Intracoronary shunts reduce transient intraoperative myocardial dysfunction during off-pump coronary operations

Yeatman, Mark; Caputo, Massimo; Narayan, Pradeep; Ghosh, Arup; Ascione, Raimondo; Ryder, Ian; Angelini, Gianni D

doi:10.1016/s0003-4975(02)03407-0

Cited by 67 publications

(40 citation statements)

References 22 publications

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“…Patients undergoing off-pump CABG but without collaterals may benefit from a number of measures such as ischemic myocardial preconditioning by short periods of repeated coronary occlusions, the use of intracoronary or aortocoronary shunting of blood, or a reduction of the coronary occlusion time by novel anastomosis techniques. [22][23][24][25][26] After preconditioning, less CK-MB release during PCI and less troponin release Kaplan-Meier estimates of proportion experiencing any event (composite of all-cause death, nonfatal stroke, nonfatal MI, and coronary reintervention) at 1 year after bypass surgery in patients with or without collaterals. Probability values were calculated with log-rank test.…”

Section: Discussionmentioning

confidence: 99%

Role of Coronary Collaterals in Off-Pump and On-Pump Coronary Bypass Surgery

Nathoe¹,

Buskens²,

Jansen³

et al. 2004

Circulation

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Background-Collaterals limit infarct size, preserve viability, and reduce mortality in patients with acute myocardial infarction. In patients with stable coronary disease, collaterals are associated with less angina and ischemia during angioplasty and fewer ischemic events during follow-up. The role of collaterals has not been studied in patients undergoing off-pump or on-pump bypass surgery. Methods and Results-The population consisted of the 281 patients randomized to off-pump or on-pump CABG in the Octopus Study. Collaterals were defined on the baseline angiogram with the Rentrop score and were present in 49% and 51% of the patients in the off-pump and on-pump group, respectively. Perioperative myocardial infarction was defined by a creatine kinase-MB to CK ratio Ͼ10% and occurred in 18.2% in the off-pump group and 32.5% in the on-pump group. The unadjusted OR of perioperative myocardial infarction in the presence of collaterals was 0.31 (95% CI 0.17 to 0.84) in the off-pump group and 1.06 (95% CI 0.29 to 3.85) in the on-pump group After adjustment for age, gender, hypertension, hypercholesterolemia, diabetes, multivessel disease, ventricular dysfunction, incomplete revascularization, and ischemic time, the OR was 0.34 (95% CI 0.14 to 0.84) in the off-pump group and 1.28 (95% CI 0.30 to 5.40) in the on-pump group, respectively. Kaplan-Meier estimates of event-free survival at 1 year were 87% in patients with and 69% in those without collaterals after off-pump CABG. These estimates were 66% and 63%, respectively, after on-pump CABG. Conclusions-Collaterals protect against perioperative myocardial infarction during off-pump surgery but not during on-pump surgery and are associated with a better 1-year event-free survival.

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Section: Discussionmentioning

confidence: 99%

Role of Coronary Collaterals in Off-Pump and On-Pump Coronary Bypass Surgery

Nathoe¹,

Buskens²,

Jansen³

et al. 2004

Circulation

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“…They found lower troponin I levels with active and passive coronary perfusion, but cardiac performance was better with active coronary perfusion. The use of intra-coronary shunt during OPCAB has also been shown to preclude left ventricular dysfunction [25].…”

Section: Myocardial Preservationmentioning

confidence: 99%

Re-engineering in OPCAB—A Vettath’s perspective

Vettath¹,

Ismail²,

Kannan³

2013

WJCD

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OPCAB (off pump coronary artery bypass) has become a preferred technique of coronary revascularization in India, and more so in the East. This technique was restarted by Buffalo and Bennetti who had published their results in 1985. Since then, there has been a great enthusiasm among coronary surgeons to develop and standardize this technique of CABG (coronary artery bypass grafting). In the late nineties, nearly all the coronary centers in India started performing this technique. But, by the early 2000, only a few surgeons continued this practice. Only those who could perform this OPCAB technique in nearly 100% of their patients continued this and the rest of them returned back to the conventional on pump CABG. To attain this result, we had to re-engineer our technique of anesthesia, surgical technique, stabilization, and positioning of the heart to enable us to perform OPCAB in all patients who needed CABG. We have analyzed our last 3000 patients operated by the same surgeon (Dr MPV), in the same center with the same team. As OPCAB was the only procedure performed for coronary revascularization, we have compared our first 1000 patients, with the second 2000 patients that underwent the procedure. Our technique and our results are presented.

