Rapid Recovery After Full Sternotomy Off-Pump Coronary Artery Bypass Grafting in Complex Cases: A Report of 3 Cases

Introduction

The concept of very early discharge after conventional full sternotomy coronary artery bypass grafting (CABG) at 4 or fewer days after surgery, which comes with host of benefits, including lower costs and earlier return to work, is not new [1]. However, the term “rapid discharge”, which indicates discharge at 2 or fewer days after surgery, was coined and put forth for the first time only recently by Ammannaya, while reporting the earliest documented discharge at 36 h after a conventional full sternotomy CABG [2]. However, no such discharges have been documented in patients with complex risk factors, such as solitary kidney with borderline renal function, severe left ventricular dysfunction with adhesive pericarditis requiring concomitant coronary artery endarterectomy (CAE) or emergency CABG.

Here, I present a series of 3 such cases of off-pump coronary artery bypass grafting (OPCAB) in which enhanced recovery after cardiac surgery (ERACS) could be successfully applied, facilitating safe second postoperative day discharges and the successful completion of 12-month follow-up.

Case Reports

CASE 1:

A 51-year-old man who presented with New York Heart Association (NYHA) grade IV angina, ejection fraction (EF) of 45%, underwent coronary angiography, revealing triple-vessel disease, with mid left anterior descending (LAD) artery 100% stenosis, proximal right coronary artery (RCA) 80%, and obtuse marginal 2-artery 100% occlusion. He had a significant past history of undergoing right laparoscopic nephrectomy 6 years prior due to non-functioning right kidney for pyonephrosis secondary to staghorn calculus. His preoperative serum creatinine and blood urea nitrogen levels were 1.70 mg/dL and 84 mg/dL, respectively. He underwent surgery for early OPCAB through full median sternotomy on July 11, 2023. Anesthetic induction was with thiopentone, and maintenance was with isoflurane, and vecuronium and fentanyl as required. Prophylactic antibiotic cefoperozone sulbactum 1.5 g was administered 30 min before incision and just before chest closure. The pedicled left internal mammary artery (LIMA) was harvested extrapleurally, and the saphenous vein was harvested through no-touch open technique. An activated clotting time of 350 s was maintained during grafting. The patient received 2 grafts of LIMA-LAD, and a reversed saphenous venous graft to the distal RCA on a beating heart, without the use of cardiopulmonary bypass. The obtuse marginal-2 caliber was very small and plaqued, with the patient having right-dominant circulation; hence, it was not grafted. The total operative time was 150 min, and intraoperative blood loss was <300 mL. The patient received 300 mg aspirin through nasogastric tube to ensure graft patency. He was shifted to the Intensive Care Unit, without inotropic support, and was extubated after 4 h. After extubation, he received a transdermal patch of tulobuterol 1 mg and continued on intravenous (i.v.) antibiotics every 8 h. Opioid-sparing analgesia was adopted with i.v. paracetamol 1 g every 6 h as the mainstay treatment. He also received i.v. acetylcysteine every 8 h. Oral fluids were started in 2 h in a graded manner, with early removal of nasogastric tube and early initiation of chest physiotherapy and spirometry. Total overnight chest drainage was 300 mL, which turned serous on postoperative day (POD) 1 and was subsequently removed by the evening of POD1, after adequate patient mobilization. He received no blood transfusions. His peak serum creatinine and blood urea nitrogen levels on the morning of POD1 were 1.84 and 105 mg/dL, respectively. Serum creatinine and blood urea nitrogen levels were on the decline, reaching closer to preoperative values, and the patient was discharged on POD2, at 42 h after surgery, as he met all criteria for rapid discharge, as per the author’s previously published checklist (Table 1) [2].

CASE 2:

A 67-year-old man who presented with acute non-ST elevation myocardial infarction on the late evening of July 12, 2023, with CAG, revealing left main plaque with triple-vessel disease, LAD proximal to mid diffuse 90% stenosis, proximal to distal RCA diffuse 80%, and distal left circumflex 60% occlusion, with right dominant circulation. After CAG, following a full loading dose (300 mg) of aspirin and clopidogrel, the patient had hypotension, for which he was on a noradrenaline infusion of 0.06 mcg/kg/min. The decision was taken to undertake emergency CABG in view of ongoing ischemia, with the troponin I level elevated to 21 ng/mL and severe angina, which was not relieved with medications. He underwent surgery for emergency OPCAB through full median sternotomy on the early morning of July 13, 2023 (<12 h after CAG). Intra-aortic balloon pump, although kept on standby, was not needed, as the patient maintained acceptable 90/60 mm hg blood pressure (mean arterial pressure 70) on 0.06 mcg/kg/min noradrenaline, without signs of organ hypoperfusion, such as oliguria. Anesthetic induction was smooth with need for further upward titration of noradrenaline to 0.08 mcg/kg/min. Anesthetic maintenance and prophylactic antibiotics were identical as in case 1. In view of the emergency surgical revascularization in this patient with very high bleeding risks and with borderline hemodynamics, the decision was made to undertake rapid grafting, as he received 2 reversed saphenous venous grafts to the LAD and distal RCA on a beating heart, without the use of cardiopulmonary bypass. Total operative time was 120 min, and intraoperative blood loss was <300 mL. The patient received 300 mg aspirin through a nasogastric tube, to ensure graft patency. He was shifted to the Intensive Care Unit, with inotropic support of noradrenaline 0.04 mcg/ kg/min, and was extubated after 4 h, with inotrope tapered off. Further management was similar to that of case 1. The total overnight chest drainage was 250 mL, which turned serous on POD1. He received 1 unit packed red blood cell transfusion on POD1. After removal of chest drains, the patient was discharged on POD2, at 42 h after surgery, as he met all criteria of the checklist for rapid discharge (Table 1) [2].

