Beating Heart Revascularization with Minimal Extracorporeal Circulation in Patients with a Poor Ejection Fraction

Authors

  • Thierry A. Folliguet
  • François Philippe
  • Fabrice Larrazet
  • Alain Dibie
  • Daniel Czitrom
  • Emmanuel Le Bret
  • Jean Bachet
  • François Laborde

DOI:

https://doi.org/10.1532/hsf.992

Abstract

Background: Coronary artery bypass grafting with cardioplegia in patients with a low ejection fraction carries a risk of myocardial ischemia. Beating heart surgery is associated with hemodynamic changes when the heart is manipulated. We assessed an alternative: minimal extracorporeal circulation for coronary artery bypass grafting on a beating heart in patients with a poor ejection fraction.

Methods: From January 2000 to January 2002, 50 patients with an ejection fraction of less than 35%, who represented 10% of all patients undergoing coronary artery procedures, underwent revascularization on a beating heart with assistance. We used a closed cardiopulmonary bypass system with a centrifugal pump without reservoir, and the surgical strategy was modified to avoid aortic cross-clamping and to decrease bypass time.

Results: The main preoperative characteristics were: age (mean ± SD) of 64 ± 11.2 years (range, 41-87 years), 35 male patients (70%), mean left ejection fraction of 24.8% ± 11.2%, and a mean EuroSCORE of 5.8 ± 2.7. Revascularizations of 146 distal anastomoses (2.9 ± 0.7 grafts/patient) were completed. Twelve percent were double bypass, 86% were triple bypasses, and 2% were quadruple bypasses; the mean bypass time was 64.2 ± 26.2 minutes. The mean graft number was 2.9, and the hospital mortality was 2%. Perioperative hematocrit levels were 30.1%, and 26% of patients received transfusions. Postoperative data showed a median extubation time of 9 hours, a median intensive care unit stay of 48 hours, and a hospital stay of 8 ± 2 days. Postoperative complications included inotropic support (14%), cerebrovascular events (2%), reoperation for homeostasis (4%), delayed sternal closure (2%), and mediastinitis (2%). Peak troponin Ic level remained a low 2.4 ± 1.9 3g/mL. Follow-up at 6 months was complete with 1 late mortality and with a mean ejection fraction of 30.5% ± 10.8% for the survivors. Conclusions: Coronary revascularization on a beating heart with extracorporeal assistance can be done in patients with a low ejection fraction. It avoids the myocardial injury associated with aortic cross-clamping and allows safe and complete coronary revascularization.

