Abstract
Purpose
To describe the mechanisms of hemodynamic changes during off-pump coronary artery bypass graft surgery (OP-CABG). Source: Pertinent medical literature in the English and French languages was identified through a Medline computerized literature search and a manual search of selected articles, using off-pump coronary artery surgery, beating heart surgery, hemodynamic, and transesophageal echocardiography as key words. Human and animal studies were included.
Principal finding
Hemodynamic variations in OP-CABG may be due to mobilization and stabilization of the heart, or myocardial ischemia occurring during coronary occlusion. Suction type and compression type stabilizers produce hemodynamic effects through different mechanisms. Heart dislocation (90° anterior displacement) and compression of the right ventricle to a greater extent than the left ventricle are responsible for hemodynamic alterations when using suction type stabilizers. Compression of the left ventricular outflow tract and abnormal diastolic expansion secondary to direct deformation of the left ventricular geometry are proposed mechanisms for hemodynamic derangements with compression type stabilizer. Coronary occlusion during the anastomosis can have additional effects on left ventricular function, depending on the status of collateral flow. The value and limitations of electrocardiographic (ECG), hemodynamic and echocardiographic monitoring modalities during OP-CABG are reviewed.
Conclusions
In summary, hemodynamic changes which can either be secondary to the stabilization technique or to transient ischemia represent an important diagnostic challenge during off-bypass procedures. The mechanism can vary according to the stabilization system. Current monitoring such as ECG and hemodynamic monitoring are used but remain limited in establishing the cause of hemodynamic instability. Transesophageal echocardiography is used in selected patients to diagnose the etiology of hemodynamic instability and can direct therapy, particularly in those with severe myocardial systolic and diastolic dysfunction, mild to moderate mitral regurgitation, or for patients who are unstable during the procedure.
Résumé
Objectif
Décrire les mécanismes de changements hémodynamiques pendant le pontage aortocoronarien (PAC-CB). Source: La documentation pertinente en anglais et en français a été trouvée par la consultation de Medline et par une recherche manuelle dans des articles sélectionnés, en utilisant les mots-clefs suivants: off-pump coronary artery surgery, beating heart surgery, hemodynamic, et transesophageal echocardiography. Nous avons inclus les études sur les humains et les animaux.
Constatations principales
Les variations hémodynamiques pendant le PAC-CB peuvent être causées par la mobilisation et la stabilisation du cœur ou l’ischémie myocardique survenant pendant l’occlusion d’une artère coronaire. Les stabilisateurs de type aspiration et compression produisent des effets hémodynamiques par des mécanismes différents. La bascule cardiaque (déplacement antérieur de 90°) et la compression du ventricule droit, plus grande que celle du ventricule gauche, sont responsables des modifications hémodynamiques avec le stabilisateur de type aspiration. La compression de la voie d’éjection du ventricule gauche et l’expansion diastolique anormale secondaire à une déformation directe de la géométrie ventriculaire gauche sont les mécanismes de changements hémodynamiques proposés avec le stabilisateur compressif. L’occlusion coronaire pendant l’anastomose peut avoir d’autres effets sur la fonction ventriculaire gauche selon l’état du débit collatéral. La valeur et les limites des modalités du monitorage électrocardiographique (ECG), hémodynamique et échocardiographique pendant le PAC-CB ont été réexaminées.
Conclusion
En résumé, les changements hémodynamiques qui peuvent être, soit secondaires à la technique de stabilisation, soit à l’ischémie transitoire, représentent un défi diagnostique important pendant les interventions à cœur battant. Le mécanisme peut varier selon le système de stabilisation. Le monitorage courant comme l’ECG et le monitorage hémodynamique sont utilisés, mais demeurent limités pour définir la cause de l’instabilité hémodynamique. L’échocardiographie transœsophagienne est utilisée chez des patients choisis pour diagnostiquer l’étiologie de l’instabilité hémodynamique et peut orienter le traitement, surtout chez ceux qui présentent une dysfonction systolique et diastolique sévères, une régurgitation mitrale faible ou modérée et chez les patients dont l’état est instable pendant l’intervention.
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References
Cartier R, Blain R. Off-pump revascularization of the circumflex artery: technical aspect and short-term results. Ann Thorac Surg 1999; 68: 94–9.
Bell MR, Gersh BJ, Schaff HV, et al. Effect of completeness of revascularization on long-term outcome of patients with three-vessel disease undergoing coronary artery bypass surgery. A report from the Coronary Artery Surgery Study (CASS) Registry. Circulation 1992; 86: 446–57.
