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Right arrow Minimally invasive surgery

Ann Thorac Surg 2002;73:1411-1417
© 2002 The Society of Thoracic Surgeons

Original article: cardiovascular

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

Mark Yeatman, FRCSa, Massimo Caputo, MDa, Pradeep Narayan, FRCSa, Arup Kumar Ghosh, FRCSa, Raimondo Ascione, MDa, Ian Ryder, FRCAa, Gianni D. Angelini, FRCS*a

a Bristol Heart Institute, University of Bristol, Bristol, United Kingdom

Accepted for publication December 28, 2001.

* Address reprint requests to Professor Angelini, Bristol Heart Institute, Bristol Royal Infirmary, Bristol BS2 8HW, UK
e-mail: gd.angelini{at}bristol.ac.uk


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
Background. This study investigated the hemodynamic changes in patients undergoing multiple vessel beating heart coronary revascularization in the presence or absence of an intracoronary shunt.

Methods. Forty patients were randomized to off-pump with a shunt (n = 20) or with the proximal coronary artery occluded by a soft snare (n = 20). Hemodynamic measurements were recorded at base line, during construction, and after completion of each distal anastomosis.

Results. Grafting of the left anterior descending coronary artery anastomosis was associated with a significant decrease in stroke volume, cardiac index, and mean arterial pressure, and an increase in pulmonary capillary wedge pressure and systemic vascular resistance in the snare but not in the shunt group. During grafting of the posterior descending coronary artery there was a marked decrease in stroke volume and cardiac index, and an increase in central venous pressure in both groups, and an increase in heart rate, mean pulmonary arterial pressure, pulmonary capillary wedge pressure, and systemic vascular resistance only in the snare group. The most extensive changes were observed during the circumflex coronary artery anastomosis with a reduction in stroke volume, cardiac index, and mean arterial pressure, and an increase in central venous pressure, pulmonary capillary wedge pressure, pulmonary arterial pressure, and systemic vascular resistance in both groups. In all settings, these changes were transient and recovered after the heart was returned to its anatomical position in the shunt group, whereas stroke volume and cardiac index remained reduced, and systemic vascular resistance was elevated in all settings in the snare group.

Conclusions. Stabilization of the left anterior descending coronary artery to perform the anastomosis resulted in temporary hemodynamic changes, which are prevented by the use of an intracoronary shunt. The hemodynamic deterioration during the construction of the posterior descending coronary artery and circumflex coronary artery anastomoses is transient in the shunt group, whereas the snaring technique is associated with an impairment of early functional recovery.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
There is now renewed interest in the benefits of off-pump coronary artery bypass (OPCAB) operations [1] with encouraging reports of early clinical outcome and economic superiority when compared with conventional coronary artery bypass operations using cardiopulmonary bypass [2–8].

However OPCAB operations have been shown to result in significant hemodynamic deterioration during positioning and stabilization of the heart [9–13], which may be further exacerbated by snaring of the coronary arteries during construction of the distal anastomoses [14]. In order to limit the regional ischemic changes that occur during snaring, some surgeons are now using intraluminal coronary shunts [15, 16], although their use is not yet widespread and remains controversial [17]. The use of intracoronary shunts has been shown to be beneficial experimentally [16], and during OPCAB operations in patients with isolated left anterior descending (LAD) coronary artery lesion [18].

The present study examines the hemodynamic changes observed in patients with three-vessel coronary artery disease who underwent OPCAB revascularization in which coronaries were either temporarily snared or an intraluminal shunt was used during construction of distal anastomoses.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 Acknowledgments
 References
 
Study design
Patients (n = 40) with three-vessel coronary artery disease and left ventricular ejection fractions >= 40% who were scheduled for elective OPCAB operations were prospectively randomized into one of two groups. The snare group (n = 20) consisted of patients in which all of the anastomoses were performed during proximal snaring of the coronary arteries. The shunt group (n = 20) consisted of patients in which the anastomoses were constructed after intraluminal insertion of a silastic intracoronary shunt (Flothru Biovascular Inc, St Paul, MN) of appropriate size. All patients had angiographic evidence of critical coronary artery disease (>= 70% luminal diameter narrowing in a major arterial branch). Eligibility for operations was based on patient’s medical history and a recent coronary angiogram. Exclusion criteria included recent (<= 1 month) myocardial infarction, reoperative operation, and emergency operation. No exclusion criteria were applied in relation to the anatomic position or size of the coronary vessel to be grafted. The study was approved by the United Bristol Healthcare Trust Ethics Committee, and all patients gave informed consent.

