Risk Factors for Myocardial Injury during Off-Pump Coronary Artery Bypass Grafting
Background: Although off-pump coronary artery bypass grafting (CABG) is now used worldwide for coronary revascularization, the pre- and intraoperative risk factors for myocardial injury associated with the surgical procedure remain to be elucidated. We performed a multivariate analysis to investigate factors that contribute to myocardial injury during off-pump CABG.
Methods: The study population consisted of 22 patients who underwent off-pump CABG without apparent intraoperative complications. Blood samples were obtained before surgery and at 3 and 12 hours after the last anastomosis and serum Troponin T (cTnT) levels were measured to assess myocardial injury. Patient characteristics and factors related to preoperative cardiac function and the intraoperative process were analyzed to determine their correlation with serum cTnT levels, and the Spearman's correlation coefficient (rs) was computed.
Results: Neither age, preoperative cardiac function, time required for anastomosis, the number of grafts, nor the total amount of bleeding were associated with serum cTnT levels. Serum cTnT at 3 and 12 hours after completed anastomosis correlated with the product of mean systolic blood pressure and mean heart rate (double product) during anastomosis. The rs values at 3 and 12 hours were 0.62 (P = .002) and 0.58 (P = .004), respectively. With respect to the serum cTnT level at 12 hours, creatinine clearance (Ccr) had a slight effect on the serum cTnT values.
Conclusions: High blood pressure and an increased heart rate during anastomosis are unfavorable factors for off-pump CABG. However, strict control of the blood pressure and heart rate makes it possible to subject even patients at high-risk to off-pump CABG from the viewpoints of myocardial injury.
Eagle KA, Guyton RA, Davidoff R, et al. 1999. ACC/AHA guidelines for coronary artery bypass graft surgery: Executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (committee to revise the 1991 guidelines for coronary artery bypass graft surgery). Circulation 100:1464-80.nGlantz SA. 2002. Primer of biostatistics, 5th ed. McGraw-Hill, Columbus, OH; 262-82.nHenrikson CA, Howell EE, Bush DE, et al. 2004. Prognostic usefulness of marginal Troponin T elevation. Am J Cardiol 93:275-9.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.nde Denus S, Pharand C, Williamson DR. 2004. Brain natriuretic peptide in the management of heart failure. Chest 125:652-68.nPrifti E, Bonacchi M, Giunti G, et al. 2000. Does on-pump/beating-heart coronary artery bypass grafting offer better outcome in end-stage coronary artery disease patients? J Card Surg 15:403-10.nAl-Ruzzeh S, Asimakopoulos G, Ambler G, et al. 2003. Validation of four different risk stratification systems in patients undergoing off-pump coronary artery bypass surgery: aUK multicentre analysis of 2223 patients. Heart 89:432-5.nKathiresan S, MacGillivray TE, Lewandrowski K, Servoss SJ, Lewandrowski E, Januzzi JL Jr. 2003. Off-pump coronary bypass grafting is associated with less myocardial injury than coronary bypass surgery with cardiopulmonary bypass. Heart Surg Forum 6(6):E174-8.nKurki TS, Häkkinen U, Lauharanta J, Rämö J, Leijala M. 2001. Evaluation of the relationship between preoperative risk score, postoperative and total length of stays and hospital costs in coronary bypass surgery. Eur J Cardiothorac Surg 20:1183-7.nMack MJ, Pfister A, Bachand D, et al. 2004. Comparison of coronary bypass surgery with and without cardiopulmonary bypass in patients with multivessel disease. J Thorac Cardiovasc Surg 127:167-73.nBeauford RB, Goldstein DJ, Sardari FF, et al. 2003. Multivessel off-pump revascularization in octogenarians: early and midterm outcomes. Ann Thorac Surg 76:12-7.nBittner HB, Savitt MA. 2002. Off-pump coronary artery bypass grafting decreases morbidity and mortality in a selected group of high-risk patients. Ann Thorac Surg 74:115-8.nPuskas JD, Williams WH, Duke PG, et al. 2003. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg 125:797-806.nBennetts JS, Baker RA, Ross IK, Knight JL. 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.nBernstein AD, Parsonnet V 2000. Bedside estimation of risk as an aid for decision-making in cardiac surgery. Ann Thorac Surg 69:823-8.nCleveland JC Jr, Shroyer ALW, Chen AY, Peterson E, Grover FL. 2001. Off-pump coronary artery bypass grafting decreases risk-adjusted mortality and morbidity. Ann Thorac Surg 72:1282-9.nRoach GW, Kanchuger M, Mangano CM, et al. 1996. Adverse cerebral outcomes after coronary bypass surgery: multicenter study of perioperative ischemia research group and the ischemia research and education foundation investigators. N Engl J Med 335:1857-63.nvan Dijk D, Nierich AP, Jansen EWL, et al. 2001. Early outcome after off-pump versus on-pump coronary bypass surgery: results from a randomized study. Circulation 102:1761-6.nBonnefoy E, Filley S, Kirkorian G, et al. 1998. Troponin I, Troponin T, or Creatine Kinase-MB to detect perioperative myocardial damage after coronary artery bypass surgery. Chest 114:482-6.n
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