The Effects of Aortic Clamping Strategy on Myocardial Protection and Early Postoperative Outcomes During Coronary Artery Bypass Grafting Operations
Aortic Clamping Strategy on Coronary Surgery
DOI:
https://doi.org/10.1532/hsf.3475Keywords:
Myocardial Protection, Ischemia-Reperfusion, Coronary Bypass, BiomarkersAbstract
Background: The purpose of the present study was to compare the effects of two different clamping strategies for the construction of the proximal aortocoronary anastomoses on myocardial protection and postoperative outcomes during coronary artery bypass grafting (CABG) operations.
Methods: In this retrospective study, we examined prospectively collected data of patients who underwent CABG for a 3-year period. Two hundred consecutive patients, who were diagnosed with triple vessel coronary artery disease (CAD), were selected and divided into two groups. In Group 1 (single clamp) (N = 100), venoaortic proximal anastomoses were performed using a single aortic cross-clamp, while in Group 2 (double clamp) (N = 100), proximal anastomoses were performed by using an aortic side clamp. Operative and postoperative outcomes of the patients were compared between the two groups. The serum levels of myocardial damage biomarkers, creatine phosphokinase-MB (CPK-MB), and high sensitive Troponin (hsTnI) results were measured preoperatively, intraoperatively, and postoperatively (6, 12, 24, and 48 hours).
Results: Patient demographics and characteristics were similar between the two groups. In Group 1, cross-clamp duration time (65 min versus 49 min; P = .0001) was longer. However, perfusion time (91 min versus 85 min; P = .61) was similar between the two groups. In Group 2, postoperative CK-MB levels were significantly higher intraoperatively
(P = .18), 6 hours (P = .22), 24 hours (P = .001), and 48 hours (P = .001) than in Group 1. HsTnI was only significantly higher in Group 2 versus Group 1 at 24 hours (P = .001) and 48 hours (P = .01) postoperatively. Time of intensive care unit stay, duration of extubation, and length of hospital stay were similar in both groups.
Conclusion: The technique used for proximal anastomosis has a significant effect on perioperative results, especially on myocardial protection.
References
Adam DH, Filsoufi F, Antmann EM. 2004. Medical management of the patient undergoing cardiac surgery. In: Zipes DP, Libby P, Bonow R, Braunwald E, eds. Braunwald’s heart disease: a textbook of cardiovascular medicine. 7th ed. Philadelphia: WB Saunders; p.1993-2019.
Ali M, Moeen M, Paras I, et al. 2020. Cardio-Protective Effects of Multiport Antegrade Cold Blood Cardioplegia Versus Antegrade Cold Blood Cardioplegia in Patients With Left Ventricular Systolic Dysfunction Undergoing Conventional Coronary Artery Bypass Grafting. Cureus. 12(9): e10308.
Angelini GD, Taylor FC, Reeves BC, et al. 2002. Early and midterm outcome after off-pump and on-pump surgery in beating heart against cardioplegic arrest studies (BHACAS 1 and 2): a pooled analysis of two randomized controlled trials. Lancet. 359:1194-9.
Blauth CI. Macroemboli and microemboli during cardiopulmonary bypass. 1995. Ann Thorac Surg. 59:1300–3.
Buckberg CD. 1979. A proposed solution to the cardioplegic controversy. J Thorac Cardiovasc Surg. 7.
Chowdhury UK, Malik V, Yadav R, et al. 2008. Myocardial injury in coronary artery bypass grafting: On-pump versus off-pump comparison by measuring high-sensitivity C-reactive protein, cardiac troponin I, heart-type fatty acid–binding protein, creatine kinase- MB, and myoglobin release. J Thorac Cardiovasc Surg. 135:1110-9.
Crescenzi G, Cedrati V, Landoni G, et al. 2004. Cardiac biomarker release after CABG with different surgical technique. J Cardiothorac Vasc Anesth. 18:34-7.
D’Ascenzo F, Cavallero E, Moretti C, et al. 2012. Remote ischaemic preconditioning in coronary artery bypass surgery: A Meta-analysis. Heart. 98(17):1267-71.
Daniel 3rd WT, Kilgo P, Puskas JD, et al. 2014. Trends in aortic clamp use during coronary artery bypass surgery: effect of aortic clamping strategies on neurologic outcomes." The Journal of thoracic and cardiovascular surgery. J Thorac Cardiovasc Surg. 147(2):652-7.
