Thorac Cardiovasc Surg 2011; 59(4): 217-221
DOI: 10.1055/s-0030-1250479
Original Cardiovascular

© Georg Thieme Verlag KG Stuttgart · New York

A Haemodynamic Study during OPCAB Surgery Using a New Multi-Suction Cardiac Positioner

J.-M. Abicht1 , A. Bauer1 , F. Christ1 , C. Vicol2
  • 1Department of Anaesthesiology, Ludwig-Maximilians-University, Munich, Germany
  • 2Department of Cardiac Surgery, Ludwig-Maximilians-University, Munich, Germany
Further Information

Publication History

received May 29, 2010

Publication Date:
15 March 2011 (online)

Abstract

Background: Displacement of the heart is necessary to expose the target vessel for distal anastomosis to achieve successful multivessel off-pump coronary artery bypass (OPCAB) grafting. In addition to complete revascularisation of the heart, a main challenge during the operation is to maintain haemodynamic stability during this procedure. A new heart positioner (Tentacles) was tested. Methods: In a prospective clinical study we used the Tentacles device in 50 patients scheduled for multivessel OPCAB procedures and investigated the haemodynamic effects during displacement of the heart and while performing the anastomoses to the anterior, lateral and posterior wall. The following haemodynamic parameters were investigated: mean arterial blood pressure (MAP), cardiac index (CI) and stroke volume index (SVI). The incidence of myocardial ischaemia was monitored by transoesophageal echocardiography (TEE) and by ST-segment analysis in the electrocardiogram (ECG). Result: The Tentacles device permitted rapid, secure and excellent exposure of the lateral and posterior wall of the heart. During exposure of the anterior wall there was a small decrease in MAP (77 ± 10 vs.71 ± 9 mmHg, p = 0.02) in combination with an increase in the CI (3.0 ± 0.7 l vs. 3.1 ± 0.8 l/min/m2, p = 0.03). When the lateral and posterior walls of the heart were exposed, the SVI decreased significantly (36 ± 11 and 38 ± 8 mL/m2, p < 0.01 and p = 0.04, respectively) compared to baseline (44 ± 11 mL/m2) while CI and MAP remained stable. The amount of norepinephrine administered during displacement of the heart was significantly higher in all three positions (0.05 ± 0.05, 0.06 ± 0.05 and 0.04 ± 0.03 µg/kg/min, p < 0.01) compared to the physiological position (0.02 ± 0.02 µg/kg/min). Sinus rhythm was maintained throughout the operation. Neither significant changes of the ST-segment in the ECG nor incidences of wall motion abnormality in TEE were observed. Six hours postoperatively the troponin I concentration was 11.7 ± 4.3 ng/mL. Conclusion: The Tentacles device provided excellent access in multivessel OPCAB surgery. Haemodynamic stability was maintained in all patients; however additional catecholamine support was used when the heart was displaced. This was the case when carrying out an anastomosis on the anterior, lateral, or posterior wall.

