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Published on: March 27, 2018
Hemodynamic changes during displacement of the beating heart using epicardial stabilization for off-pump coronary
Manisha Mishra1, Rajneesh Malhotra, Anil Mishra
1Escorts Heart Institute and Research Centre, New Delhi, India. manishamishra@yahoo.com
Insights
Off-pump coronary artery bypass graft surgery can cause hemodynamic changes, but these are often manageable with fluids and inotropes. Transesophageal echocardiography monitoring enhances procedural safety, particularly for high-risk patients.
Area of Science:
- Cardiovascular Surgery
- Anesthesiology
- Cardiac Hemodynamics
Background:
- Off-pump coronary artery bypass graft (OPCAB) surgery aims to revascularize the myocardium without cardiopulmonary bypass.
- Hemodynamic stability during OPCAB is crucial, especially with cardiac displacement for accessing coronary targets.
- Understanding and managing intraoperative hemodynamic alterations is key to patient safety.
Purpose of the Study:
- To evaluate hemodynamic alterations during off-pump coronary artery bypass graft surgery.
- To determine the degree of hemodynamic impairment caused by cardiac displacement.
- To identify techniques for rectifying these hemodynamic changes.
Main Methods:
- Prospective observational cohort study of 500 patients undergoing multivessel OPCAB surgery.
- Utilized the Octopus tissue stabilizer for cardiac stabilization.
- Monitored hemodynamics via radial artery and pulmonary artery catheters, and transesophageal echocardiography (TEE).
Main Results:
- Vertical heart displacement decreased mean arterial pressure (18%) and increased central venous pressure (66%).
- Stroke volume and cardiac index reduced significantly (35.7% and 45%, respectively).
- TEE revealed new regional wall motion abnormalities (59.2%) and decreased global LV function (61.2%); inotropes were frequently required (78.4% for posterior wall).
Conclusions:
- Hemodynamic changes during OPCAB are often correctable with fluids and inotropes.
- Transesophageal echocardiography monitoring is recommended to enhance procedural safety.
- The Octopus II tissue stabilizer is a safe and versatile tool for OPCAB, particularly in high-risk individuals.
Objective:
To evaluate the hemodynamic alterations during off-pump coronary artery bypass graft surgery to determine the degree of impairment caused and the techniques to rectify them.
Design:
Prospective, observational cohort study performed from January 2000 through September 2000.
Participants:
Patients (n = 500) with coronary artery disease undergoing multivessel off-pump coronary artery bypass graft surgery using the Octopus tissue stabilizer (Medtronic, Inc, Minneapolis, MN). Unstable patients with ongoing ischemia were excluded from the study.
Interventions:
All patients were monitored with radial artery and pulmonary artery catheters and continuous transesophageal echocardiography monitoring with a multiplane transducer. The perioperative requirement of an intracoronary shunt, inotropes, or an intra-aortic balloon pump was noted. The effect of the Trendelenburg position and fluids on hemodynamics was observed. The need for defibrillation and institution of emergency cardiopulmonary bypass were major endpoints to determine the inability of the patient to tolerate displacement of the heart.
Measurements And Main Results:
Mean patient age was 59.3 +/- 11.6 years. There were 204 (40%) patients in the high-risk category; 54 (10.8%) patients had left ventricular ejection fraction <25%. The mean number of grafts was 2.7 +/- 0.8. Vertical displacement of the heart to access the lateral and inferior walls decreased the mean arterial pressure by 18 +/- 4% (p < 0.01), with a concomitant increase in central venous pressure of 66 +/- 18% (p < 0.001). The stroke volume and the cardiac index were reduced by 35.7 +/- 11% (p < 0.001) and 45 +/- 13% (p < 0.001). On transesophageal echocardiography, there was development of new regional wall motion abnormalities in 59.2% and a decrease in global left ventricular functions in 61.2%. The use of inotropes was highest during anastomosis on the posterior wall-78.4% compared with 21.9% for the anterior wall. An intra-aortic balloon pump was used in 55 (11.2%) patients, and 7 (0.71 %) patients had to be put on emergency CPB. The in-hospital mortality was 1.2%.
Conclusion:
Most patients had hemodynamic changes easily correctable by fluids and inotropes. Monitoring of left ventricular and right ventricular function by transesophageal echocardiography enhances safety of the procedure and is recommended. The use of the Octopus II tissue stabilizer proved to be a safe and versatile means to stabilize the heart during off-pump coronary artery bypass procedures, especially in high-risk patients.