Anesthesia and anticoagulation
A standard anesthetic technique was used for all patients. This consisted of an oral premedication (20 mg temazepam) followed by total intravenous anesthesia (3 mg kg-1 hr-1 propofol combined with 10 to 20 µg/kg fentanyl). Neuromuscular blockade was achieved by administering pancuronium (0.15 mg kg-1) or vecuronium (0.15 mg kg-1). After induction of anesthesia, a quadruple lumen central venous catheter and pulmonary artery flotation catheter (Ohmeda; Erlangen, Germany) were inserted into the right internal jugular vein. The pulmonary artery catheter was connected to the cardiac output module of the patient monitor (Solar 8000 Patient Monitor; Marquette Medic Systems, Milwaukee, WI). Cardiac output measurements were carried out using intermittent 10 mL boluses of iced dextrose 5% solution at a temperature of 4°C to 8°C as measured by the inline injectate sensor of the thermodilution injectate set. Patients received 100 IU kg-1 heparin before commencing the distal anastomoses with a target activated clotting time of 250 to 350 seconds. Protamine sulfate was used to reverse the heparin effect at the completion of the surgical procedure [10].

Surgical procedures
All procedures were performed through a median sternotomy using a standard technique recently described [10, 19]. Briefly, a single 0-silk suture, which had been passed through a large (12 x 70 cm) gauze swab, was inserted into the posterior pericardium midway between the inferior vena cava and the left inferior pulmonary vein. The gauze swab was then securely snared into position on the pericardium. This retraction stitch enabled anterior displacement of the cardiac apex and better visualization of the target coronary arteries during the distal anastomoses. A reusable stabilizer incorporating a footplate (Abbey Surgical Ltd, Mitcham, Surrey, UK) was used during the construction of the anastomoses. To further assist good exposure of the inferior and obtuse marginal surfaces of the heart, the patient was placed in a gentle right decubitus Trendelenburg position. The sequence of grafting was always the LAD coronary artery first, followed by the posterior descending coronary artery, and the circumflex coronary artery anastomosis.

Following exposure and stabilization of the target vessel, preparations were made for the coronary arteriotomy. For the snare group, a 4-0 Prolene (Ethicon, Somerville, NJ) and a soft plastic subcoronary snare was placed 1 cm proximal to the intended target site and the vessel occluded throughout the anastomosis. For the shunt group, the coronary was opened during transient (<= 1 minute) occlusion of the coronary artery and a suitably sized intraluminal shunt inserted. Shunt size was estimated before opening the coronary by examination of the external appearance of the vessel, and shunts were available in sizes ranging from 1.5 to 3.5 mm (in 0.25 mm increments). Shunts were inserted under direct vision, proximal end first. Coronary anastomoses were performed using 7-0 Prolene (Ethicon) and standard techniques.

Hemodynamic and clinical monitoring
Heart rate, mean systemic arterial pressure, central venous pressure, mean pulmonary arterial pressure, pulmonary capillary wedge pressure (PCWP), cardiac index (CI), stroke volume (SV), systemic vascular resistance index (SVRI), and pulmonary vascular resistance index were recorded for each position. Each data set consisted of the average of three taken during approximately 3 minutes, and values that varied by more than 10% were excluded. To minimize the influence of variations of manual injection on the accuracy of the thermodilution measurements, the same anesthetist always carried out the bolus injections. Hemodynamic monitoring was performed according to the following timing:

Base Line Position: (heart in its natural position): 5 minutes before any cardiac manipulation and before exposure and stabilization of the target vessel.

Exposed Position: 5 minutes into the construction of each distal coronary anastomosis with the heart exposed and stabilized in the LAD coronary artery, circumflex coronary artery, or posterior descending coronary artery positions.

Recovery Position: 5 minutes after completion of each coronary anastomosis with the heart back in its anatomical position.

