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Ann Thorac Surg 2001;71:122-127
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Coronary endothelial injury after local occlusion on the human beating heart

^a Department of Cardiac Surgery, Leopold-Franzens-University, Innsbruck, Austria
^b Institute of Anatomy and Histology, Leopold-Franzens-University, Innsbruck, Austria
^c Städtische Kliniken, Oldenburg, Germany

Accepted for publication July 11, 2000.

Address reprint requests to Dr Hangler, Department of Cardiac Surgery, Leopold-Franzens-University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
e-mail: herbert.hangler{at}uibk.ac.at

	Abstract

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. Occlusion of coronary arteries during beating heart surgery bears the potential for mechanical trauma to the arterial wall with consequent endothelial injury. The aim of this study was to elucidate the effects of local occlusion on the beating heart in human coronary arteries.

Methods. Coronary arteries of patients with dilated cardiomyopathy (n = 7) or ischemic heart disease (n = 10) undergoing heart transplantation were locally occluded after starting cardiopulmonary bypass. Immediately after excision of the diseased heart, the vessels were fixed. Unoccluded segments served as controls. Integrity of endothelial lining was observed with scanning electron microscopy.

Results. Scanning electron microscopy revealed significantly more severe endothelial injury in the area of occlusion than in the adjacent, not manipulated control segments. In the region of local occlusion, plaque rupture was noted in three of 34 atherosclerotic vessel specimens, injury to side branches was evident in two of 44, and local microthrombus formation was evident in six of 44 samples.

Conclusions. Local occlusion of human coronary arteries during beating heart coronary surgery may cause focal endothelial denudation, local microthrombosis, atherosclerotic plaque rupture, and injury to target vessel side branches.

	Introduction

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
In beating heart coronary artery surgery, mechanical aids are required to achieve a clear and stabilized operative field enabling the surgeon to perform a technically appropriate coronary artery anastomoses. Therefore, in some instances, the target vessels are encircled with elastic silicone tapes or polypropylene sutures buttressed with pieces of silicone tubing and frapped with tourniquets to diminish native coronary blood flow. The sutures are usually placed deep into the myocardium to have a cushion of subjacent epimyocardial tissue protecting the posterior and lateral vessel wall against direct compression injury [1]. In contrast to these self-made snaring devices, commercially available tools such as the MyOcclude vessel occlusion device (Vascular Therapies, USSC, Elancourt, France) enable the surgeon to occlude coronary arteries with a standardized force and without the need to blindly underpass the target coronary artery. As shown in animal models, manipulation of coronary arteries during revascularization in off-pump surgery can lead to marked endothelial cell loss and local coronary dysfunction [2]. The aim of this investigation was to elucidate the effects of commonly used local coronary occlusion techniques on integrity of endothelial lining in human coronary arteries on the beating heart.

	Material and methods

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Experimental groups and operative technique
Multiple coronary artery segments of patients undergoing orthotopic heart transplantation for dilated cardiomyopathy (group I, DCMP) (n = 7) or ischemic coronary heart disease (group II, ICHD) (n = 10) were occluded for a period of 15 minutes to simulate the average duration of a coronary anastomoses, immediately after starting cardiopulmonary bypass before the diseased recipient heart was explanted. The occlusion was carried out proximal as well as distal to the point where grafts are usually placed during coronary artery bypass grafting (middle third of left anterior descending coronary artery, right coronary artery before the Crux cordis, first to middle third of diagonal branch). The coronary arteries were occluded by encircling with either a 3/0 polypropylene suture, buttressed with a piece of silicone tubing (n = 10), or a Teflon felt pledget (n = 10) as abutment and lashed with a soft silicone tube. Coronary arteries were underpassed once with an elastic silicone loop (Ethiloop; Ethicon, Norderstedt, Germany) (n = 10) passed through a tourniquet and frapped. Care was taken to have a pad of epimyocardial tissue included to avoid direct compression of the posterior and lateral coronary vessel wall. In addition, the MyOcclude vessel occlusion device (n = 7) and Bulldog clamps (19-8097; Codman, Raynham, MA) (n = 7) were applied for local coronary occlusion. Uninstrumented segments adjacent to the occlusion site of the same coronary artery served as controls (n = 27). After the occlusion period of 15 minutes, the aorta was cross-clamped and the heart immediately excised. The period from end of occlusion to the start of pressure fixation of the coronary arteries was 9 ± 3 minutes.

