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      Myocardial revascularization using on-pump beating heart among patients with left ventricular dysfunction

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          Abstract

          Objectives

          On-pump beating heart technique for myocardial revascularization has been used successfully among both low and high risk patients. Its application among low ejection fraction patients is limited. The aim of our study is to evaluate this technique among patients with low ejection fraction and to compare results with off-pump bypass technique.

          Methods

          This retrospective study includes 137 patients with ejection fraction below 0.35 who underwent isolated coronary artery bypass surgery. 39 patients underwent myocardial revascularization using on-pump beating heart (ONCAB/BH), while 98 patients had off-pump beating heart (OPCAB). Different preoperative, operative and postoperative variables were evaluated among both groups.

          Results

          Patients profiles and risk factors were similar among both groups, except for the number of patients undergoing redo CABG which was significantly higher among ONCAB/BH (13% vs 3%; p = 0.025). Ejection fraction (EF) varied from 10-34%. The mean EF for patients who underwent ONCAB/BH was 28 ± 6 in comparison to 26 ± 5 for OPCAB patients (P = 0.093). Predicted risk for surgery according to EuroSCORE was similar among both groups (P = 0.443). The number of grafts performed per patient was significantly more among patients who underwent ONCAB/BH (2.2 ± 0.7 Vs 1.7 ± 0.7; P = 0.002). Completeness of revascularization was significantly greater in the ONCAB/BH patients (72% Vs 46%, P = 0.015). The incidence of hospital mortality and combined major morbidity was more among ONCAB/BH in comparison to OPCAB, but the difference was not significant. However, the incidence of blood loss, ventricular arrythmias, inotropic support, ICU, hospital stay and blood transfusion were significantly greater among patients who underwent ONCAB/BH.

          Conclusions

          On-pump beating heart technique can be used in myocardial revascularization among patients with left ventricular dysfunction. The technique was found to be associated with better myocardial revascularization when compared with OPCAB technique. However, the incidence of morbidity and mortality was more than OPCAB.

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          Most cited references 12

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          On-pump beating heart versus off-pump coronary artery bypass surgery-evidence of pump-induced myocardial injury.

          By maintaining native coronary blood flow in on-pump beating heart surgery (OnP-BH) and comparing with OPCAB strategy pump-related effects on myocardial injury and cardiac dysfunction could be specifically differentiated from ischemia/reperfusion-related consequences of surgical coronary revascularization. In a randomized-prospective design, 40 elective patients with normal EF and three vessels coronary artery disease (left main disease excluded) were assigned to OPCAB or OnP-BH surgery. Before coronary occlusion and 1, 30, 60, and 90 min after reperfusion with the LIMA graft, coronary sinus (CS) blood was sampled to determine intraoperative myocardial ischemia (pH, lactate, pO2) and oxidative stress (malondialdehyde, MDA). Additionally to CS blood arterial blood was analyzed 4, 12, and 24 h postoperatively to determine myocardial necrosis (CK-MB, cardiac troponin I), myocardial dysfunction (NT-proBNP) and inflammation (C-reactive protein). Groups were identical with regards to age and gender (OPCAB 63.0+/-6.0 versus OnP-BH 65.3+/-3.9 y, 20% female patients). Number of grafts were 3.0+/-0.5 in OPCAB versus 2.9+/-0.3 in OnP-BH (n.s.) with 44 versus 34% bilateral IMAs and 56 versus 50% complete arterial revascularization. Regarding ischemia, intraoperatively only lactate values increased significantly in the OnP-BH group. Significantly higher CK-MB and troponin I levels were found from LIMA-LAD flow release onwards to 4 h postoperatively in the OnP-BH group. NT-proBNP levels were significantly higher in the OnP-BH group during the entire study period. CRP levels were higher in the OnP-BH group 12 and 24 h postoperatively. In this randomized study on routine coronary patients with normal ventricular function, OPCAB revealed less myocardial injury than OnP-BH. These findings implicate that CPB slightly affects the myocardium.
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            Beating heart revascularization with or without cardiopulmonary bypass: evaluation of inflammatory response in a prospective randomized study.

            On-pump beating heart coronary artery surgery provides the opportunity to examine the isolated effect of cardiopulmonary bypass. This prospective randomized study compares the early clinical outcomes and inflammatory response of patients undergoing elective on-pump and off-pump beating heart coronary artery bypass grafting. Thirty-seven consecutive patients undergoing elective coronary artery bypass grafting were recruited from a pool of 73 patients, with 19 patients randomized to on-pump beating heart surgery and 18 patients to off-pump coronary bypass surgery. Intraoperative events and postoperative outcomes were recorded. Plasma levels of interleukin-6, interleukin-8, and interleukin-10, tumor necrosis factor-alpha, and vascular cell adhesion molecule-1 were measured before the operation, intraoperatively, after the operation, and 4, 24, and 48 hours thereafter. There was no significant difference in clinical outcomes between the 2 groups. The operating time was longer and consumption of platelets was greater for the on-pump beating heart group. There was no postoperative mortality or major complication in either group. There was significant elevation in the levels of interleukin-6, interleukin-8, and interleukin-10 and tumor necrosis factor-alpha during and immediately after the operations in the on-pump beating heart group when compared with the off-pump group. Levels of interleukin-8 (P =.01) and tumor necrosis factor-alpha (P =.0004) remained significantly elevated 4 hours after the operation in the on-pump beating heart group. The level of vascular adhesion molecule dropped significantly during the operation but was elevated 4 hours (P =.026) after the operation in the on-pump beating heart group. The use of cardiopulmonary bypass alone without global myocardial ischemia secondary to aortic crossclamping and cardioplegic cardiac arrest can trigger intense inflammatory responses.
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              Conversion to on pump from OPCAB is associated with increased mortality: results from a randomized controlled trial.

              Recent developments in cardiac stabilization devices, have made OPCAB feasible. However, there is conflicting evidence to date regarding the rate and adverse events associated with conversion from OPCAB to CABG with CPB. The objective of the present study was to review all conversions in the setting of a randomized controlled trial comparing CABG with or without CPB. Three hundred patients requiring CABG surgery at a single institution were prospectively randomized to have the procedure performed with CPB (n=150) or OPCAB (n=150). Patients that could not be performed OPCAB were defined as conversion group (cross over). Twenty patients were converted from OPCAB to CABG with CPB because of hemodynamic instability (14/20), small target vessel (5/20), or inadequate visualization (1/20). Seventeen were converted during attempts at coronary anastomosis: LAD/diagonal (7/20), circumflex (8/20), or right coronary (2/20). The overall in hospital mortality rate for the trial was 1% but was significantly higher in converted patients (10 vs. 0%; P=0.01). Converted patients required significantly more inotropes (P=0.001) and blood transfusions (P=0.05). An elevated BMI was the only pre-operative variable that appeared to be associated with conversion. In the setting of a randomized controlled trial the overall conversion rate associated with OPCAB reached 13% and was associated with an increased risk of mortality.
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                Author and article information

                Journal
                J Cardiothorac Surg
                Journal of Cardiothoracic Surgery
                BioMed Central
                1749-8090
                2010
                10 November 2010
                : 5
                : 109
                Affiliations
                [1 ]Department of Cardiac Surgery, Makassed Hospital, Jerusalem, Israel
                [2 ]Department of Cardiology, Makassed Hospital, Jerusalem, Israel
                Article
                1749-8090-5-109
                10.1186/1749-8090-5-109
                2993703
                21067597
                Copyright ©2010 Darwazah et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Research Article

                Surgery

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