Finally, intraoperative and postoperative data, including complications and adverse events, were recorded as previously described [20]. Clinical diagnostic criteria for perioperative myocardial infarction were new Q waves of greater than 0.04 ms or a reduction in R waves greater than 25% in at least two leads, or both.

Management of preoperative and postoperative medications
Preoperative medications including ß-blockers, diuretics, antihypertensives, and calcium-channel blockers were routinely omitted on the day of operation. On the first postoperative day, in accordance with the intensive care unit protocol (heart rate > 55 bpm, systolic blood pressure > 110 mm Hg), ß-blockers, and other antihypertensive drugs were recommenced.

Statistical analysis
Continuous data are presented as mean ± standard deviation for base line values and as difference of the mean with lower and upper 95% confidence intervals for the exposed-stabilized and recovery positions for each hemodynamic variable measured. Changes between time points were compared using the Bonferroni repeated measurements of analysis of variance. A p value of less than 0.05 was considered as a statistically significant difference. Analyses were performed using Statview (SAS Institute Inc, Cary, NC).


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 Acknowledgments
 References
 
Preoperative characteristics are shown in Table 1. All patients completed the study without any technical difficulty during the OPCAB procedure and no requirement for intraoperative inotropic support. All the preoperatively intended grafts were performed. In the shunt group, all the anastomosis were performed using an appropriate size shunt. Hemodynamic recordings were completed for 20 LAD coronary artery anastomoses, 31 posterior descending coronary artery anastomoses, and 32 circumflex coronary artery anastomoses.


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  		Table 1. Baseline Characteristics

 
LAD coronary artery anastomoses
The hemodynamic data recorded during LAD coronary artery grafting in each of the study groups are summarized in Table 2. Snaring of the LAD coronary artery as seen resulted in a marked decrease in CI (Fig 1A), SV, and mean arterial pressure, as well as a statistically significant increase in PCWP, SVRI, and pulmonary vascular resistance index. These changes were not apparent in the shunted group as the changes did not achieve statistical significance with the one exception of SV that decreased from 81.9 to 70.6 mL (a decrease of 13.8%), a fall that compares favorably with the 24.7% decrease for the snared group. Furthermore, there were no measured differences in hemodynamic indices between base line position and recovery position in the shunted group, suggesting that myocardial recovery was both rapid and complete. However, the changes in CI, SV, heart rate, and SVRI persisted into the recovery position measurements in the snared group suggesting that myocardial dysfunction persisted.


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  		Table 2. Left Anterior Descending Coronary Artery Position

 


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  		Fig 1. Changes in cardiac index during the exposure and release positions for the (A) left anterior descending coronary artery, (B) posterior descending coronary artery, and (C) circumflex coronary artery anastomosis in the shunt (open bars) and snare (solid bars) groups. *p less than 0.05 versus baseline.

 
Posterior descending coronary artery anastomoses
The hemodynamic data recorded during posterior descending coronary artery grafting in each of the study groups are summarized in Table 3. In both groups there was a statistically significant decrease in CI (Fig 1B) and SV. However, for each of these indices the decrease was greater in the snared group than in the shunted group (18.1% vs 27.7% and 19.4% vs 31.1%, respectively). Furthermore, in each group there was a statistically significant increase in central venous pressure, but the increase was several-fold higher in the snared group (29.9% and 55.5% increase in the shunted and snared groups, respectively). Heart rate, pulmonary arterial pressure, PCWP, and SVRI increased significantly in the snared group but not in the shunted group. All measured indices returned to the base line values in the recovery position for the shunted group. However, in the snared group, in the recovery position, both SV and CI were significantly lower than base line, and the heart rate, PCWP, and SVRI were still marginally elevated; these findings suggest significant biventricular dysfunction and relatively delayed recovery.


