Conventional CABG Or On Pump Beating Heart: A Difference In Myocardial Injury?

Transcription

1 Conventional CABG Or On Pump Beating Heart: A Difference In Myocardial Injury? Kornelis J. Koopmans Medical Center Leeuwarden Leeuwarden, The Netherlands

2 I have no disclosures Disclosures

3 Different techniques of Extra Corporeal Circulation for CABG In our hospital: Conventional CABG > heart lung machine, full bypass, cross clamping and cardioplegic arrest (CCABG) On Pump Beating Heart > Cardiohelp, partial bypass, no cross clamp (OPBH) Cannulation in both situations: aorta/two stage venous canula

4 Golden standard in cardiac surgery Safe and reliable way to perform cardiac surgery Possible adverse effects: Inflammatory response activation Coagulation disorders Micro-embolisation Hemodilution Conventional CABG Cross clamping with cardiac arrest > ischemia

5 On Pump Beating Heart Minimized system (Cardiohelp) Use of stabilizer No cardiac arrest Luxation of the heart is not a problem > increasing the flow reduces the preload Positioning of the heart is simple, although it is not completely empty Low risk of introducing venous air by active suction Disadvantages compared to conventional CABG can be reduced by minimized system

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7 Literature: CCABG versus OPBH OPBH: a safe and simple technique > alternative for reduced ventricular function or acute myocardial infarction Significant reduction of myocardial injury by use OPBH compared to conventional CABG Most common use: high risk patients with ejection fraction < 30% What about patients with an ejection fraction >30%? Fouda M.: Coronary artery bypass surgery with on-pump beating-heart technique.asiancardiovascthorac Ann Oct;15(5): Perrault LP, Menasché P, Peynet J, Faris B, Bel A, de Chaumaray T, Gatecel C, Touchot B, Bloch G, Moalic JM.: On-pump, beating-heart coronary artery operations in high-risk patients: an acceptable trade-off? AnnThorac Surg Nov;64(5): Ferrari E, Stalder N, von Segesser LK.: On-pump beating heart coronary surgery for high risk patients requiring emergency multiple coronary artery bypass grafting. JCardiothorac Surg Jul 2;3:38. Folliguet TA, Philippe F, Larrazet F, Dibie A, Czitrom D, Le Bret E, Bachet J, Laborde F.: Beating heart revascularization with minimal extracorporeal circulation in patients with a poor ejection fraction.heartsurg Forum. 2002;6(1): Izumi Y, Magishi K, Ishikawa N, Kimura F.: On-pump beating-heart coronary artery bypass grafting for acute myocardial infarction. AnnThorac Surg Feb;81(2):573-6.

8 Primary: Is there a difference in myocardial injury in patients with EF > 30% who underwent CCABG or OPBH? Hypothesis: Expectation: less myocardial injury using OPBH Secondary: The aim Is there a difference in postoperative left ventricle function? This in relation of the use of inotropics and postoperative echo?

9 Method Permission local ethics committee Written informed consent 40 patients: prospective randomized trial 20 patients CCABG 20 patients OPBH Inclusion criteria Elective CABG Age:18 85 years

10 Exclusion criteria Combined procedures Re-do CABG EF < 30% Severe aortic calcifications Renal dysfunction Anemia: Ht < 35% Known pathology leading to clotting disorders Increased pre-op cardiac markers

11 Extra corporeal circulation CCABG OPBH HLM HL30 Cardiohelp HCU HCU40 HU35 Priming 1500 ml 600 ml Temperature 34.0 C (93.2 F) 37.0 C (98.6 F) Cardioplegia St. Thomas II No cardioplegia ECC-flow 2.6 l/min/m ,6 l/min/m 2 Ventilation Stop during ECC Adjust, don t stop

12 Time table

13 Statistics Continuous variables Kolmogorov-Smirnov-test Mean and standard deviation: unpaired t-test Median en confidance interval: Mann-Whitney U-test Categorical variable: Chi-square test A value of p < 0.05 was considered significant

14 Exclusion of 4 patients Results Group OPBH OPBH CCABG CCABG Reason unexpected increased Troponin T preoperative postoperative increased cardiac markers by infarction in ungraftable area; angiogram shows good function of grafts anaphylactic shock: fluids and inotropics not enough graft material available; successful PCI Postoperative: 2 cancellations (1 OPBH and 1 CCABG) for postoperative echo

