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Beating heart revascularization with minimal extracorporeal circulation in patients with a poor ejection fraction
Thierry A Folliguet1, Francois Philippe, Fabrice Larrazet
1Department of Cardio-Vascular Surgery, L'Institut Mutualiste Montsouris, Paris, France. thierry.folliguet@imm.fr
Insights
Minimal extracorporeal circulation (MECC) on a beating heart offers a safe alternative for coronary artery bypass grafting in patients with low ejection fraction. This technique avoids myocardial injury from aortic cross-clamping, enabling complete revascularization.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Cardiac Surgery
- Cardiopulmonary Bypass
Background:
- Coronary artery bypass grafting (CABG) with cardioplegia in patients with low ejection fraction (EF) risks myocardial ischemia.
- Beating heart surgery can cause hemodynamic changes due to heart manipulation.
Purpose of the Study:
- To assess minimal extracorporeal circulation (MECC) for on-beating heart CABG in patients with poor ejection fraction.
- To evaluate the safety and efficacy of MECC in this high-risk patient group.
Main Methods:
- Fifty patients with EF < 35% underwent on-beating heart CABG using a closed cardiopulmonary bypass system with a centrifugal pump.
- Surgical strategy modified to avoid aortic cross-clamping and minimize bypass time.
Main Results:
- 146 distal anastomoses completed (mean 2.9 grafts/patient) with a mean bypass time of 64.2 minutes.
- Hospital mortality was 2%; 26% of patients received transfusions.
- Postoperative median extubation time was 9 hours, ICU stay 48 hours, and hospital stay 8 days. Mean EF improved to 30.5% at 6-month follow-up.
Conclusions:
- On-beating heart CABG with MECC is feasible in patients with low ejection fraction.
- This approach avoids myocardial injury associated with aortic cross-clamping.
- Safe and complete coronary revascularization is achievable with MECC in high-risk patients.
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 g/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.