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The Annals of Thoracic Surgery, Vol 58, 1040-1049, Copyright © 1994 by The Society of Thoracic Surgeons
GT Christakis, SE Fremes, JP Koch, S Harwood, S Juhasz, E Sharpe, KA Deemar, C Hamilton, E Chen and V Rao
Although low systemic vascular resistance occurs during normothermic and
hypothermic cardiopulmonary bypass, the determinants of depressed systemic
vascular resistance and its effect on outcomes are unknown. To assess the
predictors and clinical effects of low systemic vascular resistance, 555
patients undergoing isolated coronary artery bypass grafting were evaluated
prospectively. The extent of low systemic vascular resistance during bypass
was estimated by the amount of the vasoconstrictor phenylephrine
administered: group 1, 0 to 160 micrograms; group 2, 161 to 800 micrograms;
group 3, more than 800 micrograms. Multivariate analysis identified bypass
temperature, bypass time, and ventricular function as determinants of low
systemic vascular resistance. Patients on normothermic bypass accounted for
65% of the patients in group 3 and only 34% of the patients in group 1 (p
< 0.0001). The bypass time was longer in the patients in group 3 (97 +/-
28 minutes) than in the patients in group 1 (89 +/- 24 minutes; p <
0.006). Patients with a preoperative left ventricular ejection fraction of
0.40 or less required less phenylephrine during cardiopulmonary bypass (498
+/- 68 micrograms) than did patients with a fraction exceeding 0.40 (1,087
+/- 88 micrograms; p < 0.001). By multivariate analysis, advanced age
and the presence of peripheral vascular disease were found to decrease the
likelihood of low systemic vascular resistance during normothermic bypass.
Diabetes, the left ventricular ejection fraction, the bypass time, and the
total cardioplegia infused were found to influence the likelihood of low
systemic vascular resistance during hypothermic bypass. Patients in group 3
had a higher cardiac index and lower-mean arterial pressure and systemic
vascular resistance postoperatively. In those patients who received a left
internal mammary artery graft, the incidences of the low-output syndrome
(group 1, 4.9%; group 3, 2.7%; p = not significant) and myocardial
infarction (group 1, 1.4%; group 3, 1.8%; p = not significant) were not
influenced by the amount of phenylephrine infused during cardiopulmonary
bypass. In those patients who were at high risk of suffering a stroke
preoperatively, the hypotension induced by the low systemic vascular
resistance and its treatment with phenylephrine was not associated with an
increased incidence of stroke (group 1, 5.8%; group 3, 2.8%; p = not
significant).
ARTICLES
Determinants of low systemic vascular resistance during cardiopulmonary bypass
Division of Cardiovascular Surgery and Clinical Epidemiology Unit, Sunnybrook Health Science Centre, University of Toronto, Ontario, Canada.
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