Applicability of noncardioplegic coronary bypass to high-risk patients. Selection of patients, technique, and clinical experience in 3000 patients.

Although some surgeons still prefer noncardioplegic coronary bypass, most surgeons are skeptical of its suitability for high-risk patients. We analyzed the first 3000 patients who had primary coronary bypass without cardioplegia since our program's inception. Patients with reoperations, valve operations, or carotid endarterectomies were excluded. Multivariate predictors of operative death included age, sex, left ventricular dysfunction, preoperative intraaortic balloon pumping, and urgency of operation. Eight hundred seventy-nine patients (29%) were more than 70 years of age; 795 (27%) were female; 290 (9.7%) had an ejection fraction less than 0.30, and another 77 (2.6%) had left ventricular aneurysms; 196 (6.5%) had an acute myocardial infarction, and another 397 (13%) had a myocardial infarction less than 1 week preoperatively; 917 (31%) had rest pain in the hospital (preinfarction angina). Only 790 (26%) had elective operations. The overall operative mortality rate was 1.47% (44/3000): The mortality rate for elective operations was 0.5% (4/790); urgent 1.7% (28/1687); emergency 2.3% (12/523). In patients with an ejection fraction less than 0.30 the mortality rate was 6.2% (18/290); with age more than 70 years, it was 3.9% (34 of 879); with acute myocardial infarction it was 3.1% (6/196); and with left ventricular aneurysmectomy it was 1.3% (1/77). Inotropic support after leaving the operating room was needed in 6.6% (199 patients), and 1% (30 patients) required new intraaortic balloon pumping postoperatively (two of these 30 patients died). These results provide reassurance that noncardioplegic coronary artery bypass grafting provides excellent myocardial protection and operating conditions for primary coronary bypass and is particularly suitable for high-risk patients.