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Ann Thorac Surg 2001;71:152-157
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Different CABG methods in patients with chronic obstructive pulmonary disease

^a Department of Cardiovascular Surgery, Kouyolu Heart and Research Hospital, stanbul, Turkey

Accepted for publication July 18, 2000.

Address reprint requests to Dr Güler, Kouyolu Heart and Research Hospital, 81020 Kadiköy, Istanbul, Turkey
e-mail: mustafaguler{at}superonline.com

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. Pulmonary dysfunction is still a major problem in coronary artery bypass grafting (CABG). The purpose of this randomized study was to determine the effect of different CABG techniques on pulmonary function.

Methods. Fifty eight patients with severe obstructive pulmonary disease had elective isolated coronary surgery. The surgical methods for the patients with chronic obstructive pulmonary disease (COPD) were standard CABG in 18 patients (group 1), beating heart surgery in 19 patients (group 2), and minimally invasive direct coronary artery bypass grafting (MIDCABG) in 21 patients (group 3).

Results. The earliest extubation time was from group 3 (p < 0.001). The average stay in the intensive care unit was significantly longer in group 1 (2.6 ± 1.5 days) than in groups 2 (1.4 ± 0.8 days) and 3 (1.1 ± 0.8 days) (p < 0.05). The most prevalent respiratory morbidity was atelectasis that developed in 6 patients from group 1, in 2 patients from group 2, and in 3 patients from group 3. Forced expiratory volumes in 1 second (FEV₁) obtained in the second postoperative month were significantly lower than preoperative values only in group 1 (p < 0.05). Forced vital capacity (FVC) values were significantly lower than the preoperative values in all three groups (p < 0.05).

Conclusions. Off-pump bypass surgical procedures are more advantageous than on-pump methods for patients with COPD. These patients can be operated on using the beating heart technique or by using MIDCABG to prevent side effects of CPB on pulmonary function and effects of sternotomy.

	Introduction

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Coronary artery bypass grafting (CABG) is a safe and effective surgical intervention that is performed successfully with advanced technologic methods and distinctive strategies for a wide range of patients. Recently CABG has been performed even on elderly patients with comorbid medical problems such as chronic obstructive pulmonary disease (COPD) more than in the past [1].

The patients with COPD, which is typically considered an important risk factor for standard CABG, are influenced negatively from detrimental effects of both sternotomy and cardiopulmonary bypass (CPB) in the mean of postoperative pulmonary complications [2].

It is well known that CPB interferes with pulmonary functions in patients undergoing CABG. Cardiopulmonary bypass has been associated with adverse effects on the alveolar stability by activation of the complement cascade, sequestration of the neutrophil in the pulmonary microvascular bed, releasing of the oxygen-derived free radicals [3, 4], and changing of the composition of alveolar surfactant [5].

The development of atelectasis is one of the most important problems after CPB especially in the first 48 hours postoperatively. Vital capacity, the inspiratory capacity, the functional residual capacity, the total lung capacity, and the pulmonary diffusion capacity are all reduced after an open heart operation, and the return of these variables to their preoperative levels takes up to approximately 4 months [6, 7].

As a major component of standard open heart operations, the influence of a median sternotomy approach on pulmonary function has been clearly evaluated and it has been shown that the structural changes in the chest wall after median sternotomy is the cause of restrictive pulmonary dysfunction, which can be prolonged for weeks after the operation [8].

View larger version (27K): [in this window] [in a new window]   Fig 1. The comparison of forced expiratory volume in 1 second (FEV1) in the preoperative period and 2 months after coronary artery bypass grafting. (*The p value of the Kruskal-Wallis test performed using the differences between preoperative and postoperative records of all groups.)

Our study was designed to answer the following questions: Can the patients with COPD be protected from the side effects of CPB by using the beating heart technique with median sternotomy? Furthermore, can the patients be protected from pulmonary complications using the minimally invasive direct coronary artery bypass grafting (MIDCABG) procedure by avoiding both median sternotomy and CPB?