Gundry SR, Romano MA, Shattuck OH, Razzouk AJ, Bailey LL. Seven-year follow-up of coronary artery bypasses performed with and without cardiopulmonary bypass. J Thorac Cardiovasc Surg 1998; 115: 1273–7.
Tasdemir O, Vural KM, Karagoz H, Bayazit K. Coronary artery bypass grafting on the beating heart without the use of extracorporeal circulation: review of 2052 cases. J Thorac Cardiovasc Surg 1998; 116: 68–73.
Benetti FJ, Naselli G, Wood M, Geffner L. Direct myocardial revascularization without extracorporeal circulation. Experience in 700 patients. Chest 1991; 100: 312–6.
Shennib H, Mack MJ, Lee AG. A survey on minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1997; 64: 110–4.
Cartier R, Hébert Y, Blain R, Tremblay N, Desjardins J, Leclerc Y. Triple coronary artery revascularization on the stabilized beating heart: initial experience. Can J Surg 1998; 41: 283–8.
Dagenais F, Perrault LP, Cartier R, et al. Beating heart coronary artery bypass grafting: technical aspects and results in 200 patients. Can J Cardiol 1999; 15: 867–72.
Cartier R. From idea to operating room: surgical innovation, clinical application, and outcome. Seminar in Cardiothoracic and Vascular Anesthesia 2000; 4: 103–9.
Borst C, Jansen EW, Tulleken CAF, et al. Coronary artery bypass grafting without cardiopulmonary bypass and without interruption of native coronary flow using a novel anastomosis site restraining device (“Octopus”). J Am Coll Cardiol 1996; 27: 1356–64.
Grundeman PF, Borst C, van Herwaarden JA, Mansvelt Beck HJ, Jansen EWL. Hemodynamic changes during displacement of the beating heart by the Utrecht Octopus method. Ann Thorac Surg 1997; 63: S88-S92.
Jansen EW, Grundeman PF, Mansvelt Beck HJ, Heijmen RH, Borst C. Experimental off-pump grafting of a circumflex branch via sternotomy using a suction device. Ann Thorac Surg 1997; 63(Suppl 6): S93-S6.
Grundeman PF, Borst C, van Herwaarden JA, Verlaan CWJ, Jansen EWL. Vertical displacement of the beating heart by the Octopus tissue stabilizer: influence on coronary flow. Ann Thorac Surg 1998; 65: 1348–52.
Grundeman PF, Borst C, Verlaan CWJ, Meijburg H, Moues CM, Jansen EWL. Exposure of circumflex branches in the tilted, beating porcine heart: echocardiographic evidence of right ventricular deformation and the effect of right or left heart bypass. J Thorac Cardiovasc Surg 1999; 118: 316–23.
Porat E, Sharony R, Ivry S, et al. Hemodynamic changes and right heart support during vertical displacement of the beating heart. Ann Thorac Surg 2000; 69: 1188–91.
Spooner TH, Dyrud PE, Monson BK, Dixon GE, Robinson LD. Coronary artery bypass on the beating heart with the Octopus: a North American experience. Ann Thorac Surg 1998; 66: 1032–5.
Nierich AP, Diephuis J, Jansen EW, Borst C, Knape JT. Heart displacement during off-pump CABG: how well is it tolerated? Ann Thorac Surg 2000; 70: 466–72.
Jansen EWL, Borst C, Lahpor JR, et al. Coronary artery bypass grafting without cardiopulmonary bypass using the Octopus method: results in the first one hundred patients. J Thorac Cardiovasc Surg 1998; 116: 60–7.
Mathison M, Edgerton JR, Horswell JL, Akin JJ, Mack MJ. Analysis of hemodynamic changes during beating heart surgical procedures. Ann Thorac Surg 2000; 70: 1355–61.
Mathison M, Buffolo E, Jatene AD, et al. Right heart circulatory support facilitates coronary artery bypass without cardiopulmonary bypass. Ann Thorac Surg 2000; 70: 1083–5.
Lönn U, Peterzén B, Carnstam B, Casimir-Ahn H. Beating heart coronary surgery supported by an axial blood flow pump. Ann Thorac Surg 1999; 67: 99–104.
Koh TW, Carr-White GS, DeSouza AC, Ferdinand FD, Pepper JR, Gibson DG. Effect of coronary occlusion on left ventricular function with and without collateral supply during beating heart coronary artery surgery. Heart 1999; 81: 285–91.
