Conventional CABG Or On Pump Beating Heart: A Difference In Myocardial Injury? Kornelis J. Koopmans Medical Center Leeuwarden Leeuwarden, The Netherlands
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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
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
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
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. 2007 Oct;15(5):392-5. 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. 1997 Nov;64(5):1368-73. 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. 2008 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):19-23. Izumi Y, Magishi K, Ishikawa N, Kimura F.: On-pump beating-heart coronary artery bypass grafting for acute myocardial infarction. AnnThorac Surg. 2006 Feb;81(2):573-6.
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?
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
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
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 2 1.3 2,6 l/min/m 2 Ventilation Stop during ECC Adjust, don t stop
Time table
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
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
Variables CCABG (n=18) OPBH (n=18) P-value Man 15 (83.3%) 14 (77.8%) 0.674 Age (years) 61.4 ± 9.6 67.1 ± 9.1 0.077 Body surface area (m 2 ) 2.08 ± 0.15 1.94 ± 0.22 0.040 Euroscore I 2.0 ± 1.8 3.1 ± 0.22 0.083 Predicted mortality EUI 1.88 ± 0.99 2.49 ± 1.21 0.108 Predicted mortality EUII 1.63 ± 0.83 1.91 ± 0.78 0.308 Coronary sclerosis 1-vessel disease 0 (0%) 1 (5.6%) 0.310 2-vessel disease 6 (33.3%) 5 (27.8%) 0.717 3-vessel disease 12 (66.7%) 12 (66.7%) 1.000 Left main disease 2 (11.1%) 1 (5.6%) 0.546 Ejection fraction left ventricle 50% 17 (94.4%) 14 (88.9%) 0.289 30 50 % 1 (5.9%) 4 (11.1%) 0.289 Diabetes Mellitus 5 (27.8%) 4 (22.2%) 0.700 Insulin dependent DM 1 (5.6%) 1 (5.6%) 1.000
Results: peroperative Variable CCABG (n=18) OPBH (n=18) P-value CPB-time (min) 94 ± 25 85 ± 20 0.260 Cross clamp time (min) 58 ± 18 0 0.000 Total number of distal anastomoses 3.8 ± 1.2 3.0 ± 0.7 0.015
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 (167-233) 272 (249-336) 265 (235-364) OPBH 0 (4-17) 85 (83-149) 124 (120-224) 183 (164-332) 189 (171-321) P-value 0.879 0.255 0.056 0.028 0.051 CK (U/l) CCABG 75 (58-123) 238 (188-317) 310 (235-362) 368 (337-522) 393 (370-650) OPBH 57 (48-99) 108 (93-135) 155 (134-187) 155 (22-424) 379 (316-617) P-value 0.159 0.000 0.000 0.033 0.506 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 0.326 0.155 0.038 0.247 0.716
Results: myocardial injury
Results: myocardial injury
Results: myocardial injury
Results: postoperative Variable CCABG (n=18) OPBH (n=18) P-value Haemodynamics Use of inotropics (no. of patients) 1 (5.6%) 3 (16.7%) 0.289 Ventilation time Ventilation time at ICU (hours) 3.5 (2.6-5.7) 3.5 (2.9-7.3) 0.681 ICU stay ICU stay (hours) 20.1 (18.6-20.5) 20.4 (17.9-25.1) 1.000
Results: postoperative Variable CCABG (n=17) OPBH (n=17) P-value Postoperative ejection fraction LV 50 % 16 (94.1%) 16 (94.1%) 1.000 30-49 % 1 (5.9%) 1(5.9%) 1.000 Postoperative echo New wall motion abnormalities 1 (5.9%) 0 0.310 New valve abnormalities 0 0 1.000 Improved wall motion compared to pre-operative 8 (47.1%) 7 (41.2%) 0.730
Fluid balance; Blood loss; Use of blood products
Variable CCABG (n=18) OPBH (n=18) P-value Fluid balance Fluid balance pre-cpb (ml) 55 ± 267 828 ± 661 0.000 Fluid balance per-cpb (ml) 1748 ± 442 1325 ± 801 0.058 Fluid balance post-cpb (ml) -181 ± 397-500 ± 696 0.100 Total fluid balance (ml) 1622 ± 548 1652 ± 972 0.908 Blood loss Blood loss OR (ml) 960 (872-1120) 1738 (1246-2165) 0.007 Blood loss ICU (ml) 498 (437-656) 498 (443-653) 0.849 Total blood loss (ml) 1405 (1370-1715) 2210 (1742-2764) 0.009 Blood transfusion Transfusion erythrocytes cellsaver (ml) 200 (158-245) 567 (401-839) 0.000 Transfusion erythrocytes (no. of patients) 1 (5.6%) 1 (5.6%) 1.000 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
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
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