Asian Cardiovasc Thorac Ann 2007;15:123-126
© 2007 Asia Publishing EXchange Ltd
Deep Pericardial Suture vs Apical Suction for Off-Pump Bypass Grafting
Hasim Ustunsoy, MD,
Hakki Kazaz, MD,
Mehmet A Celkan, MD,
Celalettin Kayiran, MD,
Rengin Hayta, MD,
Ekrem Bayar, MD
Department of Cardiovascular Surgery, Gaziantep University School of Medicine, Gaziantep, Turkey
For reprint information contact: Hakki Kazaz, MD Tel/Fax: 90 342 360 1126 Email: hakki{at}kazaz.info, Department of Cardiovascular Surgery, Gaziantep University School of Medicine, Universite Bul Kilis yolu, Gaziantep, Turkey.
 |
ABSTRACT
|
|---|
Hemodynamic changes during heart luxation and stabilization are major problems in off-pump coronary artery bypass surgery. The hemodynamic effects of an apical suction device were compared with those of the classic posterior pericardial suture in 45 patients with multivessel coronary disease undergoing off-pump coronary artery bypass. Mean age was 63.78 ± 8.11 years; 31 patients were male and 14 were female. Transesophageal Doppler echocardiography was used for hemodynamic monitoring. All hemodynamic parameters were significantly better when the apical suction device was used to position the heart for anastomoses on the posterior descending and circumflex arteries.
|
INTRODUCTION
|
|---|
Off-pump coronary artery bypass (OPCAB) is an increasingly widespread procedure. To avoid the deleterious effects of cardiopulmonary bypass, less invasive coronary artery bypass grafting has evolved and become safer with continued pharmacological and mechanical innovation. Tissue stabilizers and heart positioning systems allow complete revascularization by OPCAB.1–4 Experienced surgeons are applying the technique to an increasing proportion of their patients, and are able to revascularize all coronary territories. It is most important that the heart tolerates luxation and tissue stabilization with good hemodynamics. The Starfish apical suction heart positioning system (Medtronic, Minneapolis, MN, USA) was designed to ensure well-tolerated heart luxation. We compared the hemodynamic effects of this system with the classic posterior pericardial suture procedure for heart position during OPCAB surgery.
|
PATIENTS AND METHODS
|
|---|
In this prospective study, 45 patients with multivessel coronary disease undergoing OPCAB were randomly divided into two groups. In 23 patients, a deep pericardial suture was used to position the heart for grafting the left anterior descending coronary artery (LAD), and the apical suction system was used to position the heart for circumflex (Cx) and posterior descending coronary artery (PDA) anastomoses. In the other 22 patients, the deep pericardial suture technique was used for all anastomoses. The Octopus III heart stabilizer (Medtronic, Minneapolis, MN, USA) was used during the anastomoses in all patients. There was no selection process for OPCAB candidates. The demographic data are summarized in Table 1
. Transesophageal Doppler echocardiography (HemoSonic 100; Arrow International, Reading, PA, USA) was used for hemodynamic monitoring.
All patients underwent a standard median sternotomy. The electrocardiogram was monitored continuously to detect myocardial ischemia, and cardiac enzymes were analyzed routinely 4 times in the first 24 hours. Additional cardiac enzyme measurements were carried out if ischemia was detected on the electrocardiogram. In our routine protocol, norepinephrine, dopamine, and nitroglycerin boluses or infusions or both are administered in combination with body position changes and gravity support to stabilize hemodynamics and maintain mean arterial pressure > 70 mm Hg, but in this study, we excluded 3 patients who need positive inotropics. Pericardial widening (a vertical incision in the pericardium from the surface of the inferior vena cava to the junction of the diaphragmatic surface and right pleura) was employed. The surgical table was routinely rotated rightwards and the Trendelenburg position (right and left table rotations) was used to stabilize hemodynamics and assist in exposing the posterior coronary territory, and to maintain right ventricular preload. The left internal thoracic artery was anastomosed to the left anterior descending artery first. Complete revascularization was performed in all patients using arterial grafts (internal thoracic and radial arteries) and saphenous vein if needed. Before anastomosis with each of the techniques, hemodynamic parameters were measured: cardiac output, stroke volume, aortic blood flow, total systemic vascular resistance, and peak velocity.
All parameters were compared using the Wilcoxon signed-ranks test.
|
RESULTS
|
|---|
There was no operative mortality. No patient was converted to cardiopulmonary bypass. Myocardial infarction was not encountered. Aortic blood flow, heart rate, and stroke volume measurements were used to calculate left ventricular systolic blood volume ejected into the descending aorta. Mean arterial pressure and systemic vascular resistance in conjunction with stroke volume provides an assessment of afterload. Cardiac output measurements demonstrated a significant difference between the 2 methods of positioning the heart during Cx anastomosis (Table 2) and PDA (Table 3). Similar results were found for the other parameters.
