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[Surgical coronary revascularization of the beating heart]
F R Waldenberger1, H Hotz, M Haisjackl
1Universitáatsklinikum Charité, Univ. Klinik für Herzchirurgie, Berlin.
Insights
Coronary artery bypass grafting (CABG) using a left ventricular assist device (LVAD) offers a safe alternative to traditional methods for select patients with advanced heart disease. This technique avoids cardioplegic arrest, minimizing ischemic damage to the heart.
Area of Science:
- Cardiovascular Surgery
- Medical Devices
- Cardiac Physiology
Context:
- Traditional aortocoronary bypass surgery (CABG) is safe but has limitations in specific patient groups.
- Patients with advanced coronary heart disease, poor left ventricular function, or acute ischemia require alternative surgical approaches.
- Percutaneous transluminal coronary angioplasty (PTCA) is not suitable for all single or double vessel disease cases.
Purpose:
- To evaluate the safety and efficacy of performing CABG without cardioplegic arrest, utilizing left ventricular unloading with a left ventricular assist device (LVAD).
- To assess the feasibility of this technique in patients with poor left ventricular function, complex coronary artery disease, and acute myocardial infarction.
- To determine if this approach reduces perioperative complications and improves patient outcomes.
Summary:
- Fifty patients (51-74 years) with advanced coronary heart disease underwent CABG with LVAD support, avoiding cardioplegic arrest and cardiopulmonary bypass.
- Esmolol was administered during LVAD support to maintain a flaccid heart for easier anastomosis on a beating heart.
- The procedure involved an average of 1.4 distal anastomoses, with the left internal mammary artery used in 34 cases. No perioperative myocardial infarctions occurred.
Impact:
- The study demonstrates a high survival rate (94%) with no perioperative myocardial infarctions, indicating the safety of CABG during LVAD support.
- This technique minimizes ischemic damage to the heart, offering a life-saving option for carefully selected patients.
- The procedure allows for shorter intensive care unit stays (mean 1.5 days) and stable patient conditions post-operatively.
Abstract:
Despite the fact that all the progress in technology, surgical technique and pathophysiological knowledge has made aortocoronary bypass surgery a safe routine procedure, there are certain clinical settings where an alternative approach seems to be advantageous. In 50 patients with age ranging from 51 to 74 years with advanced coronary heart disease and poor left ventricular (LV) function, as well as in patients with good LV function and single or double vessel disease not amenable for PTCA and in patients with acute ischemia or recent myocardial infarction, we performed coronary artery bypass grafting (CABG) without cardioplegic arrest during a short period of left ventricular unloading by means of a left ventricular assist device (LVAD). During LVAD support we administered Esmolol to decrease the heart rate and to keep the heart flaccid to facilitate easier peripheral anastomosis on a breathing heart. Preoperative ejection fraction ranged from 15 to 56%. In two patients of the acute MI-group, we continued the left ventricular mechanical support postoperatively, one of them survived. We performed on average 1,4 distal anastomoses and used in 34 cases the left internal mammary artery. All but three patients survived the procedure in stable conditions and could leave intensive care after a mean stay of 1.5 days. There were no perioperative myocardial infarctions. In our view, CABG during LVAD support without heart lung machine and cardioplegia is a safe and life saving procedure. No ischemic damage is applied to the heart and it can be recommended for cautions use in select patients.