes during beating heart surgery. Can J Cardiol 1998;14:127. 33. Bach RG, Kern MJ, Donohue TJ, Aguirre FV, Caracciolo EA. Comparison of phasic blood flow velocity characteristics of arterial and venous coronary artery bypass conduits. Circulation 1993;88(part 2):133-40. 34. Crowley JJ, Shapiro LM. Noninvasive assessment of left internal mammary artery graft patency using transthoracic echocardiography. Circulation 1995;92:25-30. 35. Takagi T, Yoshikawa J, Yoshida K, Akasaka T. Noninvasive assessment of left internal mammary graft patency using duplex doppler echocardiography from supraclavicular fossa. J Am Coll Cardiol 1993;22:1647-52. 36. Mariani MA, Gu J, Boonstra PW, Grandjean JG, van Oeveren W, Ebels T. Procoagulant activity after off-pump coronary operation: Is the current anticoagulation adequate?. Ann Thorac Surg 1999;67:1370-5. 37. Cuenca JJ, Herrera JM, Rodríguez-Delgadillo MA et al. Revascularización miocárdica arterial completa con ambas arterias mamarias sin circulación extracorpórea. Rev Esp Cardiol 2000; 53:632-641. 38. Lytle BW, Loop FD, Cosgrove DM et al. Long-term (5-12 years) serial studies of internal mammary artery and saphenous vein coronary bypass grafts. J Thorac Cardiovasc Surg 1985;89:248-58. 39. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. New England Journal of Medicine 1986;314:1-6. 40. Grossi EA, Esposito R, Harris LJ et al. Sternal wound infections and use of internal mammary artery grafts. Journal of Thoracic and Cardiovascular Surgery 1991;102:342-7. 41. He GW, Ryan WH, Acuff TE et al. Risk factors for operative mortality and sternal wound infection in bilateral internal mammary artery grafting. Journal of Thoracic and Cardiovascular Surgery 1994;107:196-202. 42. Kouchoukos NT, Wareing TH, Murphy SF, Pelate C, Marshall WG Jr. Risks of bilateral internal mammary artery bypass grafting. Annals of Thoracic Surgery 1990;49:210-9. 43. Calafiore AM, Michele Di Mauro, Giovanni Teodori et al. Impact of aortic manipulation on incidence of cerebrovascular accidents after surgical myocardial revascularization. Ann Thorac Surg 2002;73:1387-1393. 44. Van Dijk D, Nierich AP, Jansen EW et al. Early outcome after off-pump versus on-pump coronary bypass surgery: results from a randomized study. Circulation 2001 Oct 9;104(15):1761-6. 45. Angelini GD, Taylor FC, Reeves BC, Ascione R. Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomized controlled trials. Lancet 2002 Apr 6;359(9313):1194-9. 46. Nathoe HM, Van Dijk D, Jansen EW et al. A comparison of on-pump and off-pump coronary bypass surgery in low-risk patients. N Engl J Med 2003 Jan 30;348(5):394-402. 47. Ascione R, Clinton T Lloyd, Malcolm J Underwood, Attilio A Lotto, Antonis A Pitsis, Gianni D Angelini. Inflammatory response after coronary revascularization with or without cardiopulmonary bypass. Ann Thorac Surg 2000;69:1198-1204. 48. Schulze C, Conrad N, Schutz A et al. Reduced expression of systemic proinflammatory cytokines after off-pump versus conventional coronary artery bypass grafting. Thorac Cardiovasc Surg 2000 Dec;48(6):364-9. 49. Martin Czerny, Harald Baumer, Juliane Kilo et al. Inflammatory response and myocardial injury following coronary artery bypass grafting with or without cardiopulmonary bypass. Eur J Cardiothorac Surg 2000;17:737-742. 50. Anderson R, Hansson L, Vaage J. Release of S100B during coronary artery bypass grafting is reduced by off-pump surgery. Ann Thorac Surg 1999;67:1721-5. 