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Ann Thorac Surg 1997;63:914-915
© 1997 The Society of Thoracic Surgeons

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Correspondence

Noncardioplegic Myocardial Protection for CABG Deserves a Second Look

Department of Cardiovascular Surgery Southern Railway Headquarters Hospital Perambur Madras 600 023 India

To the Editor:

We agree with Alhan and colleagues [1] that noncardioplegic intermittent aortic cross-clamping (IAC) or intermittent fibrillatory arrest is as effective and less costly than cardioplegia in low-risk cases of first-time coronary artery bypass grafting (CABG). They have shown even ultrastructurally that IAC is as good as crystalloid cardioplegia with respect to myocardial protection. Because of much skepticism, only a substantial minority of cardiac surgeons still use intermittent aortic cross-clamping in spite of evidence that it is suitable for even high-risk CABG [2] and has equal if not superior myocardial protection as compared with blood cardioplegia with substrate-enhanced reperfusion in CABG for acute myocardial infarction [3].

We have been using this technique of IAC routinely for all CABG, both low-risk and high-risk, and have been fully satisfied with the results. It offers several advantages over cardioplegia apart from versatility, ease of procedure, and cost benefit.

Intermittent aortic cross-clamping has some special advantages over cardioplegia in at least three special situations of CABG, in terms of utter simplicity of procedure, at the same time being equally effective.

First, there is a lower risk of development of new conduction blocks after CABG with IAC than with cardioplegia [4]. It follows that in patients with preexisting conduction blocks who need CABG there is a greater risk of progression of their preexisting conduction defect with cardioplegia. We have analyzed 14 of 890 patients (1.57%) with preexisting conduction blocks who had first-time CABG at our institute using IAC. All had two or more preoperative risk factors for the development of new conduction blocks. Transient complete heart block developed in only 1 patient (7.1%) and reverted to the preoperative bifascicular block pattern after 12 hours. No progression of blocks developed in any of these patients during a follow-up period of 1.7 ± 0.8 years.

Second, in developing countries there is a high incidence of cold agglutinemia. The various techniques of handling this described in the literature are cumbersome, complicated, and costly. Using the IAC method the only technical modification needed to tackle all levels of cold agglutinemia, of whatever amplitude or titer, is to maintain the core body temperature at 37°C and proceed with CABG without changing the established method of IAC [5]. We have operated on 5 patients with cold agglutinemia since then, all needing CABG for severe disease. None of the patients had perioperative myocardial infarction or needed inotropic support.

Third, in patients who have a permanent pacemaker implanted before CABG, cardioplegic techniques require explantation of the pacemaker to abolish pacing or use of low-voltage fibrillatory currents to the skin to inhibit the pacemaker. We have operated on 3 such patients, in whom the technique itself was such that the pacemaker was inhibited during cross-clamping because of induced electrical fibrillation and when the proximal anastomosis was being constructed the pacemaker kept the heart beating regularly.

We therefore think that IAC is as effective in all risk categories of CABG and is more versatile and less costly. It also has a distinct advantage over cardioplegia in some special situations. This letter was written to rejuvenate the technique of IAC and hopefully to establish IAC as an accepted technique of myocardial protection for CABG.

References

1. Alhan CH, Karabulut H, Tosun R, et al. Intermittent aortic cross-clamping and cold crystalloid cardioplegia for low-risk coronary patients. Ann Thorac Surg 1996;61:834–9.[Abstract/Free Full Text]
2. Bonchek LI, Burlingame MV, Vazales BE, et al. Applicability of non-cardioplegic coronary bypass to high risk patients. Selection of patients, technique, and clinical experience in 3000 patients. J Thorac Cardiovasc Surg 1992;103:230–7.[Abstract]
3. Bonchek LI, Burlingame MW, Vazales BE, Lundy EF, Gassmann CJ. Coronary bypass with substrate-enhanced cardioplegia versus noncardioplegic technique for early revascularisation in acute infarction. Eur J Cardiothorac Surg 1990;4:124–9.[Abstract/Free Full Text]
4. O'Connell JB, Wallis D, Johnson SA, Pifarré R, Gunnar RM. Transient bundle branch block following use of hypothermic cardioplegia in coronary artery bypass surgery: high incidence without perioperative myocardial infarction. Am Heart J 1982;103:85–91.[Medline]
5. Koppula AS, Jagannath BR, Kanhere AS, Das M, Gupta CM. Management of cold agglutinemia using normothermic intermittent fibrillatory arrest [Letter]. Ann Thorac Surg 1994;58:1566.[Free Full Text]

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