Surgical technique
blood loss, cardioplegia arrest, stenosis
LUNG, BLOOD LOSS, HEART, STENOSIS, CAD
All surgeries were performed by an expert and high-volume surgeon (S.K.F) with experience in more than 10,000 off-pump and 5,000 on-pump surgeries during the past 25 years. General anesthesia was induced and maintained with a fast-track cardiac anesthesia method. Patients were positioned, prepped, and draped in a standard fashion. Median sternotomy was used as the surgical access in all cases. Left internal mammary arteries (LIMA) were harvested in all cases, and saphenous veins were used as other conduits. In both off-pump and on-pump groups, cardiac displacement was achieved by placing two moisturized gauze pads (10 × 10 cm) between the pericardium and the left ventricle. This maneuver elevated and rotated the left ventricle toward the midsternal incision area, bringing the LAD into view. In the off-pump group, The chosen device for coronary artery stabilization was the Medtronic Octopus (Medtronic, Minneapolis, Minn). The target vessel was then opened, and an intracoronary shunt (Medtronic, Minneapolis, Minn) was introduced to prevent blood loss and maintain distal perfusion during the performance of anastomosis. The operative field was visualized using the carbon dioxide surgical blower system. Surgical revascularization was mainly started from LIMA to the left anterior descending artery (LAD) grafting. Following this, the right coronary system was approached, and the circumflex territory was finally revascularized. In patients with left main CAD, LAD, and circumflex arteries were always grafted regardless of the degree of stenosis. All other vessels with significant lesions (> 70%) were identified preoperatively in the angiogram and selected as a target for revascularization. All proximal anastomoses were performed using the side-biting aortic clamp and 6–0 polypropylene sutures. Distal anastomoses (LIMA-LAD and SVGs) were performed using 8–0 and 7–0 polypropylene suture, respectively. Sorin Stockert’s S3 Heart–Lung Machine was used for the conventional CPB for the on-pump group. The standard CPB technique was employed with ascending aortic cannulation and venous drainage via a 2-stage venous cannula within the right atrium with complete clamping of the aorta with cardioplegia arrest.