CASE 3:

A 48-year-old man presented with NYHA grade III dyspnea, NYHA grade II angina, and very low EF of 20%–25%. CAG revealed distal left main 30% stenosis, 100% stenosis of proximal to mid LAD, and 80% stenosis of proximal to mid RCA. He underwent OPCAB through full median sternotomy on July 29, 2023. After sternotomy, dense adhesive pericarditis was noted (Figure 1). Pericardial adhesions were carefully released anteriorly, inferiorly, and laterally, with partial pericardiectomy. The patient received 2 grafts, LIMA-LAD (after LAD endarterectomy with removal of 5 cm plaque (Figure 2)), and reversed saphenous venous graft to the distal RCA on a beating heart, without the use of cardiopulmonary bypass. Total operative time was 150 min, with blood loss <300 mL. Similar to the previous cases, the patient received 300 mg aspirin through a nasogastric tube. He was shifted to the Intensive Care Unit without inotropic support and was extubated after 4 h. He additionally received once daily acenocoumarol 2 mg to maintain an international normalized ratio (INR) of 2.0. Further management was similar to that of the previous cases. Overnight chest drainage was 200 mL, which turned serous on POD1. He received 1 packed red blood cell transfusion. After removal of chest drains, he was discharged on POD2, 42 h after surgery, as he met all criteria for rapid discharge as per author’s previously published checklist (Table 1) [2].

No special postoperative care or monitoring at home was necessary for any of the 3 patients, who were fully ambulant and feeding normally. Twice-daily phone calls for 3 days and once-daily calls from there on, with questioning of general and overall well-being, was conducted until the patients returned for dressings or drain stitch removal. All 3 patients were clinically well during follow-ups, including at the 1-year follow-up, with significant improvement in EF (45% to 55%, 40% to 55%, and 20%–25% to 45% in cases 1, 2, and 3, respectively), with none needing hospital readmission during the 12-month follow-up period.

Discussion

The incidence of postoperative renal failure is significantly higher in patients with solitary kidney undergoing on-pump cardiac surgery, apart from a substantially increased length of hospital stay [3]. Complications observed in adult patients with solitary kidney undergoing on-pump cardiac surgery include increased risk of renal failure (26% vs 5%), increased length of hospital stay (mean 15.5 vs 8.5 days), and higher blood transfusion requirement, as per the only such study done so far in this subset [3]. As OPCAB has been shown to reduce the risk of acute kidney injury, as compared with on-pump CABG (17.5% vs 20.8%) [4], with improved in-hospital renal outcomes [5], it is therefore logical, although still arguable, that OPCAB would be preferable in a patient with a solitary kidney needing CABG. However, such rapid discharge after CABG (≤2 days) in a patient with a solitary kidney has never been reported. Apart from an off-pump strategy, meticulous intraoperative hemostasis, and zero blood transfusion, avoidance of intraoperative hypotension to prevent renal hypoperfusion and very carefully monitored i.v. fluid administration played a pivotal role in achieving this earliest, successful rapid discharge (at 42 h), reported in medical literature so far. I further propose specific factors to facilitate rapid discharge after CABG in this special subset of patients (Table 2). However, large, sufficiently powered studies are required to confirm the feasibility and success of such a fast-track protocol.

Likewise, there has never been a documented emergency OPCAB done through a full sternotomy reporting such an early discharge as described in this report. I further propose specific factors to facilitate rapid discharge after CABG in this special subset of patients undergoing emergency CABG, who are at greatly increased risks of surgical bleed (Table 3). Large well-powered studies are required in the future to confirm the feasibility and success of such rapid discharge consistently in these high-risk patients. It is to be noted that the author routinely adopts the reported fast-track protocol in all cases of OPCAB, wherever the indications permit, as per his checklist previously published [2]. The author has 15 months of successful follow-up for his first such reported cases.

Concomitant OPCAB and pericardiectomy is reported very rarely in medical literature [6]. Furthermore, there has never been a concomitant CAE and pericardiectomy documented till date. Also, there has been no report of ERACS extended to pericarditis, CAE, or in very low EF (20–25%). Therefore, this is the first case report illustrating the feasibility of ERACS in such a complex scenario, with the earliest reported successful discharge (at 42 h) after OPCAB with concomitant pericardiectomy and CAE in the setting of very low EF of 20% to 25%. CAE facilitates completeness of revascularization and 100% patency with arterial grafts, with excellent outcomes in LAD territory having been reported [7]. The key risk associated with CAE is lack of endothelium, which can lead to activation of the coagulation cascade. However, no standard anticoagulation protocol exists after CAE [8]. Considering the overall safety profile, acenocoumarol was used with a dose to maintain moderate INR of 2.0, as per the institutional protocol, which was well tolerated, with no bleeding complications.

Conclusions

Rapid discharge after CABG is safely achievable even in high-risk circumstances, such as in patients with a solitary kidney with borderline function, with poor left ventricular function, and dense adhesive pericarditis needing CAE, as well as in emergency CABG, with no observed complications. Longer follow up is needed to confirm the safety and durability of these early results.