Ann Thorac Surg 2002;73:1417
© 2002 The Society of Thoracic Surgeons
Invited commentary
John D. Puskas, MD, MSc, FACS, Associate Professor of Surgery (Cardiothoracic)a
a Emory University School of Medicine, Crawford Long Hospital, 550 Peachtree Street, NE, 6th Floor Medical Office Tower, Atlanta, GA 30308 USA
e-mail: John_puska{at}emoryhealthcare.org
Dr Yeatman and colleagues have addressed an important question, namely, whether hemodynamic derangements during off-pump coronary bypass surgery (OPCAB) are ameliorated by the use of an intracoronary shunt, rather than simple proximal snaring. The authors chose hemodynamic endpoints at baseline (5 minutes before cardiac manipulation), "expose position" (5 minutes into the construction of each coronary distal anastomosis), and "recovery position" (5 minutes after completion of each coronary anastomosis). There was no measurement at the end of the operation, prior to chest closure, or later in the ICU, to serve as a final comparison between these two groups.
The clinical significance between groups is unclear for two reasons. First, the magnitude of the difference observed between groups, although reaching statistical significance in several comparisons, was not impressive in an absolute sense. Indeed, the difference in decline in mean arterial pressure between groups in the LAD position was 1 mm Hg. Similarly, the difference in increase in pulmonary capillary wedge pressure was 1.4 mm Hg. Although these changes have reportedly reached statistical significance, their clinical significance is questionable. Second, the duration of these changes is not demonstrated by the present data. Indeed, all patients in both groups did well throughout clinical course and none were reported to have suffered a low cardiac output state in the intensive care unit. Finally, no mention is made in the present report of several published papers documenting injury to endothelium by the use of intracoronary shunts. The clinical relevance, both short and long term, of the denuding of coronary endothelium that must accompany the use of intracoronary shunts is uncertain. However, this obigatory risk must be balanced by documented clinical benefit before routine use of intracoronary shunts can be recommended. At present, a more cautious approach may be to use intracoronary shunts selectively, for those cases and circumstances where critical ischemia poses a direct and clear threat to hemodynamic stability, and to avoid the use of intracoronary shunts on those routine anastomoses where they have little demonstrable benefit.
Related Article
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Intracoronary shunts reduce transient intraoperative myocardial dysfunction during off-pump coronary operations
- Mark Yeatman, Massimo Caputo, Pradeep Narayan, Arup Kumar Ghosh, Raimondo Ascione, Ian Ryder, and Gianni D. Angelini
Ann. Thorac. Surg. 2002 73: 1411-1417.
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