Effects of Beating- versus Arrested-Heart Revascularization on Cardiac Autonomic Regulation and Arrhythmias


  • Jurij M. Kalisnik
  • Viktor Avbelj
  • Roman Trobec
  • Daroslav Ivaskovic
  • Gaj Vidmar
  • Giovanni Troise
  • Borut Gersak




Background. Altered autonomic regulation after cardiac operations precipitates cardiac arrhythmias, affects repolarization, and increases the risk of sudden cardiac death. We sought to clarify how the 2 different techniques of coronary artery bypass grafting (CABG), namely conventional CABG using cardiopulmonary bypass (on-pump) and beating-heart CABG without cardiopulmonary bypass (off-pump), affect cardiac autonomic regulation and arrhythmic disturbances postoperatively.

Methods. We included 57 consecutive patients, 28 in the on-pump group and 29 in the off-pump group. The electro-cardiographic recordings were performed on the preoperative day and the fourth, seventh, and twenty-eighth day after operation. Fifteen-minute digital recordings were taken; one channel was used to record electrocardiogram and the other breathing. Detailed analyses of arrhythmia, heart rate, and heart rate variability indices were performed on respective days to assess sympathetic and parasympathetic modulation of the heart and relate it to detected arrhythmic disturbances.

Results. Total power, low-frequency power, which indicates baroreceptor-mediated sympathetic modulation, and high-frequency power, indicating parasympathetic vagal modulation, declined significantly in both groups after CABG (P < .001); however, 7 days after CABG, total and high-frequency power were better preserved in the off-pump group. Mean RR interval was longer in the off-pump group at 7 (P= .006) and 28 days (P= .008) after surgery. The total incidence of arrhythmic events was higher in the on-pump group on the seventh day (P = .017, adjusted odds ratio = 8.6, 95% confidence interval 1.4-80.3).

Conclusions. The results show profound impairment of cardiac autonomic regulation after CABG, showing better preserved cardiac autonomic modulation 7 days after beating-heart revascularization. Evidence suggests that slower restoration of heart rate and increased incidence of arrhythmic events after CABG using cardiopulmonary bypass are the result not only of impaired cardiac autonomic regulation but also of the involvement of additional factors of nonautonomic origin.