In spite of a few reports on the selection of the CABG methods for patients with COPD in the literature, this prospective randomized study determined the effect of different CABG techniques on pulmonary function.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Fifty-eight patients undergoing elective isolated coronary surgery with severe obstructive pulmonary disease were included in this prospective randomized study. None of the patients were informed about operation options beforehand. All the patients had one-vessel coronary disease and received a left internal mammary artery graft for proximal LAD lesion. These patients were investigated in mean postoperative lung functions. Eighteen patients were operated on by conventional CABG techniques with a CPB and median sternotomy approach (group 1). Nineteen patients were operated on by using the beating heart technique with a median sternotomy incision and without using CPB (group 2). Twenty-one patients were operated on by using the MIDCABG technique with a left anterior minithoracotomy incision (group 3).

All patients were evaluated by preoperative spirometric pulmonary function tests and clinical studies (smoking history, auscultation findings, Roentgenograms) before the operation. Measurements of arterial blood gases were done before induction on all of the patients.

The three comparison groups in patients with preexisting COPD were studied for abnormal results of pulmonary system examination, abnormal chest radiography and smoking history, and abnormal pulmonary functional tests as FEV₁ less than 70%. Forced vital capacity less than 70% and FEV₁/FVC less than 60%. None of the patients suffered a myocardial infarction in the 2 months before the coronary operations.

The preoperative variables of the patients are summarized in Table 1. There were no significant differences among the three groups.

The patients in group 1 were operated on with the median sternotomy approach, and CPB was installed through the ascending aorta and right atrial cannulation. Cardiopulmonary bypass was performed with centrifugal pump and membrane oxygenation. Cooling was not used but the patients cooled to 34.8 ± 1.22°C. Continuous retrograde isothermal blood cardioplegia was used for myocardial protection and cardiac venting was performed through the ascending aorta [13]. While weaning from CPB the patients were warmed to 36°C. The patients in group 2 were operated on with the beating heart technique through median sternotomy. While performing the anastomosis the proximal part of the LAD was occluded with a bulldog clamp. The corrected form is added (5). The patients in group 3 were operated on through a left anterior minithoracotomy by a 6 to 7 cm length in ethic regiment that was followed by fraction of inspired oxgen (FiO₂) of 60% to 70%. The blood gases and O₂ saturation rates were monitored.

The patients were transferred to the intensive care unit (ICU) immediately after the operation and received ventilator assistance and monitoring. Ventilation was in a controlled mandatory ventilation mode (Erica Ventilator; Engström Erica, Sweden) with a tidal volume of 10 mL/kg and a respiratory rate of 10 to 12 breaths per minute with positive end-expiratory pressure (5cm H₂O). Extubation was undertaken when patient criteria was stable.

For early postoperative period assessments, the extubation time, the hemodynamic complications, and the pulmonary complications were noted. For the late postoperative period (mean, 2 months) analyses of blood gases and spirometric studies were repeated for pulmonary function assessments.

Statistical analysis
Data were evaluated by computing means and percentages, plus or minus standard deviations. The groups were compared using the Kruskal-Wallis test, Mann-Whitney U test, and the Wilcoxon signed ranks test for the variables of the pulmonary functions. The Kruskal-Wallis test, which is a nonparametric test, should be used to compare three groups, because the distribution of the groups is not normal; it was also used to compare the preoperative and postoperative differences. A p value of less than 0.05 was regarded as statistically significant.

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
There were no deaths in all three groups. However, in the early postoperative period, 4 patients from group 1 and 2 patients from group 2 required ventilator assistance for more than 12 hours. There was a statistical significant difference among the mean intubation time of the comparison groups in the early postoperative period. The extubation time of group 1 was later than that of group 2, and the earliest extubation time was in group 3 (p < 0.05). The average stay in the intensive care unit for group 1 patients was significantly longer (2.6 ± 1.5 days) compared with group 2 patients (1.4 ± 0.8 days) and group 3 patients (1.1 ± 0.8 days) (p < 0.05). The pulmonary complications were responsible for the increased stay in the intensive care unit.