View this table:
[in this window]
[in a new window]
|
Table 2. Hemodynamic Differences Between the Starfish System and Deep Pericardial Suture for Circumflex Anastomoses
|
|
View this table:
[in this window]
[in a new window]
|
Table 3. Hemodynamic Differences Between the Starfish System and Deep Pericardial Suture for Posterior Descending Coronary Artery Anastomoses
|
|
|
DISCUSSION
|
|---|
The postulated benefits of OPCAB are reduced morbidity, a shorter hospital stay and convalescence period, lower costs, equivalent angiographic graft quality and event-free survival in the first year after the procedure, and increased patient comfort compared to conventional coronary artery bypass on cardiopulmonary bypass.2,5,6 However, patient selection, effective epicardial stabilization, and heart positioning appear to be crucial.5 During off-pump surgery, hemodynamic monitoring is very important but it has not been standardized. A pulmonary artery catheter, and transesophageal echocardiography have been used with some difficulties (tricuspid valve regurgitation, arrhythmia, undetectable wall ischemia). Determination of aortic blood flow by transesophageal Doppler echocardiography has been proposed as a less invasive hemodynamic monitoring method. It offers accuracy equal to that of the right heart catheter.7 This method gives noninvasive continuous real-time monitoring of aortic blood flow, descending aortic diameter, and cardiac output.
Initial experiences with a heart stabilization device were limited to vessels on the anterior surface of the heart, which were easily bypassed with excellent stabilization.8 Lateral and posterior vessels pose greater technical challenges because hemodynamic tolerance to the cardiac displacement necessary for exposure is poor. Following experimental evaluation of the hemodynamic consequences of vertical cardiac displacement, techniques evolved, and gradually more surfaces of the heart could be approached safely.9 Excellent stabilization with good hemodynamic tolerance allowed complete revascularization. The tolerance of the heart to luxation is very important. Many reports do not specify whether additional traction was used to position the heart, but of those that did, 2 used pericardial sutures and 3 used a suture and swab or suture and sponge/laparotomy pad combination.10–14 In the last few years with the development of mechanical supports, heart positioning is safer. For PDA and Cx anastomosis, the apical suction heart positioner system has made OPCAB easier and safer. However, these supports produce additional operative costs, and the question of whether they are cost effective is still unresolved. It is also very important to widen the pericardium for maximum heart relaxation during cardiac displacement. Pericardial widening helps the positioning and hemodynamic stabilization. This gave us 1.5–2.5 times more space in the pericardial cavity. This procedure decreases tension on the heart and great vessels during cardiac displacement.
The decrease in cardiac output during anastomoses on the posterior coronary arteries was greater when the deep posterior pericardial suture was used for heart positioning, compared to the apical suction device. There were also significant differences between the two groups in terms of flow and volumetric parameters in our study. Monitoring mean arterial pressure and systemic vascular resistance in conjunction with stroke volume can provide an assessment of afterload.15 We found a significantly greater increase in these afterload parameters when the deep pericardial suture technique was used, compared to the apical suction device. The left ventricular contractility and systolic time interval was used for assessment of left ventricular performance. Monitoring this parameter improves our understanding of the altered contractile events that accompany left ventricular decompensation, and provides a sensitive measure of the effects of pharmacological agents on the heart.15 Maximum acceleration of aortic flow has been validated as a sensitive indicator of global left ventricular performance and myocardial contractility.15
Our results indicate that the differences between the two positioning methods were greater during Cx anastomosis. This was attributed to the fact that Cx anastomosis was performed before the PDA anastomosis, thus a greater area of the heart was perfused during PDA anastomosis. Furthermore, it is well known that the traction and mobilization necessary for Cx anastomosis are more distorting to heart anatomy. The most important problem with apical suction heart positioning is damage due to suction pressure on the myocardium. Experimental studies showed that at the pressure needed, which is less than 450 mm Hg, the damage should be minimal and reversible.16–19 The area where the apical suction positioner is sited must be free from coronary vessels and contain thick fat tissue above the myocardium. In most cases, thick fat serves as a pillow to limit the damage of suction pressure on the myocardium. This damage disappears in a few minutes.
It was concluded from this study that the apical suction heart positioner was safe and useful in controlling hemodynamic stability during OPCAB, with superior results compared to the classic deep pericardial suture.