References

Cartier R, Brann S, Dagenais F, Martineau R, Couturier A. 2000. Systematic off-pump coronary artery revascularization in multivessel disease: experience of three hundred cases. J Thorac Cardiovasc Surg 119:221-9.nGrover FL, Johnson RR, Shroyer AL, Marshall G, Hammermeister KE. 1994. The Veterans Affairs Continuous Improvement in Cardiac Surgery Study. Ann Thorac Surg 58:1845-51.nGründeman PF, Borst C, van Herwaaden JA, Mansvelt Beck HJ, Jansen EW. 1997. Hemodynamic changes during displacement of the beating heart by the Utrecht Octopus method. Ann Thorac Surg 63:S88-92.nGründeman PF, Borst C, van Herwaarden JA, Verlaan CW, Jansen EW. 1998. Vertical displacement of the beating heart by the Octopus tissue stabilizer: influence on coronary flow. Ann Thorac Surg 65:1348-52.nGundry SR, Romano MA, Shattuck OH, Razzouk AJ, Bailey LL. 1998. Seven-year follow-up of coronary artery bypasses performed with and without cardiopulmonary bypass. J Thorac Cardiovasc Surg 115:1273-8.nHammermeister K, Burchfiel C, Johnson R, Grover F. 1990. Identification of patients at greatest risk for developing major complications at cardiac surgery [published erratum in Circulation 84:446, 1991]. Circulation 82(suppl 5):IV380-9.nNashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. 1999. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 16:9-13.nNierich AP, Diephuis J, Jansen EW, Borst C, Knape JT. 2000. Heart displacement during off-pump CABG: how well is it tolerated? Ann Thorac Surg 70:466-72.nPagni S, Qaqish NK, Senior DG, Spence PA. 1997. Anastomotic complications in minimally invasive coronary bypass grafting. Ann Thorac Surg 63(suppl 6):S64-7.nRicci M, Karamanoukian HL, Abraham R, et al. 2000. Stroke in octogenarians undergoing coronary artery surgery with and without cardiopulmonary bypass. Ann Thorac Surg 69:1471-5.nSternick L, Moshkovitz Y, Hod H, Mohr R. 2000. Comparison of myocardial revascularization without cardiopulmonary bypass to standard open-heart technique in patients with left ventricular dysfunction. Eur J Cardiothorac Surg 11:123-8.nSweeney MS, Frazier OH. 1992. Device supported revascularization: safe help for sick hearts. Ann Thorac Surg 54:1065-70.nHammerschmidt DE, Stroncek DF, Bowers TK. 1981. Complement activation and neutropenia occurring during cardiopulmonary bypass. J Thorac Cardiovasc Surg 81:370-7.nHart JC, Spooner TH, Pym J, et al. 2000. A review of 1,582 consecutive Octopus off-pump coronary bypass patients. Ann Thorac Surg 70:1017-20.nLocker C, Shapira I, Paz Y, et al. 2000. Emergency myocardial revascularization for acute myocardial infarction: survival benefits of avoiding cardiopulmonary bypass. Eur J Cardiothorac Surg 17:234-8.nLönn U, Peterzén B, Carnstam B, Casimir-Ahn H. 1999. Beating heart coronary surgery supported by an axial blood flow pump. Ann Thorac Surg 67:99-104.nMorrison DA, Sethi G, Sacks J, et al. 2001. Percutaneous coronary intervention versus coronary artery bypass graft surgery for patients with medically refractory myocardial ischemia and risk factors for adverse outcomes with bypass: a multicenter, randomized trial. Investigators of the Department of Veterans Affairs Cooperative Study #385, the Angina with Extremely Serious Operative Mortality Evaluation (AWESOME). J Am Coll Cardiol 38:143-9.nMoshkovitz Y, Sternik L, Paz Y, et al. 1997. Primary coronary artery bypass grafting without cardiopulmonary bypass in impaired left ventricular function. Ann Thorac Surg 63(suppl 6): S44-7.nArom KV, Flavin TF, Emery RW, Kshettry VR, Janey PA, Petersen RJ. 2000. Safety and efficacy of off-pump coronary artery bypass grafting. Ann Thorac Surg 69:704-10.nArom KV, Flavin TF, Emery RW, Kshettry VR, Petersen RJ, Janey PA. 2000. Is low ejection fraction safe for off-pump coronary artery operation? Ann Thorac Surg 70:1021-5.nAscione R, Lloyd CT, Gomes WJ, Caputo M, Bryan AJ, Angelini GD. 1999. Beating versus arrested heart revascularisation: evaluation of myocardial function in a prospective randomized study. Eur J Cardiothorac Surg 15:685-90.nBergsland J, Hasnan S, Lewin AN, Bhayana J, Lajos TZ, Salerno TA. 1997. Coronary artery bypass grafting without cardiopulmonary bypass: an attractive alternative in high risk patients. Eur J Cardiothorac Surg 11:876-80.nCalafiore AM, Di Gimmarco G, Teodori G, et al. 1998. Midterm results after minimally invasive coronary surgery (LAST operation). J Thorac Cardiovasc Surg 115:763-71.n

Published

2005-02-02

How to Cite

Folliguet, T. A., Philippe, F., Larrazet, F., Dibie, A., Czitrom, D., Bret, E. L., Bachet, J., & Laborde, F. (2005). Beating Heart Revascularization with Minimal Extracorporeal Circulation in Patients with a Poor Ejection Fraction. The Heart Surgery Forum, 6(1), 19-23. https://doi.org/10.1532/hsf.992

Issue

Section

Articles

Most read articles by the same author(s)