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[Coronary surgery on the beating heart under extracorporeal circulation in high-risk patients. An acceptable
1Service de chirurgie cardiovasculaire hôpital Lariboisière, Paris.
Insights
Beating heart coronary artery bypass surgery using cardiopulmonary bypass offers a safe alternative for high-risk patients, minimizing myocardial ischemia and inflammation while improving outcomes.
Area of Science:
- Cardiovascular Surgery
- Cardiac Anesthesia
- Myocardial Protection
Context:
- High-risk patients undergoing coronary artery surgery face risks of myocardial ischemia and technical challenges without cardiopulmonary bypass.
- Traditional cardiopulmonary bypass can lead to myocardial damage and systemic inflammation.
Purpose:
- To evaluate the safety and efficacy of beating heart coronary artery surgery with hemodynamic assist via cardiopulmonary bypass in high-risk patients.
- To assess myocardial ischemia and inflammation markers, and heat shock protein expression post-surgery.
Summary:
- Forty-three high-risk patients with poor left ventricular function, evolving ischemia, or myocardial infarction underwent beating heart surgery with cardiopulmonary bypass.
- Clinical outcomes included one cardiac death and one myocardial infarction. Biochemical markers showed minimal troponin Ic increase and significant heat shock protein 70 expression, indicating myocardial adaptation.
- Inflammatory mediators showed no significant changes, suggesting cardiopulmonary bypass effects were mitigated.
Impact:
- Beating heart surgery under cardiopulmonary bypass is a viable alternative for selected high-risk patients, reducing myocardial ischemia and potentially mitigating cardiopulmonary bypass-related complications.
- This technique preserves myocardial function and may improve surgical outcomes in complex cardiac cases.
Abstract:
Coronary artery surgery with cardioplegia in high risk patients carries a risk of myocardial ischaemia and, without cardiopulmonary bypass, is not always technically feasible. The authors assessed an alternative, surgery on the beating heart with haemodynamic assist by cardiopulmonary bypass in 43 consecutive patients with poor left ventricular function (mean ejection fraction: 0.26), evolving myocardial ischaemia or acute myocardial infarction, old age (mean: 79.5 years) and comorbid conditions. Results were assessed mainly on clinical criteria. In addition, 9 patients had pre- and post-cardiopulmonary bypass measurements of markers of myocardial ischaemia (troponine Ic) and systemic inflammation (interleukines 6 and 10, elastase). In 6 cases, right atrial biopsy was analysed for expression of messenger ribonucleic acid coding for heat shock protein (HSP) 70; the data were compared with those of patients operated under warm blood cardioplegia. There was one cardiac death and one myocardial infarction. Myocardial conservation was confirmed by the minimal increase in troponine Ic levels and the significant increase in HSP 70 in RNA suggesting myocardial adaptation to stress. On the other hand, the minimal concentrations of mediators of inflammation were not significantly changed. In selected high risk patients, coronary revascularisation on the beating heart under cardiopulmonary bypass could be a valuable alternative. It conserves the potentially deleterious effects of cardiopulmonary bypass but peroperative global myocardial ischaemia, an important factor in the aggressivity of cardiac surgery, is eliminated.