Beating Heart Revascularization with Minimal Extracorporeal Circulation in Patients with a Poor Ejection Fraction
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.
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
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).