Elassal AA, Al-Ebrahim K, Al-Radi O, et al. 2020. Myocardial Protection by Blood-Based Del Nido versus St. Thomas Cardioplegia in Cardiac Surgery for Adults and Children. In The Heart Surg Forum. 23(5):E689-E695.
Erdolu B, As AK, Engin M. 2020. The Relationship between the HATCH Score, Neutrophil to Lymphocyte Ratio and Postoperative Atrial Fibrillation After Off-Pump Coronary Artery Bypass Graft Surgery. Heart Surg Forum 23(1);E088-E092.
Hausenloy DJ, Boston-Griffiths E, Yellon DM. 2012. Cardioprotection during cardiac surgery. Cardiovasc Res. 94(2):253–65.
Jelodar G, Zarrabi K, Nazifi S, et al. 2017. Comparison of Serum Myocardial Biomarkers Following Two Different Methods of Venoaortic Connection in Coronary Artery Bypass Grafting: A Randomized Clinical Trial. Zahedan J Res Med Sci. 19(7):e10740.
Jørgensen PH, Nybo M, Jensen MK, et al. 2014. Optimal cut-off value for cardiac troponin I in ruling out type 5 myocardial infarction. Interact Cardiovasc Thorac Surg. 18:544–550.
Khouri SF, Warner KG, Butler M, et al. 1988. The superiority of continuous cold blood cardioplegia in the metabolic protection of the hypertrophied human heart. J Thorac Cardiovasc Surg. 95(3):442-54.
Mills SA. Cerebral injury and cardiac operations. 1993. Ann Thorac Surg. 56:S86 –91.
Pegg TJ, Maunsell Z, Karamitsos TD, et al. 2011. Utility of cardiac biomarkers for the diagnosis of type V myocardial infarction after coronary artery bypass grafting: Insights from serial cardiac MRI. Heart. 97:810–816.
Rahimi K, Banning AP, Cheng AS, et al. 2009. Prognostic value of coronary revascularisation-related myocardial injury: A cardiac magnetic resonance imaging study. Heart. 95:1937–1943.
Ram H, Dwarakanath S, Green AE, et al. 2020. Iatrogenic aortic dissection associated with cardiac surgery: A narrative review. Journal of Cardiothoracic and Vascular Anesthesia. Online ahead of print.
Sanjay OP, Srikrishna SV, Prashanth P, et al. 2003. Antegrade versus antegrade with retrograde delivery of cardioplegic solution inmyocardial revascularisation. A clinical study in patients with triple vessel coronary artery disease. Ann Card Anaesth. 6(2):143– 8.
Scarsini R, Zivelonghi C, Pesarini G, et al. 2016. Repeat revascularization: percutaneous coronary intervention after coronary artery bypass graft surgery. Cardiovascular Revascularization Medicine. 17(4):272-278.
Sirvinskas E, Kinderyte A, Trumbeckaite S, et al. 2015. Effects of sevoflurane vs. propofol on mitochondrial functional activity after ischemia-reperfusion injury and the influence on clinical parameters in patients undergoing CABG surgery with cardiopulmonary bypass. Perfusion. 30:590–595.
Sobral MLP, Santos GG, Santos LAS, et al. 2006. Comparative randomized study of the immediate outcomes of patients with radial arteries proximally anastomosed to the aorta or as a composite graft. Rev Bras Cir Cardiovasc. 21(1):35-41.
Thielmann M, Sharma V, Al-Attar N, et al. 2017. ESC Joint Working Groups on Cardiovascular Surgery and the Cellular Biology of the Heart Position Paper: Peri-operative myocardial injury and infarction in patients undergoing coronary artery bypass graft surgery. Eur Heart J. 38:2392–2411.
Turer AT, Hill JA. 2010. Pathogenesis of myocardial ischemia-reperfusion injury and rationale for therapy. Am J Cardiol. 106(3):360–8.
Ucak HA, Uncu H. 2019. Impact of Coronary Collateral Circulation of Perioperative Myocardial Damage in High-Risk Patients Undergoing Coronary Artery Bypass Grafting Surgery. Heart Surg Forum. 11;22(5):E375-E379.
Zakkar M, Guida G, Suleiman MS, et al. 2015. Cardiopulmonary bypass and oxidative stress. Oxid Med Cell Longev. 2015:189863.
