Early clinical outcomes of on-pump beating-heart versus off-pump technique for surgical revascularization in patients with severe left ventricular dysfunction: the experience of a single center

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Abstract

Background

Limited experiences of applying an on-pump beating-heart technique for surgical revascularization in patients with severe left ventricular dysfunction have been reported. Which strategy, either off-pump coronary artery bypass grafting (CABG) or on-pump beating-heart CABG surgery, is the best strategy for surgical revascularization in patients with severe left ventricular dysfunction is still controversial. This single-center study aimed to evaluate the impacts of an on-pump beating-heart versus an off-pump technique for surgical revascularization on the early clinical outcomes in patients with a left ventricular ejection fraction (LVEF) of 35% or less to explore which technique would be more suitable for surgical revascularization in patients with severe left ventricular dysfunction.

Methods

A total of 216 consecutive patients with an echocardiographic estimated LVEF of 35% or less who underwent non-emergency, primary, isolated CABG from January 2010 to December 2014 were included in this study and were divided into either an ONBEAT group (patients who received on-pump beating-heart CABG surgery, n = 88) or an OFF group (patients who received off-pump CABG surgery, n = 128). The early clinical outcomes were investigated and compared.

Results

Patients in the ONBEAT group compared to the OFF group had a significant higher early postoperative LVEF (35.6 ± 2.9 vs. 34.8 ± 3.3%, p = 0.034) but shared a similar baseline LVEF (31.0 ± 2.8 vs. 31.0 ± 2.9%, p = 0.930). Patients in the ONBEAT group compared to the OFF group received a greater number of grafts and an increased amount of drainage during the first 24 h (3.7 ± 0.8 vs. 2.8 ± 0.6, p <0.001; 715 ± 187 ml vs. 520 ± 148 ml, p <0.001, respectively), without evidence of worse in-hospital mortality or major postoperative morbidity. Additionally, logistic regression analysis showed that surgical technique (on-pump beating-heart CABG vs. off-pump CABG) had no independent influence on in-hospital mortality or major postoperative morbidity in patients with preoperative LVEF of 35% or less.

Conclusions

The on-pump beating-heart technique may be an acceptable alternative to the off-pump technique for surgical revascularization in patients with an estimated LVEF of 35% or less.

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Most cited references 20

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

Friedrich-Wilhelm Mohr, Ardawan Julian Rastan, Thomas Walther … (2005)

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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The intraaortic balloon pump in cardiac surgery.

Roger Baskett, William A Ghali, Andrew Maitland … (2002)

The intraaortic balloon pump (IABP) has been used in cardiac operations since the late 1960s. Over the years, with refinements in technology, its use has expanded; the IABP is now the most commonly used mechanical assist device in cardiac operative procedures. This review provides an evaluation of evidence for the efficacy of IABP use in different clinical scenarios, using the American College of Cardiology/American Heart Association classification of evidence where appropriate. We evaluated complications and outcomes associated with IABP use, and attempted to draw conclusions regarding the use of the IABP in different clinical situations. We examined the trends and variation in utilization over time and across centers. We discussed the IABP in light of new cardiac assist devices and the changing patient population and management strategies. Lastly, we identified areas of future research.

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Troponin levels in patients with myocardial infarction after coronary artery bypass grafting.

Michel Carrier, Michel Pellerin, Louis P Perrault … (2000)

The objective of this study was to evaluate serum cardiac troponin T and I levels in patients in whom electrocardiogram, myocardial scan, and serum CK-MB levels of the MB isoenzyme of creatine kinase indicated perioperative myocardial infarction (MI) after coronary artery bypass grafting (CABG). We studied 590 patients who underwent CABG at the Montreal Heart Institute between 1992 and 1996. Postoperative cardiac troponin T levels (493 patients), troponin I levels (97 patients), and activity of the MB isoenzyme of creatine kinase, electrocardiograms, clinical data, and clinical events were recorded prospectively. The diagnosis of perioperative PMI was defined by a new Q wave on the electrocardiogram, by serum levels of the MB isoenzyme of creatine kinase higher than 100 IU/L within 48 hours after operation, or both. After CABG, 22 patients in whom troponin T levels (22/493, 4.5%) and 6 patients in whom troponin I levels (6/97, 6.2%) were measured had sustained a perioperative MI according to current diagnostic criteria. In these patients, troponin T levels higher than 3.4 microg/L 48 hours after CABG best detected the presence of perioperative MI, with an area under the receiver operating characteristic curve of 0.95, a sensitivity of 90%, a specificity of 94%, a positive predictive value of 41%, a negative predictive value of 99%, and a likelihood ratio of 15. Serum troponin I levels higher than 3.9 microg/L 24 hours after CABG confirmed the perioperative MI with an area under the receiver operating curve of 0.86, a sensitivity of 80%, a specificity of 85%, a positive predictive value of 24%, a negative predictive value of 99%, and a likelihood ratio of 5. Serum troponin T levels higher than 3.4 microg/L 48 hours after CABG correlated best with the diagnosis of perioperative MI. Serum troponin T levels greater than 3.9 microg/L 24 hours after CABG also correlated with the diagnosis of perioperative MI, although a larger experience is needed to confirm the validity of the chosen cutoff value.

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Author and article information

Contributors

ChunSheng Wang: wang.chunsheng@zs-hospital.sh.cn

Journal

Journal ID (nlm-ta): J Cardiothorac Surg

Journal ID (iso-abbrev): J Cardiothorac Surg

Title: Journal of Cardiothoracic Surgery

Publisher: BioMed Central (London )

ISSN (Electronic): 1749-8090

Publication date (Electronic): 23 February 2017

Publication date PMC-release: 23 February 2017

Publication date Collection: 2017

Volume: 12

Electronic Location Identifier: 11

Affiliations

[1 ]Shanghai Cardiovascular Disease Research Institute, 180 Fenglin Rd., Shanghai, 200032 People’s Republic of China

[2 ]ISNI 0000 0004 1755 3939, GRID grid.413087.9, , Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University, ; 1609 XieTu Rd., Shanghai, 200032 People’s Republic of China

Article

Publisher ID: 572

DOI: 10.1186/s13019-017-0572-x

PMC ID: 5322671

PubMed ID: 28231841

SO-VID: 7bef71ee-a9e2-441c-9d27-ed11bb036eb2

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 24 August 2016

Date accepted : 25 January 2017

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ScienceOpen disciplines: Surgery

Keywords: coronary artery bypass grafting,severe left ventricular dysfunction,on-pump beating heart surgery,off-pump

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ScienceOpen disciplines: Surgery

Keywords: coronary artery bypass grafting, severe left ventricular dysfunction, on-pump beating heart surgery, off-pump

Early clinical outcomes of on-pump beating-heart versus off-pump technique for surgical revascularization in patients with severe left ventricular dysfunction: the experience of a single center

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Abstract

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SICOT-J (Orthopedic surgery and traumatology)

Most cited references 20

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

The intraaortic balloon pump in cardiac surgery.

Troponin levels in patients with myocardial infarction after coronary artery bypass grafting.

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