15 Variables CCABG (n=18) OPBH (n=18) P-value Man 15 (83.3%) 14 (77.8%) Age (years) 61.4 ± ± Body surface area (m 2 ) 2.08 ± ± Euroscore I 2.0 ± ± Predicted mortality EUI 1.88 ± ± Predicted mortality EUII 1.63 ± ± Coronary sclerosis 1-vessel disease 0 (0%) 1 (5.6%) vessel disease 6 (33.3%) 5 (27.8%) vessel disease 12 (66.7%) 12 (66.7%) Left main disease 2 (11.1%) 1 (5.6%) Ejection fraction left ventricle 50% 17 (94.4%) 14 (88.9%) % 1 (5.9%) 4 (11.1%) Diabetes Mellitus 5 (27.8%) 4 (22.2%) Insulin dependent DM 1 (5.6%) 1 (5.6%) 1.000

16 Results: peroperative Variable CCABG (n=18) OPBH (n=18) P-value CPB-time (min) 94 ± ± Cross clamp time (min) 58 ± Total number of distal anastomoses 3.8 ± ±

17 Troponin T (ng/l) After induction 10 min after protamin Arrival ICU 4 hrs after arrival ICU 10 hrs after arrival ICU CCABG 11 (4-19) 112 (95-146) 206 ( ) 272 ( ) 265 ( ) OPBH 0 (4-17) 85 (83-149) 124 ( ) 183 ( ) 189 ( ) P-value CK (U/l) CCABG 75 (58-123) 238 ( ) 310 ( ) 368 ( ) 393 ( ) OPBH 57 (48-99) 108 (93-135) 155 ( ) 155 (22-424) 379 ( ) P-value CK-MB (U/l) CCABG 7 (3-9) 21 (17-26) 21 (18-26) 24 (19-27) 21 (18-27) OPBH 10 (5-16) 15 (14-21) 16 (15-21) 19 (18-27) 22 (19-32) P-value

18 Results: myocardial injury

19 Results: myocardial injury

20 Results: myocardial injury

21 Results: postoperative Variable CCABG (n=18) OPBH (n=18) P-value Haemodynamics Use of inotropics (no. of patients) 1 (5.6%) 3 (16.7%) Ventilation time Ventilation time at ICU (hours) 3.5 ( ) 3.5 ( ) ICU stay ICU stay (hours) 20.1 ( ) 20.4 ( ) 1.000

22 Results: postoperative Variable CCABG (n=17) OPBH (n=17) P-value Postoperative ejection fraction LV 50 % 16 (94.1%) 16 (94.1%) % 1 (5.9%) 1(5.9%) Postoperative echo New wall motion abnormalities 1 (5.9%) New valve abnormalities Improved wall motion compared to pre-operative 8 (47.1%) 7 (41.2%) 0.730

23 Fluid balance; Blood loss; Use of blood products

24 Variable CCABG (n=18) OPBH (n=18) P-value Fluid balance Fluid balance pre-cpb (ml) 55 ± ± Fluid balance per-cpb (ml) 1748 ± ± Fluid balance post-cpb (ml) -181 ± ± Total fluid balance (ml) 1622 ± ± Blood loss Blood loss OR (ml) 960 ( ) 1738 ( ) Blood loss ICU (ml) 498 ( ) 498 ( ) Total blood loss (ml) 1405 ( ) 2210 ( ) Blood transfusion Transfusion erythrocytes cellsaver (ml) 200 ( ) 567 ( ) Transfusion erythrocytes (no. of patients) 1 (5.6%) 1 (5.6%) Transfusion platelets (no. of patients) 0 0 Transfusion FFP (no. of patients) 0 0 Transfusie Haemocomplettan / fibrinogen (no. of patients) 1 (5.6%) 3 (16.7%) 0.289

25 Primary: In patients with an ejection fraction > 30%: OPBH shows a trend of reduced myocardial injury OPBH presents a significantly lower CK level Secondary: No difference in the use of inotropics, ventilation time, postoperative echo and stay at the ICU. Additional: Conclusion No difference in use of blood products in relation to the fluid balance in spite of a significant difference in blood loss

26 Conventional CABG Or On Pump Beating Heart: A Difference In Myocardial Injury? Kornelis J. Koopmans Medical Center Leeuwarden Leeuwarden, The Netherlands kees.koopmans@znb.nl