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J Thorac Cardiovasc Surg 2003;125:1394-1400
© 2003 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Operative techniques in awake coronary artery bypass grafting

From the Department of Thoracic and Cardiovascular Surgery,^a and the Department of Anesthesiology, Intensive Care and Pain Therapy,^b Johann Wolfgang Goethe University, Frankfurt, Germany.

Received for publication May 26, 2002. Revisions requested July 12, 2002; revisions received Aug 28, 2002. Accepted for publication Sept 9, 2002. Address for reprints: Tayfun Aybek, MD, Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University Frankfurt, Theodor Stern Kai 7, 60590 Frankfurt, Germany (E-mail: T.Aybek{at}em.uni-frankfurt.de).

Background: Off-pump coronary artery bypass grafting was implemented to reduce trauma of surgical coronary revascularization by avoiding extracorporeal circulation. High thoracic epidural anesthesia further reduces intraoperative stress and postoperative pain. In addition, this technique even allows awake coronary artery bypass grafting, avoiding the drawbacks of mechanical ventilation and general anesthesia in high-risk patients.
Methods: Thirty-four patients underwent awake coronary artery bypass grafting with left internal thoracic artery to left anterior descending coronary artery by partial lower ministernotomy (n = 20), H-graft technique (n = 2), or rib cage-lifting technique (n = 2). In 9 cases we performed double bypass grafting, and in 1 case we performed triple-vessel coronary artery revascularization through complete median sternotomy. In addition to clinical outcomes, visual analog scale pain scores were recorded on days 1, 2, and 3 after surgery.
Results: Thirty-one patients remained awake throughout the whole procedure. Three patients required secondary intubation because of incomplete analgesia (n = 1) or pneumothorax (n = 2). Procedure time was 90 ± 31 minutes, and recovery room stay was 4.2 ± 0.6 hours. There were no in-hospital deaths or serious postoperative complications. In 1 case a graft occlusion was documented on predischarge angiography. Early postoperative pain was low (visual analog scale score of 30 ± 6).
Conclusion: These data demonstrate the feasibility and safety of various surgical coronary revascularization techniques without general anesthesia. Continuation of thoracic epidural analgesia provides good pain control and fast mobilization postoperatively. Surprisingly, the awake coronary artery bypass grafting procedure was well accepted by the patients.

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