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[Coronary artery bypass grafting in patients with poor left ventricular function using retrograde continuous cold
1Division of Cardiovascular Surgery, Hyogo Brain and Heart Center, Himeji, Japan.
Insights
Retrograde Coronary Cardiopulmonary Bypass (RC-CBCP) effectively preserves myocardial function during coronary artery bypass grafting (CABG) in patients with poor left ventricular function, improving outcomes even in urgent cases.
Area of Science:
- Cardiovascular Surgery
- Cardiac Anesthesia
- Myocardial Protection
Context:
- Patients with compromised left ventricular ejection fraction (LVEF ≤ 0.3) or those needing urgent surgery face increased risk of ischemic myocardial injury during coronary artery bypass grafting (CABG).
- Incomplete myocardial preservation can exacerbate myocardial damage in these high-risk patients.
- Traditional methods may be insufficient for protecting ischemic areas distal to severe coronary artery stenosis or obstruction.
Purpose:
- To evaluate the operative results of coronary artery bypass grafting (CABG) using Retrograde Coronary Cardiopulmonary Bypass (RC-CBCP) in patients with poor left ventricular function (LVEF ≤ 0.3).
- To assess the efficacy of RC-CBCP in myocardial preservation during aortic cross-clamping in this specific patient cohort, including those requiring urgent surgery.
- To determine if complete revascularization achieved with RC-CBCP leads to improved postoperative ventricular function and survival rates.
Summary:
- Twenty-five patients with LVEF ≤ 0.3 underwent CABG with RC-CBCP, aiming for complete revascularization during a single aortic cross-clamping period (mean 142 minutes).
- Despite prolonged cross-clamping, postoperative isoenzymatic evaluation and improved ventricular function indicated preferable myocardial protection.
- Fifteen elective CABG patients survived and improved to NYHA class I-II; among 10 urgent CABG patients, 4 with acute myocardial infarction died, while the rest improved.
Impact:
- RC-CBCP facilitates complete coronary revascularization in patients with poor left ventricular function, offering superior myocardial protection during CABG.
- The technique demonstrates improved ventricular function and survival rates, particularly in elective cases.
- This approach is crucial for managing high-risk cardiac surgery patients, potentially reducing perioperative myocardial injury and improving long-term outcomes.
Abstract:
Patients with poor left ventricular function or those requiring urgent surgery may have more extensive ischemic myocardial injury if myocardial preservation is incomplete. We have performed coronary artery bypass grafting (CABG) aimed at complete revascularization in such cases using RC-CBCP, which is considered more effective on myocardial preservation during aortic cross-clamping in particular to protect ischemic area distal to severe coronary artery stenosis or obstruction. In the present study, in 25 patients with poor left ventricular function (left ventricular ejection fraction; LVEF less than or equal to 0.3) including 10 patients who required urgent surgery, the operative results were evaluated. All the distal and proximal anastomoses of grafts (average 2.5 grafts) were completed during one aortic cross-clamping using RC-CBCP, therefore graft flow was obtained immediately after release of the aortic clamping. Though this method required 142 minutes of a mean aortic cross-clamping time, myocardial protection was considered to be preferable judging from postoperative isoenzymatic evaluation and improved ventricular function. Fifteen patients with elective CABG were all alive and restored to NYHA class I to II. Among 10 patients requiring urgent CABG, 4 patients with acute myocardial infarction died but others were restored to NYHA class I to II. We conclude that it is important to aim at complete coronary revascularization in patients with poor left ventricular function and RC-CBCP achieves more effective myocardial protection during CABG in the patients.