Procurement of tissue
Instantly after excision of the diseased recipient heart, the coronary arteries were perfused for 10 minutes with 2.5% glutaraldehyde in 0.1 mol/L cacodylate buffer (pH 7.4) at a controlled pressure of 120 mm Hg through a perfusion cannula (P616; Stöckert, Munich, Germany) inserted into the left or right coronary ostium. In this way, the endothelium was fixed in situ at physiologic pressure before being further processed for scanning electron microscopy. Subsequently, the vessels were carefully dissected free from the adherent epicardial tissue in a no-touch technique under 12x magnification and cut transverse 5 mm apart from the occlusion area on each side. Control samples were taken from the adjacent not-instrumented areas of the same coronary artery.

Preparation of the coronary arteries for scanning electron microscopy (SEM)
The coronary artery cylinders were cut longitudinally, pinned on cork plates, and postfixed in 1% Osmiumtetroxide (OsO₄), further dehydrated in a graded ethanol series, and subjected to critical-point drying (CPD 030; Bal Tec, Balzers, Lichtenstein). After drying, samples were mounted on specimen stubs using colloidal silver and coated with 15 nm gold (MED 020; Bal Tec). The entire endothelial surface of each specimen was examined with a Zeiss DSM 982 Gemini scanning electron microscope, operated at 5 kV.

Histomorphology of the endothelial layer was classified into three grades
In grade I, the entire surface was covered by intact endothelial cells with a tight intercellular attachment (intact endothelial layer). In grade II, there were dehiscent intercellular junctions with isolated detachment of endothelial cells (minor endothelial injury). In grade III, there was an expanse of local endothelial denudation with the subendothelial tissue exposed (severe endothelial injury). Figure 1 depicts the three different categories of endothelial lining.

View larger version (138K): [in this window] [in a new window]   Fig 1. (A) Control specimen. Scanning electron micrograph depicts an overview of a coronary artery cut into halves longitudinally after pressure fixation with an intact endothelial surface. (B) Inset of A. Higher magnification with tight endothelial cell attachment completely covering the vascular surface, according to grade I classification. (C and D) Micrographs representing grade II classification of endothelial injury with dehiscent intercellular junctions and isolated detachment of endothelial cells (white arrow). (E) Expanse endothelial denudation with complete loss of endothelial cell coverage exposing the subendothelial tissue to the blood stream (white arrow). (F) Higher magnification of denuded area.

	Results

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
During preparation for SEM under 12x magnification in two of 44 manipulated coronary segments (DCMP and ICHD), injury to a septal branch of the left anterior descending coronary artery with perforation and a perivascular hematoma was evident.

None of the control coronary artery segments exhibited endothelial damage greater than grade II. These minor changes of the coronary endothelial layer in atherosclerotic human coronary arteries have already been reported [3]. In contrast, 24 of 44 manipulated segments from both patient groups (DCMP and ICHD) showed grade III endothelial injury (p < 0.001). There was no significant difference in regard to grade III injury between instrumented coronary segments from patients with DCMP (14 of 23) and ICHD (10 of 21) (p = NS). Table 1 lists the incidence of endothelial injury according to the five different occlusion methods applied. There was a trend towards a lesser occurrence of grade III injury when occlusion was performed with elastic silicone loops and the MyOcclude device. Occlusion of coronary arteries led to local micro-thrombus formation in six of 44 samples (Fig 2). In three specimens of patients with ICHD after local occlusion, rupture of an atherosclerotic plaque was encountered (Fig 3).

View larger version (73K): [in this window] [in a new window]   Fig 2. (A) Scanning electron micrograph of an intraluminal local thrombus formation (arrow) in a coronary artery cylinder, cut open longitudinally in the region after local occlusion. (B) Inset of (A), higher magnification of local thrombus formation depicting red blood cells (*) trapped in a fibrin network based on the inner vascular wall.

View larger version (89K): [in this window] [in a new window]   Fig 3. (A) Scanning electron micrograph (overview) of the inner surface of a coronary artery: the local occlusion having been applied around the vessel in the region of an atherosclerotic plaque with disruption (arrows) of the vessel wall. (B) Inset of (A), higher magnification of the area with "plaque cracks" attributed to local occlusion with the snare-technique.

