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Shunt or snare: coronary endothelial damage due to hemostatic devices for beating heart coronary surgery
Herbert Hangler1, Ludwig Mueller, Elfriede Ruttmann
1Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria.
Insights
Intracoronary shunts used during off-pump coronary bypass surgery cause significant endothelial injury and plaque rupture in human coronary arteries. Selective use is recommended to minimize damage.
Area of Science:
- Cardiovascular Surgery
- Vascular Biology
- Surgical Device Research
Background:
- Off-pump coronary artery bypass (OPCAB) surgery involves manipulating coronary arteries.
- Potential for endothelial injury exists during coronary artery occlusion in OPCAB procedures.
Purpose of the Study:
- To investigate the impact of hemostatic devices on human coronary arteries during OPCAB.
- To evaluate endothelial integrity using scanning electron microscopy (SEM).
Main Methods:
- SEM analysis of human coronary artery segments from 22 heart transplant patients.
- Comparison of segments treated with intracoronary shunts, external snaring, and control segments.
- Evaluation performed after cannulation but before cardiopulmonary bypass initiation.
Main Results:
- Intracoronary shunts caused severe endothelial denudation in nearly all treated segments.
- Significantly higher endothelial injury with shunts compared to external occlusion devices or controls (p < 0.001).
- Plaque rupture observed in 3 manipulated samples.
Conclusions:
- Coronary artery manipulation during OPCAB, particularly with shunts, leads to endothelial denudation and plaque rupture.
- Recommend selective use of intracoronary shunts in OPCAB.
- Further clinical trials are needed to assess the clinical significance of these structural damages.
Background:
Occlusion of coronary arteries during off-pump coronary bypass operations bears the potential for endothelial injury. The aim of this study was to elucidate the effects of hemostatic devices on the beating heart in human coronaries by means of scanning electron microscopy.
Methods:
The coronary arteries of 9 patients with dilated cardiomyopathy and 13 with ischemic heart disease undergoing heart transplantation were handled with intracoronary shunts as well as external snaring techniques on a beating heart, after cannulation but before starting cardiopulmonary bypass. Adjacent noninstrumented coronary artery segments served as controls. Integrity of endothelial lining was observed with scanning electron microscopy.
Results:
Nearly all coronary artery segments manipulated with a shunt exhibited a severe injury with extensive endothelial denudation. Endothelial injury was significantly higher after manipulation with intracoronary shunts compared with external occlusion devices (p < 0.001) or control specimens (p < 0.001). Plaque rupture was apparent in 3 samples.
Conclusions:
Manipulation of human coronary arteries during off-pump operations leads to endothelial denudation and plaque rupture. From this investigation we conclude that insertion of intracoronary shunts during beating heart operations leads to severe endothelial denudation in human coronary arteries. We therefore recommend using shunts selectively in cases where critical ischemia or technical difficulties due to anatomic conditions are expected during anastomosis. The clinical significance of these structural damages has to be further investigated with clinical trials.