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  		Table 3. Posterior Descending Coronary Artery Position

 
Circumflex anastomoses
The hemodynamic data recorded during circumflex coronary artery grafting in each of the study groups are summarized in Table 4. In both groups there was a statistically significant decrease in CI (Fig 1C), SV, and mean arterial pressure, and a statistically significant increase in central venous pressure, pulmonary arterial pressure, and PCWP. The increase in central venous pressure and PCWP was very similar in both groups. The increase in SVRI was statistically significant in the snared group, but not in the shunted group. However, despite similar trends in hemodynamic changes in both groups, the changes were more marked in the snare group. Thus snare and shunt CI fell by 38.1% versus 25%, and SV fell by 40.5% versus 28.7%, respectively. Furthermore, the snare group demonstrated less rapid recovery as CI and SV were still depressed, and the heart rate and SVRI were still elevated during the recovery position readings, in marked contrast to the shunt group measurements which had already normalized.


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  		Table 4. Circumflex Position

 
Postoperative clinical data are summarized in Table 5, and as shown there were no differences between the two groups.


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  		Table 5. Postoperative Data

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
Acknowledgments
 References
 
Off-pump coronary artery bypass operations through median sternotomy are gaining increased popularity worldwide [1–8]. Exposing posterior branches by displacing the beating heart has been reported to produce hemodynamic compromise both in animals [13, 21] and humans [9] caused by changes in ventricular geometry and valve competence [21]. However, many of these deleterious changes in hemodynamics may be averted by volume loading and use of low-dose intraoperative inotropic agents.

Recently investigators have appreciated that additional regional myocardial dysfunction may be related to the temporary occlusion of the target coronary vessel [14, 15, 22] when this technique is used to perform the anastomosis. Temporary occlusion of the coronary artery results in a bloodless field and therefore aids a precise and accurate anastomosis. However, the use of proximal or distal occlusion of the target vessel, or both, is not without complication as it may be associated with temporary regional ischemia (at the time requiring cardiopulmonary bypass), inadvertent injury to septal coronary artery branches, and damage to the coronary endothelial cells [16]. Thus, Dapunt and colleagues [15] demonstrated severe left ventricular wall motion abnormalities in porcine hearts subjected to LAD coronary artery occlusion in an animal model of operation and also in 40% of patients undergoing Minimally Invasive Direct Coronary Artery Bypass (MIDCAB; CardioThoracic Systems, Inc, Cupertino, CA) operations. Similarly, in patients undergoing a single left internal mammary artery to LAD coronary artery anastomosis on the beating heart, we have demonstrated a significant impairment of left ventricular global and regional wall motion during the construction of the anastomosis. This deterioration of ventricular function was prevented by the use of intracoronary shunts [18].

In the present study we have demonstrated the superiority of intraluminal shunting compared with temporary coronary artery occlusion while performing grafts to all three major coronary systems. These benefits were apparent for each of the three coronary artery systems grafted where there was marked deterioration in ventricular performance in the snared vessels but not in the shunted patients. In addition, recovery was complete after 5 minutes of reperfusion in the shunted vessels, but ventricular dysfunction was still evident in the recovery positions in the snared groups. These findings are consistent with those of other investigators who have found that snaring results in ventricular dysfunction [14, 15, 22] and the use of intracoronary shunts may be protective against ischemia [17]. The nature of these changes is, however, of short duration and of no consequence in terms of myocardial injury. In a recent study [7] we have showed that OPCAB operations were not associated with significant troponin I release. Furthermore, in another study [23] we provided evidence that snaring of the LAD coronary artery during beating heart revascularization does not induce myocardial intracellular damage as assessed by changes in high energy phosphates and metabolite measurements in ventricular biopsies taken during the reperfusion period.

Shunting of coronary arteries during distal anastomosis is not yet widespread because some do not recognize regional ischemic dysfunction as an important clinical problem, and because some consider shunts difficult to insert and potentially injurious to endothelial cells. However, as we have shown in the present study, significant transient hemodynamic changes occur after manipulation of the heart, and some of these adverse alterations may be reduced by using shunts rather than snares. In our experience the use of intracoronary shunts, by improving visualization and avoiding ischemia, allows trainees to perform the anastomoses in an unhurried and technically precise manner, making it a very important tool for teaching OPCAB to residents [24].

In conclusion, this study demonstrates the beneficial effects of using intraluminal coronary shunts in contrast to proximal snaring techniques in preserving intraoperative myocardial function during OPCAB operations in patients with three-vessel coronary artery disease.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
References
 
This work was supported by the British Heart Foundation and the Garfield Weston Trust.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 

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