No abstract

Cardiopulmonary bypass is acknowledged to be one of the major causes of a complex systemic inflammatory response after cardiac surgery. Leukocyte‐endothelial binding followed by neutrophil migration appears to play a central role. These interactions are mediated by adhesion molecules on the surface of activated cells. The present study compared the perioperative levels of soluble adhesion molecules after coronary artery bypass grafting (CABG) in patients with or without cardiopulmonary bypass (CPB). Altogether, 9 patients underwent off‐pump revascularization and 11 did so with CPB. Plasma levels of soluble adhesion molecules sE‐selectin and sP‐selectin and soluble intercellular adhesion molecule‐1 (sICAM‐1) were measured before anesthesia induction and 1, 4, and 20 hours after reperfusion to the myocardium. The baseline plasma levels of the adhesion molecules were similar in the two groups. Perioperative levels of sE‐selectin remained the same and did not differ between groups. Plasma sP‐selectin increased in both groups, the change being significantly greater in the CPB group than that in the off‐pump group (p = 0.001). Plasma sICAM‐1 decreased during an early stage after CABG with CPB, recovering at 4 hours after reperfusion; and a significant increase in ICAM‐1 was observed 20 hours later. In the off‐pump group, sICAM‐1 levels did not change at 1 and 4 hours after reperfusion but increased 20 hours later. Postoperative creatine kinase–muscle bound (CK‐MB) levels were significantly higher in the CPB group than in the off‐pump group (p = 0.001). The change in sP‐selectin levels also showed a correlation with CK‐MB values (r = 0.676, p = 0.001). The results indicated that off‐pump revascularization is associated with reduced endothelial activation and myocardial injury.

The results indicated that off-pump revascularization was associated with reduced cytokine responses and less severe myocardial injury. The degree of myocardial injury, as defined by CK-MB release, correlated with cytokine release. Intervention designed to reduce cytokine responses in cardiac surgery may be advantageous for patients with severe comorbidity.

During the past 10 years, 50 patients underwent combined coronary artery bypass grafting (CABG) and mitral valve replacement (MVR) at our clinic, with additional aortic valve replacement (AVR) in six cases. The early mortality was 8%. During the first half of the study period this mortality was 4/11 patients, but in the second half it was 0/39. All six patients with CABG + MVR + AVR survived the operation. Adverse factors were found to be advanced functional impairment, female sex, concomitant untreated aortic valvulopathy and elevated pulmonary vascular resistance. All 46 patients who survived the operation were followed up for a mean period of 31 months, and during that time there were nine deaths. The survival rate was 54% after 3 years and 40% after 5 years. Most of the patients had improved by at least one functional class. The good results in this series probably were attributable to improvements in surgical procedure (introduction of cold potassium cardioplegia) and in postoperative management (intra-aortic balloon pumping).