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“…Coronary shunts are inserted into the native coronary artery during construction of the anastomoses; this is thought to improve distal perfusion and thereby reduce local ischemia during surgery. 16,17 Cardiovascular magnetic resonance imaging (CMR) is accepted as the gold standard for the assessment of biventricular function. 18 The technique allows serial cardiac assessment with excellent reproducibility, permitting a significant sample size reduction for heart failure trials.…”

Section: Clinical Perspective P 2138mentioning

confidence: 99%

“…The present study suggests that the combination of bypass and intracoronary shunts may still not be adequate to perfuse the distal coronary territories, especially in the presence of significant proximal coronary disease. Furthermore, although 2 studies using intracoronary shunts have demonstrated improved intraoperative regional and global cardiac function during the insertion of a shunt, 16,17 both studies examined only the short-term effect. Actual shunt insertion may cause endothelial trauma or plaque disruption in the native vessel, producing embolization of material and possible downstream myocardial injury.…”

Section: Irreversible Myocardial Injurymentioning

confidence: 99%

“…The full extent of this injury may take several hours to develop, much longer than the period covered by these studies. 16,17 Other Insights From DE-CMR Three patients had significant transmural myocardial injury (2 ONBEAT, 1 ONSTOP) consistent with either native vessel (endarterectomy) or acute graft compromise (1 left internal mammary artery, 1 radial artery). Neither of these was confirmed by angiography because this was beyond the scope of this study.…”

Section: Irreversible Myocardial Injurymentioning

confidence: 99%

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A Randomized Trial of On-Pump Beating Heart and Conventional Cardioplegic Arrest in Coronary Artery Bypass Surgery Patients With Impaired Left Ventricular Function Using Cardiac Magnetic Resonance Imaging and Biochemical Markers

et al. 2008

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Background-Beating heart coronary artery bypass grafting (CABG) improves early postoperative cardiac function in patients with normal ventricular function, but its effect in patients with impaired function is uncertain. We compared a novel hybrid technique of on-pump beating heart CABG (ONBEAT) with conventional on-pump CABG (ONSTOP) in patients with impaired ventricular function. Methods and Results-In a single-center randomized trial, 50 patients with impaired ventricular function were randomly assigned to ONBEAT or ONSTOP. Patients underwent cardiac magnetic resonance imaging for function and delayed hyperenhancement early and later after surgery. Serial assessment of biochemical markers was also undertaken. Preoperative characteristics were well matched; cardiac index was 2.85Ϯ0.53 (ONBEAT) and 2.62Ϯ0.59 L · min Ϫ1 · m Ϫ2 (ONSTOP). Early after surgery, there was a trend toward a greater reduction in end-systolic volume index in ONSTOP patients versus ONBEAT (Ϫ9Ϯ8 versus Ϫ4Ϯ11 mL · m Ϫ2 ; Pϭ0.06). The changes were sustained and significant at 6 months (Ϫ14Ϯ18 versus Ϫ2Ϯ19 mL · m Ϫ2 ; Pϭ0.04). Furthermore, the incidence of new hyperenhancement at 6 days was higher in ONBEAT patients (Pϭ0.05), with 6 of 17 (35%) sustaining 8.2Ϯ5.2 g of new hyperenhancement each versus 2 of 23 (9%) in the ONSTOP group, each with 9.8Ϯ9.0 g (Pϭ0.86). Finally, median area under the curve for troponin was higher in ONBEAT at 461 (interquartile range, 226 to 1141) g/L versus 160 (interquartile range, 98 to 357) g/L for ONSTOP (Pϭ0.002). Conclusions-The incidence of new irreversible myocardial injury was significantly higher in ONBEAT than in ONSTOP patients. Furthermore, at 6 months, only ONSTOP patients demonstrated an improvement in ventricular geometry. The most likely mechanism is inadequate coronary perfusion to distal myocardial territories in patients with severe proximal coronary disease. (Circulation. 2008;118:2130-2138.)

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Intracoronary shunts reduce transient intraoperative myocardial dysfunction during off-pump coronary operations

Cited by 67 publications

References 22 publications

Role of Coronary Collaterals in Off-Pump and On-Pump Coronary Bypass Surgery

Role of Coronary Collaterals in Off-Pump and On-Pump Coronary Bypass Surgery

Re-engineering in OPCAB—A Vettath’s perspective

A Randomized Trial of On-Pump Beating Heart and Conventional Cardioplegic Arrest in Coronary Artery Bypass Surgery Patients With Impaired Left Ventricular Function Using Cardiac Magnetic Resonance Imaging and Biochemical Markers

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