Awake versus combined general and epidural technique for off-pump coronary artery bypass grafting surgery: A retrospective comparative study

Objectives
Our aim was to evaluate the effectiveness of thoracic epidural anesthesia and analgesia in off-pump coronary artery bypass grafting surgery. We examined its validity in patients under combined general/epidural anesthesia and in awake patients receiving epidural anesthesia as a sole anesthetic technique.
Patients and methods
We evaluated 318 patients who underwent off-pump coronary artery bypass graft surgery between January 2008 and September 2009. Group A ( = 242 patients, 76.2%) received combined general/epidural anesthesia and group B ( = 76 patients, 23.8%) received only a thoracic epidural catheter as the sole anesthetic technique without general anesthesia or endotracheal intubation (awake). We compared the intraoperative hemodynamic and respiratory variables, postoperative pain (by Visual Analogue Scale), myocardial infarction, atrial fibrillation, intensive care, and hospital stay. We followed our patients for 1 year, clinically and angiographically, and compared the rate of graft occlusion.
Results
There was no statistical difference in the intraoperative hemodynamic and respiratory variables (mean arterial pressure, heart rate, and partial pressure of arterial carbon dioxide) between the two groups, except for the partial pressure of arterial oxygen, which was higher in group A because of mechanical ventilation. There was no intraoperative mortality or postoperative myocardial infarctions in both groups. There was no statistical difference in the operative time between the two groups, but the patients in group A received a higher number of grafts than those in group B. There was no statistical difference in the postoperative pain scores; the mean pain score was 1.425 ± 0.42 in group A and 1.29 ± 0.3 in group B. The rate of atrial fibrillation was higher in group B (17%) than group A (7.02%) ( = 0.025). The mean intensive care stay and the mean hospital stay were higher (2.77 ± 0.9 and 7.314 ± 2.8 days) in group A than group B (1.269 ± 0.4 and 3.743 ± 1.2 days) ( = 0.0038 and 0.0021, respectively). Follow-up through the first postoperative year with coronary angiography indicated vein graft occlusion in three patients of group A (1.23%) and one patient in group B (1.31%), but this was not statistically significant.
Conclusion
We successfully performed off-bypass coronary revascularization surgery, including multivessel disease, under combined general/epidural anesthesia and in awake patients with thoracic epidural anesthesia as the sole anesthetic technique. Patients who are considered at high risk for general anesthesia and/or prolonged endotracheal intubation were good candidates for the awake technique as a valid alternative.