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Heart displacement during off-pump CABG: how well is it tolerated?
A P Nierich1, J Diephuis, E W Jansen
1Department of Anesthesiology and Heart-Lung Institute Utrecht, Utrecht University Medical Center, The Netherlands. a.nierich@anest.azu.nl
Background:
Heart displacement during off-pump coronary artery bypass grafting (CABG) is necessary to expose the anastomosic sites. We analyzed the hemodynamic changes in relation to the grafted arteries.
Methods:
The relationship between surgical exposure and hemodynamic management was assessed in 150 consecutive patients undergoing off-pump CABG utilizing the Octopus Tissue Stabilization System (Medtronic, Minneapolis, MN).
Results:
Surgical exposure by anterolateral thoracotomy showed no significant hemodynamic changes. Through sternotomy, stroke volume was significantly reduced by dislocation at all target sites: by 6% at the left anterior descending artery (LAD), 25% at the diagonal branch artery (D), 14% at the right coronary artery (RCA), and 21% at the obtuse marginal artery (OM). The application of head-down positioning (LAD, 56%; D, 74%; RCA, 90%; OM, 96%) increased not only surgical exposure but also preload, producing correction of ventricular filling pressures and output. In a minority of cases, dopamine (3 to 5 microg x kg(-1) x min(-1)) was added to maintain baseline hemodynamic values (LAD, 5%; D, 15%; RCA, 7%; OM, 28%).
Conclusions:
Revascularization during anterolateral thoracotomy was uneventful. The sternotomy approach with heart displacement induced right heart compression. Mainly fluid redistribution was sufficient to correct cardiac output. Once stabilized, systemic circulation remained unchanged during revascularization.