References

  • 1 American Heart Association .Heart Disease and Stroke Statistics – 2007 Update.. Dallas, Texas: American Heart Association; 2007
  • 2 Parolari A, Alamanni F, Polvani G et al. Meta-analysis of randomized trials comparing off-pump with on-pump coronary artery bypass graft patency.  Ann Thorac Surg. 2005;  80 (6) 2121-2125
  • 3 Cleveland J C, Shroyer A L, Chen A Y, Peterson E, Grover F L. Off-pump coronary artery bypass grafting decreases risk-adjusted mortality and morbidity.  Ann Thorac Surg. 2001;  72 1282-1288
  • 4 Weerasinghe A, Athanasiou T, Al-Ruzzeh S et al. Functional renal outcome in on-pump and off-pump coronary revascularization: a propensity-based analysis.  Ann Thorac Surg. 2005;  79 1577-1583
  • 5 Plomondon M E, Cleveland Jr J C, Ludwig S T et al. Off-pump coronary artery bypass is associated with improved risk adjusted outcomes.  Ann Thorac Surg. 2001;  72 114-119
  • 6 Cheng W, Denton T A, Fontana G P et al. Off-pump coronary surgery: effect on early mortality and stroke.  J Thorac Cardiovasc Surg. 2002;  124 313-320
  • 7 Lima R. Surgical techniques of coronary artery exposure.. In: Salerno TA, Ricci M, Karamanoukian H L, D'Ancona G, Bergsland J, eds. Beating Heart Coronary Artery Surgery.. Armonk: Futura Publishing Company; 2001: 21-34
  • 8 Spooner T H, Hart J C, Pym J. A two-year, three institution experience with the Medtronic Octopus: systemic off-pump surgery.  Ann Thorac Surg. 1999;  68 1478-1481
  • 9 Ricci M, Karamanoukian H L, D'Ancona G et al. Exposure and mechanical stabilization in off-pump coronary artery bypass grafting via sternotomy.  Ann Thorac Surg. 2000;  70 1736-1740
  • 10 Dullum M K, Resano F G. Xpose: a new device that provides reproducible and easy access for multivessel beating heart bypass grafting.  Heart Surg Forum. 2000;  3 113-118
  • 11 Connolly M W, Subramanian V A. Mechanical stabilization system: the Guidant OPCAB system.. In: Goldstein D J, Oz M C, eds. Minimally Invasive Cardiac Surgery.. 2nd ed. Totowa: Humana Press; 2004: 105-112
  • 12 Arai H, Mizuno T, Yoshizaki T et al. A new multisuction cardiac positioner for multivessel off-pump coronary artery bypass grafting.  Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery. 2006;  1 (3) 126-130
  • 13 Roques F, Michel P, Goldstone A R, Nashef S A. The logistic EuroSCORE.  Eur Heart J. 2003;  24 (9) 882-883
  • 14 Magee M J, Alexander J H, Hafley G et al. PREVENT IV Investigators. Coronary artery bypass graft failure after on-pump and off-pump coronary artery bypass: findings from PREVENT IV.  Ann Thorac Surg. 2008;  85 (2) 494-499
  • 15 Sellke F W, DiMaio J M, Caplan L R et al. Comparing on-pump and off-pump coronary artery bypass grafting: numerous studies but few conclusions: a scientific statement from the American Heart Association Council on cardiovascular surgery and anesthesia in collaboration with the interdisciplinary working group on quality of care and outcomes research. American Heart Association.  Circulation. 2005;  111 (21) 2858-2864
  • 16 Shroyer A L, Grover F L, Hattler B Veterans Affairs Randomized On/Off Bypass (ROOBY) Study Group et al. On-pump versus off-pump coronary-artery bypass surgery.  N Engl J Med. 2009;  361 (19) 1827-1837
  • 17 Chang W I, Kim K B, Kim J H, Ham B M, Kim Y L. Hemodynamic changes during posterior vessel off-pump coronary artery bypass: comparison between deep pericardial sutures and vacuum-assisted apical suction device.  Ann Thorac Surg. 2004;  78 (6) 2057-2062
  • 18 Beckman D J, Bumb K, Bandy M, Evans M, Romanyk C. Evaluation of hemodynamics: comparison of vacuum and mechanical stabilization in the beating heart.  Heart Surg Forum. 2003;  6 (4) 220-223
  • 19 Gründeman P F, Budde R, Beck H M, van Boven W J, Borst C. Endoscopic exposure and stabilization of posterior and inferior branches using the EndoStarfish cardiac positioner and the EndoOctopus stabilizer for closed-chest beating heart multivessel CABG: hemodynamic changes in the pig.  Circulation. 2003;  108 (Suppl. 1) II34-II38
  • 20 Gründeman P F, Borst C, Verlaan C W, Damen S, Mertens S. Hemodynamic changes with right lateral decubitus body positioning in the tilted porcine heart.  Ann Thorac Surg. 2001;  72 (6) 1991-1996
  • 21 Gründeman P F, Borst C, Verlaan C W, Meijburg H, Mouës C M, Jansen E W. Exposure of circumflex branches in the tilted, beating porcine heart: echocardiographic evidence of right ventricular deformation and the effect of right or left heart bypass.  J Thorac Cardiovasc Surg. 1999;  118 (2) 316-323
  • 22 Gründeman P F, Verlaan C W, van Boven W J, Borst C. Ninety-degree anterior cardiac displacement in off-pump coronary artery bypass grafting: the Starfish cardiac positioner preserves stroke volume and arterial pressure.  Ann Thorac Surg. 2004;  78 (2) 679-685
  • 23 Schmauss D, Kaczmarek I, Beiras-Fernandez A et al. Tentacles: a novel device for exposing the heart for the insertion of left apical assist device cannulae.  Heart Surg Forum. 2009;  12 (2) E116-E118
  • 24 Michel S, Kaczmarek I, Beiras-Fernandez A et al. Off-pump coronary surgery for allograft vasculopathy 8 years after heart transplant.  Exp Clin Transplant. 2009;  7 (4) 261-263
  • 25 Serruys P W, Morice M C, Kappetein A P SYNTAX Investigators et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.  N Engl J Med. 2009;  360 (10) 961-972
  • 26 Takagi H, Matsui M, Umemoto T. Off-pump coronary artery bypass may increase late mortality: a meta-analysis of randomized trials.  Ann Thorac Surg. 2010;  89 (6) 1881-1888

Dr. Jan-Michael Abicht

Department of Anaesthesiology
Ludwig-Maximilians-University

Marchioninistr. 15

81377 Munich

Germany

Phone: +49 89 70 95 64 19

Fax: +49 89 70 95 88 86

Email: jabicht@med.uni-muenchen.de