Abildstrom SZ, Jensen BT, Agner E, et al. 2003. Heart rate versus heart rate variability in risk prediction after myocardial infarction. J Cardiovasc Electrophysiol14:168-73.nArmour JA. 1999. Myocardial ischemia and the cardiac nervous system. Cardiovasc Res41:41-54.nAronson D, Burger AJ. 2001. Effect of beta-blockade on heart rate variability in decompensated heart failure. Int J Cardiol79:31-9.nBittar MN, Carey JA, Barnard J, et al. 2005. Interleukin 6 G-174C polymorphism influences outcome following coronary revascularization surgery. Heart Surg Forum8:140-5.nBruins P, Velthuis H, Yazdanbakhsh AP, et al. 1997. Activation of the complement system during and after cardiopulmonary bypass surgery. Postsurgery activation involves C-reactive protein and is associated with postoperative arrhythmia. Circulation96:3542-48.nBrown TE, Beightol LA, Koh J, Eckberg DL. 1993. Important influence of respiration on human R-R interval power spectra is largely ignored. J Appl Physiol75:2310-7.nBudeus M, Feindt P, Gams E, Wieneke H, Erbel R, Sack S. 2006. Risk factors of ventricular tachyarrhythmias after coronary artery bypass grafting. Int J Cardiol113:201-8.nCarpeggiani C, L'Abbate A, Landi P, et al. 2004. Early assessment of heart rate variability is predictive of in-hospital death and major complications after acute myocardial infarction. Int J Cardiol96: 361-8.nChung MK. 2000. Cardiac surgery: postoperative arrhythmias. Crit Care Med28:136-44.nCrystal E, Connoly ST, Sleik K, Ginger TJ, Yusuf S. 2002. Interventions on prevention of postoperative atrial fibrillation in patients undergoing heart surgery. A meta analysis. Circulation106:75-80.nDe Carvalho Lima R, de Escobar MA, et al. 2002. How much myocardial revascularization can we do without extracorporeal circulation? Heart Surg Forum5:163-7.nDewey TM, Herbert MA, Prince SL, et al. 2004. Avoidance of cardiopulmonary bypass improves early survival in multivessel coronary artery bypass patients with poor ventricular function. Heart Surg Forum7: 45-50.nEckberg DL. 1997. Sympathovagal balance. A critical appraisal. Circulation96:3224-32.nEdwards FH, Grover FL, Shroyer AL, Schwartz M, Bero J. 1997. The Society of Thoracic Surgeons national cardiac surgery database: current risk assessment. Ann Thorac Surg63:903-8.nFurlan R, Jacob G, Palazzolo L, et al. 2001. Sequential modulation of cardiac autonomic control induced by cardiopulmonary and arterial baroreflex mechanisms. Circulation104:2932-7.nGoldberger JJ, Challapalli S, Tung R, Parker MA, Kadish AH. 2001. Relationship of heart rate variability to parasympathetic effect. Circulation103:1977-83.nHayano J, Sakakibara Y, Yamada M, et al. 1990. Decreased magnitude of heart rate spectral components in coronary artery disease: its relation to angiographic severity. Circulation81:1217-24.nHogue CW, Domitrovich PP, Stein PK, et al. 1998. RR interval dynamics before atrial fibrillation in patients after coronary artery bypass graft surgery. Circulation98:429-34.nHuikuri HV, Yli-Mäyry S, Airaksinen KEJ, Ikäheimo MJ, Linnaluoto MK, Takkunen JT. 1990. Prevalence and prognostic significance of complex ventricular arrhythmias after coronary arterial bypass graft surgery. Int J Cardiol27:333-9.nHuikuri HV, Niemelä MJ, Ojala S, Rantala A, Ikäheimo MJ, Airaksinen J. 1994. Circadian rhythms of frequency domain measures of heart rate variability in healthy subjects and patients with coronary artery disease. Effects of arousal and upright posture. Circulation90: 121-6.nKalisnik JM, Avbelj V, Trobec R, et al. 2006. Assessment of cardiac autonomic regulation and ventricular repolarization after off-pump coronary artery bypass grafting. Heart Surg Forum9:661-7.nKalman JM, Munawar M, Howes LG, et al. 1995. Atrial fibrillation after coronary artery bypass grafting is associated with sympathetic activation. Ann Thorac Surg60:1709-15.nKaul TK, Fields BL, Riggins LS, Wyatt DA, Jones CR. 1998. Ventricular arrhythmia following successful myocardial revascularization: incidence, predictors and prevention. Eur J Cardiothorac Surg13: 629-36.nKoh J, Brown TE, Beightol LA, et al. 1994. Human autonomic rhythms: vagal cardiac mechanisms in tetraplegic subjects. J Physiol474:483-95.nKuo CD, Lai ST, Wang YY, Shih CC, Wang JH. 1999. Sequential changes in heart rate variability after coronary artery bypass grafting. Am J Cardiol83:777-9.nLombardi F, Mäkikallio TH, Myerburg RJ, Huikuri HV. 2001. Sudden cardiac death: role of heart rate variability to identify patients at risk. Review. Cardiovasc Res50:210-7.nMalliani A, Pagani M, Lombardi F, Cerutti S. 1991. Cardiovascular neural regulation explored in the frequency domain. Circulation84:482-92.nNiemela MJ, Airaksinen KEJ, Tahvanainen KUO, Linnaluota MK, Takkunen JT. 1992. Effect of coronary artery bypass grafting on cardiac parasympathetic nervous function. Eur Heart J13:932-5.nRastan AJ, Bittner HB, Gummert JF, et al. 2005. On-pump beating heart versus off-pump coronary artery bypass surgery—evidence of pump-induced myocardial injury. Eur J Cardiothorac Surg27:1116-8.nSalamon T, Michler RE, Knott KM, Brown DA. 2003. Off-pump coronary artery bypass grafting does not decrease the incidence of atrial fibrillation. Ann Thorac Surg75:505-7.nScharf C, Redecker H, Duru F, et al. 2001. Sudden cardiac death after coronary artery grafting is not predicted by signal-averaged ECG. Ann Thorac Surg72:1546-51.nSpecial Report. 1996. Heart rate variability. Standards of measurement, physiological interpretation, and clinical use. Task force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Circulation93:1043-65.nStein KM, Karagounis LA, Markowitz SM, Anderson JL, Lerman LB. 1998. Heart rate changes preceding ventricular ectopy in patients with ventricular tachycardia caused by reentry, triggered activity, and automaticity. Am Heart J136:425-34.nTuinenburg AE, Van Gelder IC, Van Den Berg MP, et al. 2004. Sinus node function after cardiac surgery: is impairment specific for the maze procedure? Int J Cardiol95:101-8.nVerrier RL, Antzelevitch C. 2004. Autonomic aspects of arrhythmogenesis: the enduring and the new. Curr Opin Cardiol19: 2-11.nZaza A, Lombardi F. 2001. Autonomic indexes based on the analysis of heart rate variability: a view from the sinus node. Cardiovasc Res50:434-42.nZipes DP. 2003. Mechanisms of clinical arrhythmias. Pace26:1778-92.n



How to Cite

Kalisnik, J. M., Avbelj, V., Trobec, R., Ivaskovic, D., Vidmar, G., Troise, G., & Gersak, B. (2007). Effects of Beating- versus Arrested-Heart Revascularization on Cardiac Autonomic Regulation and Arrhythmias. The Heart Surgery Forum, 10(4), E279-E287. https://doi.org/10.1532/HSF98.20071055