Deep Pericardial Traction Suture versus Vacuum-Assisted Apical Suction to Expose the Posterior Wall of the Heart in Off-Pump Coronary Artery Bypass: A Prospective, Randomized Study
DOI:
https://doi.org/10.1532/HSF98.20121028Abstract
Background: Displacement of the heart to expose the posterior vessels during off-pump coronary artery bypass (OPCAB) may cause hemodynamic instability. Deep pericardial traction suture (DPTS) and vacuum-assisted apical suction (VAS) with the Starfish positioning device help to provide good exposure without relevant hemodynamic changes. Our aim was to compare these two methods in patients undergoing multivessel OPCAB.
Methods: We prospectively randomized 20 patients undergoing multivessel OPCAB to the use of VAS or DPTS. The Octopus device was used in both groups to stabilize the target vessel. Hemodynamic parameters, including venous oxygen content (SvO2), cardiac index (CI), central venous pressure (CVP), mean arterial pressure (MAP), pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP), were measured before grafting (baseline), after heart positioning, and during performance of peripheral anastomoses.
Results: Perioperative data for the two groups were similar. During exposure of the lateral wall, there were fewer hemodynamic changes in the DPTS group (increase in CVP) than in the VAS group (increases in CVP, PAP, and PCWP); the CVP was significantly higher in the DPTS group (P < .05). During exposure of the posterior wall, significant hemodynamic changes occurred only in the DPTS group (increase in PCWP). Values for all other parameters were similar, including anastomosis time, graft flow, postoperative myocardial enzymes, and inotropic support.
Conclusions: Heart positioning during OPCAB with either VAS or DPTS is a safe and effective maneuver for exposure of coronary arteries. In our study, the use of the VAS device produced less hemodynamic impairment during exposure of the lateral and posterior walls.
References
Abicht JM, Bauer A, Christ F, Vicol C. 2011. A haemodynamic study during OPCAB surgery using a new multi-suction cardiac positioner. Thorac Cardiovasc Surg 59:217-21.nBeckman DJ, Bumb K, Bandy M, Evans M, Romanyk C. 2003. Evaluation of hemodynamics: comparison of vacuum and mechanical stabilization in the beating heart. Heart Surg Forum 6:220-3.nBiancari F, Rainio A, Mosorin M, et al. 2010. Deep pericardial sling versus lateral pericardial sutures in off-pump coronary artery bypass surgery. J Cardiovasc Surg (Torino) 51:273-5.nChang WI, Kim KB, Kim JH, Ham BM, Kim YL. 2004. Hemodynamic changes during posterior vessel off-pump coronary artery bypass: comparison between deep pericardial sutures and vacuum-assisted apical suction device. Ann Thorac Surg 78:2057-62.nChassot PG, van der Linden P, Zaugg M, Mueller XM, Spahn DR. 2004. Off-pump coronary artery bypass surgery: physiology and anaesthetic management. Br J Anaesth 92:400-13.nDullum MK, Resano FG. 2000. Xpose: a new device that provides reproducible and easy access for multivessel beating heart bypass grafting. Heart Surg Forum 3:113-8.nGeorge SJ, Kapetanakis EI, Dhadwal K, et al. 2007. A three-dimensional echocardiographic comparison of a deep pericardial stitch versus an apical suction device for heart positioning during beating heart surgery. Eur J Cardiothorac Surg 32:604-10.nGründeman PF, Borst C, Verlaan CW, Damen S, Mertens S. 2001. Hemodynamic changes with right lateral decubitus body positioning in the tilted porcine heart. Ann Thorac Surg 72:1991-6.nGründeman PF, Borst C, Verlaan CW, Meijburg H, Mouës CM, Jansen EW. 1999. Exposure of circumflex branches in the tilted, beating porcine heart: echocardiographic evidence of right ventricular deformation and the effect of right or left heart bypass. J Thorac Cardiovasc Surg 118:316-23.nGründeman PF, Verlaan CW, van Boven WJ, Borst C. 2004. Ninety-degree anterior cardiac displacement in off-pump coronary artery bypass grafting: the Starfish cardiac positioner preserves stroke volume and arterial pressure. Ann Thorac Surg 78:679-84; discussion 684-5.nGummert JF, Raumanns J, Opfermann UT, et al. 2008. Hemodynamic assessment using apical suction versus pericardial retraction in beating heart surgery. Innovations (Phila) 3:125-13.nGurbuz AT, Hecht ML, Arslan AH. 2007. Intraoperative transesophageal echocardiography modifies strategy in off-pump coronary artery bypass grafting. Ann Thorac Surg 83:1035-40.nMagee MJ, Alexander JH, Hafley G, et al, PREVENT IV Investigators. 2008. Coronary artery bypass graft failure after on-pump and off-pump coronary artery bypass: findings from PREVENT IV. Ann Thorac Surg 85:494-9.nMueller XM, Chassot PG, Zhou J, et al. 2002. Hemodynamics optimization during off-pump coronary artery bypass: the ‘no compression’ technique. Eur J Cardiothorac Surg 22:249-54.nParolari A, Alamanni F, Polvani G, et al. 2005. Meta-analysis of randomized trials comparing off-pump with on-pump coronary artery bypass graft patency. Ann Thorac Surg 80:2121-5.nRicci M, Karamanoukian HL, D'Ancona G, et al. 2000. Exposure and mechanical stabilization in off-pump coronary artery bypass grafting via sternotomy. Ann Thorac Surg 70:1736-40.nShroyer AL, Grover FL, Hattler B, et al, Veterans Affairs Randomized On/Off Bypass (ROOBY) Study Group. 2009. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med 361:1827-37.nUstunsoy H, Kazaz H, Celkan MA, Kayiran C, Hayta R, Bayar E. 2007. Deep pericardial suture vs apical suction for off-pump bypass grafting. Asian Cardiovasc Thorac Ann 15:123-6.n