51. Ascione R, Lloyd C, Undewood M, Gomes W, Angelini G. On-pump versus Off-pump coronary revascularization: evaluation of renal function. Ann Thorac Surg 1999;68:493-8. 52. Ascione R, Clinton T Lloyd, Malcom J Underwood, Walter J Gomes, Gianni D Angelini. On-pump versus off-pump coronary revascularization: evaluation of renal function. Ann Thorac Surg 1999;68:93-498. 53. Engelman RM, Pleet AB, Rousou JA et al. Influence of cardiopulmonary bypass perfusion temperature on neurological and hematological function after coronary artery bypass grafting. Ann Thorac Surg 1999;67:1547-56. 54. Selnes OA, Goldsborough MA, Borowicz LM, Enger Ch, Quaskey SA, Mckhann GM. Determinants of cognitive change after coronary artery bypass surgery: a multifactorial problem. Ann Thorac Surg 1999;67:1669-76. 55. Gaudino M, Glieca F, Alessandrini F et al. Individualized surgical strategy for the reduction of stroke risk in patients undergoing coronary artery bypass grafting. Ann Thorac Surg 1999;67:1246-53. 56. Van Dijk D, Jansen EW, Hijman R et al. Cognitive outcome after off-pump and on-pump coronary artery bypass graft surgery: a randomized trial. JAMA 2002 Mar 20;287(11):1405-12. 57. Ascione R, Massimo Caputo, Giliola Calori, Clinton T Lloyd, Malcom J Underwood, Gianni D Angelini. Predictors of Atrial Fibrillation After Conventional and Beating Heart Coronary Surgery: A Prospective, Randomized Study. Circulation Sep 2000;102:1530-1535. 58. Bouchard D, Cartier R. Off-pump revascularization of multivessel coronary artery disease has a decreased myocardial infarction rate. Eur J Cardiothorac Surg 1998;14:S20-S24. 59. Theodore C Koutlas, Joseph R Elbeery, J Mark Williams et al. Myocardial revascularization in the elderly using beating heart coronary artery bypass surgery. Ann Thorac Surg 2000;69:1042-1047. 60. Kit V Arom, Thomas F Flavin, Robert W Emery et al. Safety and efficacy of off-pump coronary artery bypass grafting. Ann Thorac Surg 2000;69:704-710. 61. Sharif Al-Ruzzeh, Koki Nakamura, Thanos Athanasiou et al. Does off-pump coronary artery bypass (OPCAB) surgery improve the outcome in high-risk patients?: a comparative study of 1398 high-risk patients. Eur J Cardiothorac Surg 2003;23:50-55. 62. Hani Shennib, Munemoto Endo, Osama Benhamed, Jean F Morin. Surgical revascularization in patients with poor left ventricular function: on- or off-pump?. Ann Thorac Surg 2002;74:1344S-1347S. 63. Moshkovitz Y, Sternik L, Paz Y. Primary coronary artery bypass grafting without cardiopulmonary bypass in impaired left ventricular function. Ann Thorac Surg 1997;63:S44-S47. 64. Bergsland J, Hasnan S, Lewin AN, Bhayana J, Lajos TZ, Salerno TA. Coronary artery bypass grafting without cardiopulmonary bypass - An attractive alternative in high risk patients. Eur J of Cardiothoracic Surg 1997;11:876-80. 65. Joseph C Cleveland Jr, A Laurie W Shroyer, Anita Y Chen, Eric Peterson, Frederick L Grover. Off-pump coronary artery bypass grafting decreases risk-adjusted mortality and morbidity. Ann Thorac Surg 2001;72:1282-1289. 66. Calafiore AM, Giovanni Scipioni, Giovanni Teodori et al. Day 0 intensive care unit discharge — risk or benefit for the patient who undergoes myocardial revascularization?. Eur J Cardiothorac Surg 2002;21:377-384.



Para comunicarse con Rubén Fernández Tarrio mencionar a SIIC como referencia: Barranco 14, 1c, 07015, Cas Catala, Calvia, Illes Balears, España Fono: 656631931 rutarrio@yahoo.es