Presented at the 14th Annual Meeting of the Mediterranean Association of Cardiology and Cardiac Surgery, Rhodes, Greece, December 9–12, 2002.
|
REFERENCES
|
|---|
- Scott NA, Knight JL, Bidstrup BP, Wolfenden H, Linacre RN, Maddern GJ. Systematic review of beating heart surgery with the Octopus Tissue Stabilizer. Eur J Cardiothorac Surg 2002;21:804–17.[Abstract/Free Full Text]
- Borst C, Grundeman PF. Minimally invasive coronary artery bypass grafting: an experimental perspective. Circulation 1999;99:1400–3.
- Borst C, Santamore WP, Smedira NG, Bredee JJ. Minimally invasive coronary artery bypass grafting: on the beating heart and via limited access. Ann Thorac Surg 1997;63(6 Suppl):S1–5.[Medline]
- Nierich AP, Diephuis J, Jansen EW, van Dijk D, Lahpor JR, Borst C, et al. Embracing the heart: perioperative management of patients undergoing off-pump coronary artery bypass grafting using the octopus tissue stabilizer. J Cardiothorac Vasc Anesth 1999;13:123–9.[Medline]
- Bredee JJ, Jansen EW. Coronary artery bypass grafting without cardiopulmonary bypass. Curr Opin Cardiol 1998;13:476–82.[Medline]
- Arom KV, Emery RW, Nicoloff DM, Flavin TF, Emery AM. Minimally invasive direct coronary artery bypass grafting: experimental and clinical experiences. Ann Thorac Surg 1997;63(6 Suppl):S48–52.[Medline]
- Cariou A, Monchi M, Joly LM, Bellenfant F, Claessens YE, Thebert D, et al. Noninvasive cardiac output monitoring by aortic blood flow determination: evaluation of the Somotec Dynemo-3000 system. Crit Care Med 1998;26:2066–72.[Medline]
- Hart JC, Spooner TH, Pym J, Flavin TF, Edgerton JR, Mack MJ, et al. A review of 1,582 consecutive Octopus off-pump coronary bypass patients. Ann Thorac Surg 2000;70:1017–20.[Abstract/Free Full Text]
- Grundeman PF, Borst C, Verlaan CW, Meijburg H, Moues CM, Jansen EW. 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;118:316–23.[Abstract/Free Full Text]
- Baker RA, Andrew MJ, Ross IK, Knight JL. The Octopus II stabilizing system: biochemical and neuropsychological outcomes in coronary artery bypass surgery. Heart Surg Forum 2001;4 Suppl 1:S19–23.
- Matata BM, Sosnowski AW, Galinanes M. Off-pump bypass graft operation significantly reduces oxidative stress and inflammation. Ann Thorac Surg 2000;69:785–91.[Abstract/Free Full Text]
- Kappert U, Gulielmos V, Knaut M, Cichon R, Schneider J, Schueler S. The application of the Octopus stabilizing system for the treatment of high risk patients with coronary artery disease. Eur J Cardiothorac Surg 1999;16 Suppl 2:S7–9.[Abstract/Free Full Text]
- Perkowski DJ, Marcus AO, Wagner SL, Gorman LM. Optimizing off-pump coronary artery bypass graft: technical and metabolic aspect. Heart Surg Forum 2001;4:80–8.[Medline]
- Ardehali A, Kessler D, Foroushani F, Laks H. Multivessel coronary artery bypass surgery without cardiopulmonary bypass. Am Heart J 1999;138(5 Pt 1):983–6.[Medline]
- Boulnois JL, Pechoux T. Non-invasive cardiac output monitoring by aortic blood flow measurement with the Dynemo 3000. J Clin Monit Comput 2000;16:127–40.[Medline]
- Nierich AP, Diephuis J, Jansen EW, Borst C, Knape JT. Heart displacement during off-pump CABG: how well is it tolerated? Ann Thorac Surg 2000;70:466–72.[Abstract/Free Full Text]
- Jansen EW, Grundeman PF, Borst C, Eefting F, Diephuis J, Nierich A, et al. Less invasive off-pump CABG using a suction device for immobilization: the ‘Octopus’ method. Eur J Cardiothorac Surg 1997;12:406–12.[Abstract]
- Jansen EW, Borst C, Lahpor JR, Grundeman PF, Eefting FD, Nierich A, et al. Coronary artery bypass grafting without cardiopulmonary bypass using the octopus method: results in the first one hundred patients. J Thorac Cardiovasc Surg 1998;116:60–7.[Abstract/Free Full Text]
- Spooner TH, Hart JC, Pym J. A two-year, three institution experience with the Medtronic Octopus: systematic off-pump surgery. Ann Thorac Surg 1999;68:1478–81.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
P. Saxena and R. Tam
PAPAVERINE HYDRODISSECTION OF INTERNAL THORACIC ARTERY
Asian Cardiovasc Thorac Ann,
December 1, 2007;
15(6):
542 - 542.
[Full Text]
[PDF]
|
|
|
TOP
ABSTRACT
INTRODUCTION
