Cardiac Troponin T Levels in On- and Off-Pump Coronary Artery Bypass Surgery
Background. Conventional coronary artery bypass graft surgery (CCAB) has been associated with greater myocardial injury than off-pump surgery (OPCAB). However, the extent of myocardial injury following CCAB and OPCAB has not been assessed by priority of surgery or the number of diseased vessels. We tested the hypothesis that the additional myocardial injury associated with CCAB compared with OPCAB is sustained when patients are stratified by priority and 2- or 3-vessel disease.
Methods and Results. In this prospective cohort, we measured 24-hour postoperative cardiac troponin T (cTnT) following CCAB and OPCAB surgery to determine if OPCAB results in less perioperative myocardial damage by priority (urgent or elective). We studied 1511 patients who underwent heart surgery in one hospital in northern New England between 2000 and 2004. Surgeons used either CCAB (778 patients) of OPCAB (733 patients). Unpaired t tests were used to test the mean difference in cTnT between CCAB and OPCAB subgroups. Mean cTnT levels were significantly higher in the CCAB group (0.94 ng/mL) than the OPCAB group (0.18 ng/mL) with P < .001; this difference was consistent across urgent and elective surgeries, and patients with both 2- and 3-vessel disease. CCAB patients consistently demonstrated higher cTnT levels. Similar results were evident when stratified by patient characteristics and surgeon.
Conclusions. In summary, higher postoperative cTnT levels are associated with CCAB than with OPCAB, regardless of priority, number of diseased vessels, patient characteristics, or surgeon. OPCAB results in less myocardial injury in patients, whether they present with 2- or 3-vessel disease and whether they undergo urgent or elective cardiac surgery.
Bennetts JS, Baker RA, Ross IK, et al. 2002. Assessment of myocardial injury by troponin T in off-pump coronary artery grafting and conventional coronary artery graft surgery. ANZ J Surg 72:105-9.nBiglioli P, Cannata A, Alamanni F, et al. 2003. Biological effects of off-pump vs. on-pump coronary artery surgery: focus on inflammation, hemostasis and oxidative stress. Eur J Cardiothorac Surg 24:260-9.nCoudrey L. 1998. The troponins. Arch Int Med 158:1173-80.nDybdahl B, Wahba A, Haaverstad R, et al. 2004. On-pump versus off-pump coronary artery bypass grafting: more heat-shock protein 70 is released after on-pump surgery. Eur J Cardiothorac Surg 25:985-92.nGhosh S, Galinanes M. 2003. Protection of the human heart with ischemic preconditioning during cardiac surgery: role of cardiopul-monary bypass. J Thorac Cardiovasc Surg 126:133-42.nGulielmos V, Menschikowski M, Dill H, et al. 2000. Interleukin-1, inter-leukin-6 and myocardial enzyme response after coronary artery bypass grafting - a prospective randomized comparison of the conventional and three minimally invasive surgical techniques. Eur J Cardiothorac Surg 18:594-601.nHernandez F, Clough RA, Klemperer JD, et al. 2000. Off-pump coronary artery bypass grafting: initial experience at one community hospital. Ann Thorac Surg 70:1070-2.nHernandez F, Cohn WE, Baribeau YR, et al. 2001. In-hospital outcomes of off-pump versus on-pump coronary artery bypass procedures: a multicenter experience. Ann Thorac Surg 72:1528-33.nKathiresan S, MacGillivray TE, Lewandrowski K, et al. 2003. Off-pump coronary bypass grafting is associated with less myocardial injury than coronary bypass surgery with cardiopulmonary bypass. Heart Surg Forum 6:E174-8.nKathiresan S, Servoss SJ, Newell JB, et al. 2004. Cardiac troponin T elevation after coronary artery bypass grafting is associated with increased one-year mortality. Am J Cardiol 94:879-81.nKhan NE, De Souza A, Mister R, et al. 2004. A randomized comparison of off-pump and on-pump multivessel coronary-artery bypass surgery. N Engl J Med 350:21-8.nKoh TW, Carr-White GS, DeSouza AC, et al. 1999. Intraoperative cardiac troponin T release and lactate metabolism during coronary artery surgery: comparison of beating heart with conventional coronary artery surgery with cardiopulmonary bypass. Heart (Brit Card Soc) 81:495-500.nKrejca M, Skiba J, Szmagala P, et al. 1999. Cardiac troponin T release during coronary surgery using intermittent cross-clamp with fibrillation, on-pump and off-pump beating heart. Eur J Cardiothorac Surg 16:337-41.nMasuda M, Morita S, Tomita H, et al. 2002. Off-pump CABG attenuates myocardial enzyme leakage but not postoperative brain natriuretic peptide secretion. Ann Thorac Cardiovasc Surg 8:139-44.nMatata BM, Sosnowski AW, Galinanes M. 2000. Off-pump bypass graft operation significantly reduces oxidative stress and inflammation. Ann Thorac Surg 69:785-91.nMazzone A, Gianetti J, Picano E, et al. 2003. Correlation between inflammatory response and markers of neuronal damage in coronary revascularization with and without cardiopulmonary bypass. Perfusion 18:3-8.nMitka M. 2004. Beat goes on in "off-pump" bypass surgery: surgeon experience may be key to best outcome. JAMA 291:1821-2.nNational Heart, Lung, and Blood Institute Coronary Artery Surgery Study. 1981. A multicenter comparison of the effects of randomized medical and surgical treatment of mildly symptomatic patients with coronary artery disease, and a registry of consecutive patients undergoing coronary angiography. Circulation 63:I1-81.nO'Connor GT, Plume SK, Olmstead EM, et al. 1992. Multivariate prediction of in-hospital mortality associated with coronary artery bypass graft surgery. Northern New England Cardiovascular Disease Study Group. Circulation 85:2110-8.nO'Connor GT, Plume SK, Olmstead EM, et al. 1991. A regional prospective study of in-hospital mortality associated with coronary artery bypass grafting. The Northern New England Cardiovascular Disease Study Group. JAMA 266:803-9.nOkubo N, Hatori N, Ochi M, et al. 2003. Comparison of m-RNA expression for inflammatory mediators in leukocytes between on-pump and off-pump coronary artery bypass grafting. Ann Thorac Cardiovasc Surg 9:43-9.nPerrault LP, Menasche P, Peynet J, et al. 1997. On-pump, beating-heart coronary artery operations in high-risk patients: an acceptable trade-off? Ann Thorac Surg 64:1368-73.nSahlman A, Ahonen J, Nemlander A, et al. 2003. Myocardial metabolism on off-pump surgery; a randomized study of 50 cases. Scand Cardiovasc J 37:211-5.nSurgenor SD, O'Connor GT, Lahey SJ, et al. 2001. Predicting the risk of death from heart failure after coronary artery bypass graft surgery. Anesth Analg 92:596-601.nTang AT, Knott J, Nanson J, et al. 2002. A prospective randomized study to evaluate the renoprotective action of beating heart coronary surgery in low risk patients. Eur J Cardiothorac Surg 22:118-23.n
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