Brown PM Jr, Kim VB, Boyer BJ, Lust RM, Chitwood WR Jr, Elbeery JR. Regional left ventricular systolic function in humans during off-pump coronary bypass surgery. Circulation 1999; 100(Suppl II): II-125-II-7.
Eldrup N, Rasmussen NH, Yndgaard S, Biggler D, Berthelsen PG. Impact of off-pump coronary artery surgery on myocardial performance and β-adrenoceptor function. J Cardiothorac Vasc Anesth 2001; 15: 428–32.
Do QB, Cartier R. Hemodynamic changes during bypass surgeries in the beating heart. Ann Chir 1999; 53: 706–11.
Do QB, Chavanon O, Couture P, Denault A, Cartier R. Hemodynamic repercussion during beating-heart CABG surgery. Can J Cardiol 1999; 15(Suppl D): 177D (abstract).
Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr 1989; 2: 358–67.
Rakowski H, Appleton C, Chan KL, et al. Canadian consensus recommendations for the measurement and reporting of diastolic dysfunction by echocardiography: from the Investigators of Consensus on Diastolic Dysfunction by Echocardiography. J Am Soc Echocardiogr 1996; 9: 736–60.
Watters MPR, Ascione R, Ryder IG, Ciulli F, Pitsis AA, Angelini GD. Haemodynamic changes during beating heart coronary surgery with the ‘Bristol technique’. Eur J Cardiothorac Surg 2001; 19: 34–40.
Burfeind WR Jr, Duhaylongsod FG, Samuelson D, Leone BJ. The effects of mechanical cardiac stabilization on left ventricular performance. Eur J Cardiothorac Surg 1998; 14: 285–9.
Jurmann MJ, Menon AK, Haeberle L, Salehi-Gilani S, Ziemer G. Left ventricular geometry and cardiac function during minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1998; 66: 1082–6.
Dagenais F, Cartier R. Pulmonary hypertension during beating heart coronary surgery: intermittent inferior vena cava snaring. Ann Thorac Surg 1999; 68: 1094–5.
London MJ, Hollenberg M, Wong MG, et al. Intraoperative myocardial ischemia: localization by continuous 12-lead electrocardiography. Anesthesiology 1988; 69: 232–41.
Smith JS, Cahalan MK, Benefiel DJ, et al. Intraoperative detection of myocardial ischemia in high-risk patients: electrocardiography versus two-dimensional transesophageal echocardiography. Circulation 1985; 72: 1015–21.
Leung JM, O’Kelly B, Browner WS, Tubau J, Hollenberg M, Mangano DT. Prognostic importance of postbypass regional wall-motion abnormalities in patients undergoing coronary artery bypass graft surgery. McSPI Research Group. Anesthesiology 1989; 71: 16–25.
Moisés VA, Mesquita CB, Campos O, et al. Importance of intraoperative transesophageal echocardiography during coronary artery surgery without cardiopulmonary bypass. J Am Soc Echocardiogr 1998; 11: 1139–44.
Kotoh K, Watanabe G, Ueyama M, et al. On-line assessment of regional ventricular wall motion by transesophageal echocardiography with color kinesis during minimally invasive coronary artery bypass grafting. J Thorac Cardiovasc Surg 1999; 117: 912–7.
van Daele ME, Sutherland GR, Mitchell MM, et al. Do changes in pulmonary capillary wedge pressure adequately reflect myocardial ischemia during anesthesia? A correlative preoperative hemodynamic, electrocardiographic, and transesophageal echocardiographic study. Circulation 1990; 81: 865–71.
Malkowski MJ, Kramer CM, Parvizi ST, et al. Transient ischemia does not limit subsequent ischemic regional dysfunction in humans: a transesophageal echocardiographic study during minimally invasive coronary artery bypass surgery. J Am Coll Cardiol 1998; 31: 1035–9.
Couture P, Denault AY, McKenty S, et al. Impact of routine use of intraoperative transesophageal echocardiography during cardiac surgery. Can J Anesth 2000; 47: 20–6.
Bernard F, Denault A, Babin D, et al. Diastolic dysfunction is predictive of difficult weaning from cardiopulmonary bypass. Anesth Analg 2001; 92: 291–8.
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Couture, P., Denault, A., Limoges, P. et al. Mechanisms of hemodynamic changes during off-pump coronary artery bypass surgery. Can J Anesth 49, 835–849 (2002). https://doi.org/10.1007/BF03017418
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DOI: https://doi.org/10.1007/BF03017418