	Comment

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

Integrity of the endothelial lining is an essential part in the equilibrium of the nonthrombogenic properties of the endothelial surface by inhibiting platelet function and coagulation [10]. When the subendothelial matrix is exposed to circulating blood elements, thrombosis may occur and result in early coronary artery or bypass graft closure. Higher postoperative platelet counts and a minor impaired platelet function, as well as a smaller decrease of circulating coagulation factors in off-pump coronary surgery than in on-pump surgery, with a procoagulant activity could boost local coronary artery thrombosis [11]. Therefore, platelet aggregation and thrombus formation in coronary artery areas denuded of endothelial cell coverage after external occlusion, as detected in this investigation, could be more at risk for thrombosis in off-pump than in on-pump surgery. We were surprised that in this series, despite full heparinization for cardiopulmonary bypass, six cases of local micro-thrombus formation were diagnosed. Because of this finding, we propose to routinely administer full heparin loading in off-pump procedures, keeping the activated coagulation time above 400 seconds with checks at 30-minute intervals. Other authors have suggested lower heparin doses [12]. At present, discussions are ongoing as to whether platelet-inhibiting drugs such as clopidogrel should be administered in the early postoperative period to counteract the procoagulant state in off-pump coronary artery bypass grafting. Perhaps a more vigorous postoperative anticoagulation and platelet-inhibiting pharmacotherapy could be effective. Adequate prospective randomized trials are needed to bring insight into these questions [13].

Furthermore, in the "response to injury hypothesis" [14], endothelial cell injury such as focal denudation or dysfunction of endothelium is considered to be a key event in the evolution of atherosclerosis by inducing growth factor secretion, and attachment of macrophages and monocytes. The loss of endothelial cell coverage because of external instrumentation, as demonstrated by our group, may be healed by regenerating endothelium. Nevertheless, regenerated endothelium is also dysfunctional, as these endothelial cells have lost some of their ability to release endothelium-dependent relaxing factors and are no longer able to prevent aggregating platelet-induced contraction [15]. Occurrence of vasospasm and atherosclerosis may be accelerated in these areas covered by regenerated endothelial cells. Up to now, experiments investigating the effects of coronary occlusion techniques have been preferably performed in normal pig coronary arteries [16] not burdened with preexisting atherosclerosis and chronic endothelial injury with vasomotor dysfunction [17] that could be aggravated by endothelial cell loss from mechanical manipulation. Perrault and colleagues found that intravascular devices create a significantly higher degree of functional damage compared with extravascular occlusion techniques. In regard to these animal experiments, one has to keep in mind the fact that there is already a difference in behavior between vessels of comparable size in the same individual, for instance, very little natural atherosclerotic disease in the internal thoracic arteries in contrast to a much higher degree in coronary arteries or the comparative rarity of naturally occurring atherosclerosis in many species [18].

Moreover, when snare sutures are placed in areas of coronary arteries with severe atherosclerotic disease and the circumferential tension on lipid-laden plaques exceeds its tensile strength, it possibly will rupture at its weakest point and expose atheromatous gruel, the most thrombogenic component of a plaque, to the blood stream. Acute coronary syndromes, depending on the extent of thrombus formation or embolization of atheromatous debris, may occur [19].

Another tool that facilitates constructing anastomosis in off-pump coronary surgery are intracoronary shunts that are carefully advanced into the proximal coronary lumen using a thumb forceps. Flow through the device affirms proper insertion and deairing. The opposite side of the shunt is then advanced into the distal part of the coronary artery so that at least partial blood flow is preserved and may prevent potential intraoperative ischemia with arrhythmias, ST segment elevations, or regional systolic dysfunction that occurs in as much as 40% of off-pump procedures [20]. On the other hand, introducing a device into the coronary lumen can be the cause of dissection or harm endothelial integrity with functional impairment of the coronary artery. Thus, intracoronary shunts could be a useful adjunct in beating heart revascularization. However, further research is required to investigate the impact of shunt insertion on coronary artery endothelial structure and function.

In the current study, a trend towards a lesser incidence regarding denuding endothelial injury was found when coronary arteries were occluded using elastic silicone loops or the MyOcclude device. We therefore propose to use these tools rather than polypropylene sutures. Another advantage of the MyOcclude device is that there is no need to underpass the target coronary artery with the potential for septal branch injury of left anterior descending coronary artery.

Limitations of the study
Limitations of our study are the differences in the techniques of occlusion between the two patient groups and the relatively small number of specimens with respect to the occluding methods.

Conclusions
From this study, we conclude that local occlusion of human coronary arteries by snaring sutures during beating heart coronary surgery can lead to injury of target coronary artery side branches, focal endothelial denudation, plaque rupture, and local micro-thrombus formation. Snaring of the target coronary artery distal to the arteriotomy should not be used. We recommend full heparin loading in off-pump coronary artery bypass procedures until there is sufficient data that lower heparin doses are safe and effective.

	Acknowledgments

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We thank Karin Gutleben and Angelika Flörl for aid in preparation of the coronary artery samples for SEM.

	Footnotes

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
The study was approved by the local human research committee, January 21, 1998.

