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Ann Thorac Surg 2003;76:1516-1522
© 2003 The Society of Thoracic Surgeons
a Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
Accepted for publication May 2, 2003.
* Address reprint requests to Dr Ascione, Cardiothoracic Surgery, Bristol Heart Institute, Bristol Royal Infirmary, Bristol BS2 8HW, United Kingdom
e-mail: r.ascione{at}bristol.ac.uk
Abstract
BACKGROUND: We investigated the changes occurring in cerebral cortical oxygenation during off-pump coronary artery bypass (OPCAB) surgery using near infrared spectroscopy (NIRS).
METHODS: Measurement of cerebral cortical oxygenation changes included concentration of deoxygenated hemoglobin [HHb], oxygenated hemoglobin [O2Hb], changes in the redox status of the cytochrome c oxidase [Cyt-Ox], cerebral saturation as expressed by the tissue oxygenation index (TOI), and cerebral blood volume (CBV) as expressed by tissue hemoglobin index (THI). Measurements were performed in 23 consecutive patients during grafting of: left anterior descending (LAD setup 1; n = 23), posterior descending (PDA setup 2; n = 17), and Circumflex (Cx setup 3; n = 19) coronary arteries. Measurements were performed before any surgical manipulation (baseline), following positioning of the pressure stabilizer during construction of the distal anastomosis and 2 minutes after the completion of each distal anastomosis with the heart returned to its natural position.
RESULTS: There were no in-hospital deaths, neurologic deficits, or myocardial infarcts. Compared to baseline, during LAD grafting there was a marked reduction in [O2Hb] [-1.08 (-1.77 to -0.39), mean difference (95% CI) (p < 0.0008)], without a significant change in [HHb]. There was also a 4% reduction in cerebral saturation and a 3% fall in CBV (both p < 0.05). Setup 2 (PDA) was associated with a marked decrease of [O2Hb] [-1.92 (-2.95 to -0.88) mean difference (95% CI) (p < 0.0025)], which was accompanied by an increase in [HHb] [1.89 (1.00 to 2.77) mean difference (95% CI) (p < 0.0025)], and a 4% reduction in cerebral saturation (p < 0.0008). Grafting of the Cx was associated with a marked increase in [HHb] [2.85 (1.46 to 4.2) mean difference (95% CI) (p < 0.0025)], with no changes in [O2Hb], a 6% reduction in cerebral saturation, and a 12% increase in CBV (both p < 0.05). In all 3 settings, however, the changes were not associated with a modification in the redox state of [Cyt-Ox]. On returning to baseline condition, the changes in [O2Hb] and TOI observed in setup 1 persisted, and a significant reduction was observed in the redox state of the [Cyt-Ox] when compared with baseline [-0.08 (-0.14 to -0.02) mean difference (95% CI) (p < 0.002)]. For setups 2 and 3 there was recovery of the cerebral cortical oxygenation.
CONCLUSIONS: Grafting of the LAD on the beating heart is responsible for changes in cerebral cortical oxygenation which persist early after returning the heart to its natural position. Grafting of the Cx and PDA result in transient reversible changes. Trendelenburg positioning and right lateral tilting of the operating table during grafting of lateral and posterior walls might have a protective role in preventing cerebral cortical ischemia. Further studies are needed to assess the clinical importance of these observations.
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Ann. Thorac. Surg. 2003 76: 1522.
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