	References

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 

1. Calafiore A.M., Di Giammarco G., Teodori G., et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-1665.[Abstract/Free Full Text]
2. Perrault L.P., Menasche P., Wassef M., et al. Endothelial effects of hemostatic devices for continuous cardioplegia or minimally invasive operations. Ann Thorac Surg 1996;62:1158-1163.[Abstract/Free Full Text]
3. Davies M.J., Woolf N., Rowles P.M., Pepper J. Morphology of the endothelium over atherosclerotic plaques in human coronary arteries. Br Heart J 1988;60:459-464.[Abstract/Free Full Text]
4. Pfister A.J., Zaki S.M., Garcia J., Mispireta L.A., et al. Coronary artery bypass without cardiopulmonary bypass. Ann Thorac Surg 1992;54:1085-1092.[Abstract]
5. Alessandrini F., Gaudino M., Glieca F., et al. Lesions of the target vessel during minimally invasive myocardial revascularization. Ann Thorac Surg 1997;64:1349-1353.[Abstract/Free Full Text]
6. Pagni S., Qaqish N.K., Senior D.G., Spence P.A. Anastomotic complications in minimally invasive coronary bypass grafting. Ann Thorac Surg 1997;63:S64-S67.
7. Splittgerber F.H., Minale C. Septal myocardial infarction: a complication of coronary artery stay sutures. Ann Thorac Surg 1993;56:400-401.[Medline]
8. Tanemoto K.T., Kuroki K., Kanaoka Y., Murakami T. Septal branch right ventricular fistula: a complication in coronary artery snaring. Ann Thorac Surg 1999;68:246-248.[Abstract/Free Full Text]
9. Izzat M.B., Yim A.P., El Zufari M.H. Snaring of a coronary artery causing distal atheroma embolization. Ann Thorac Surg 1998;66:1806-1808.[Abstract/Free Full Text]
10. Boyle E.M., Verrier E.D., Spiess B.D. The procoagulant response to injury. Ann Thorac Surg 1997;64:S16-S23.
11. Mariani M.A., Gu Y.J., Boonstra P.W., Grandjean J.G., van Oeveren W., Ebels T. Procoagulant activity after off-pump coronary operation: is the current anticoagulation adequate. Ann Thorac Surg 1999;67:1370-1375.[Abstract/Free Full Text]
12. Jansen E.W., Grundemann P.F., Borst C., et al. Less invasive off-pump CABG using a suction device for immobilization: the Octopus method. Eur J Cardiothorac Surg 1997;12:406-412.[Abstract]
13. Ascione R., Lloyd C.T., Gomes W.J., Caputo M., Bryan A.J., Angelini G.D. Beating versus arrested heart revascularization: evaluation of myocardial function in a prospective randomized study. Eur J Cardiothorac Surg 1999;15:685-690.[Abstract/Free Full Text]
14. Ross R., Gloset J.A. Atherosclerosis and arterial smooth muscle cell. Science 1973;180:1332-1339.[Free Full Text]
15. Vanhoutte P.M., Perrault L.P., Vilaine J.P. Endothelial dysfunction and vascular disease. In: Rubanyi G.M., Dzau V.J., eds. The endothelium in clinical practice. New York: Marcel Decker, 1997:265-289.
16. Chavanon O., Perrault L.P., Menasche P., Carrier M., Vanhoutte P.M. Endothelial effects of hemostatic devices for continuous cardioplegia or minimally invasive operations. Ann Thorac Surg 1999;63:1118-1120.[Abstract/Free Full Text]
17. Forstermann U., Mugge A., Alheid U., Haverich A., Frolich J.C. Selective attenuation of endothelium-mediated vasodilation in atherosclerotic human coronary arteries. Circ Res 1988;62:185-190.[Abstract/Free Full Text]
18. Sims F. A comparison of structural features of the wall of coronary arteries from 10 different species. Pathology 1989;21:115-124.[Medline]
19. Cheng G., Loree H., Kamm R., Fishbein M., Lee R. Distribution of circumferential stress in ruptured and stable atherosclerotic lesions. A structural analysis with histopathological correlation. Circulation 1993;87:1179-1187.[Abstract/Free Full Text]
20. Dapunt O.E., Raji M.R., Jeschkeit S., et al. Intracoronary shunt insertion prevents myocardial stunning in a juvenile porcine MIDCAB model absent of coronary artery disease. Eur J Cardiothorac Surg 1999;15:173-178.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Otto E. Dapunt Johannes O. Bonatti Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hangler, H. B. Articles by Bonatti, J. O. Search for Related Content PubMed PubMed Citation Articles by Hangler, H. B. Articles by Bonatti, J. O. Related Collections Cardiac - physiology Coronary disease Related Article