The most prevalent respiratory complication was atelectasis, which developed in 6 patients (6 of 18) in group 1, 4 patients (4 of 19) in group 2, and 2 patients (2 of 21) in group 3. Severely increased bronchial secretions were the major problem in 77.5% (45 patients) of all the groups, and the patients were treated by nasotracheal suction, and mucolitic and chest physical therapy. One patient in group 3 had an episode of bronchospasm necessitating bronchodilatator therapy on the third postoperative day. There was one patient in group 1 with pleural effusion that was drained. Neither pneumonia nor pneumothorax occurred in any of the patients.

Perioperative myocardial infarction occurred in 1 patient in group 1. Inotropic and intraaortic balloon pump (IABP) support were required for this patient. No other hemodynamic complications were recorded in any of the groups. Superficial wound infection developed in 1 patient in group 3 and it was cured with antibiotherapy. The early postoperative outcomes are shown in Table 2.

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

Pulmonary dysfunction has been a well-documented complication of CPB. During the initial phase of CPB, primarily the alternative pathway resulting in release of the anaphylatoxins C3a and C5a activates complement, which is known to be associated with pulmonary dysfunction [15]. With the increase in the alveolar-capillary permeability, CPB leads the shifting of fluid and macromolecules into the pulmonary interstitium and ultimately the alveoli. This can be responsible for different types of pulmonary dysfunction and can progress into adult respiratory distress syndrome [16]. Previously reported data have drawn different inferences about the pulmonary dysfunction degree or the period of this dysfunction after CPB. A significant reduction in lung volumes, diffusion capacity, and oxygenation was demonstrated 2 weeks after operation, with partial improvement 4 months later [7]. In another study it was found that FEV₁, FVC, and FRC decreases 30% to 50% in the early postoperative period and remained below base line for about 6 weeks in patients operated on for coronary artery disease [17]. The effect of CPB temperature on pulmonary function is controversial. In one study it was proposed that normothermic perfusion had better effects on pulmonary functions [18]. Although another study suggested that CPB temperature did not influence alveolar/arterial PaO₂ gradient in the early postoperative period after coronary revascularization [19].

Median sternotomy has become the usual approach in cardiac operations because it provides excellent exposure, but one disadvantage is its adverse effect on pulmonary functions. The structural changes in the thoracic anatomy were blamed on the median sternotomy incision causing pulmonary impairments by affecting mechanical forces of respiratory system in the postoperative period [8]. Shapira and colleagues [20] showed that median sternotomy had considerably transient bad effects on postoperative pulmonary functions. It was reported in this study that peak expiratory flow rate was decreased by 65% just after extubation and by 35% before discharge in patients undergoing CABG. It was proved that short-term pulmonary rehabilitation programs before operation, applied to coronary artery disease patients with severe pulmonary impairment, could decrease the surgical mortality and shorten the ventilation and hospitalization time [21].

The surgical strategy of the patients undergoing CABG with COPD should be considered with the relative postoperative pulmonary complications. A renewed emphasis has been focused on performing CABG without using CPB on the beating heart that can be regarded as more advantageous because it avoids the detrimental side effects of extracorporeal circulation and its results have the least requirements of blood transfusion and early mobilization in patients with COPD. The revascularization of proximal LAD lesions on the beating heart with median sternotomy or through anterior minithoracotomy used with or without videothoracoscopic assistance is additionally associated with significant reduction of resource utilization and morbidity related to initial hospitalization, also providing faster recovery and better patient comfort compared with standard CABG operations [10–13, 22].

The MIDCABG was compared with that of conventional CABG and percutaneous transluminal coronary angioplasty in King and colleagues’ study [23]. They found that the shortest hospitalization period was in the MIDCABG group. Early extubation, decreased intensive care unit stay, and total hospital stay existed as important factors for CABG operations. It was stressed that early extubation not only decreased the hospital mortality and morbidity rates, but also the total cost of hospitalization significantly [24]. Total cost of MIDCABG was calculated as almost 50% lower than conventional CABG, and also the same as the cost of percutaneous transluminal coronary angioplasty.

There have not been any studies in the literature comparing the effect of different CABG procedures regarding pulmonary functions. In this study we investigated the effects of different CABG techniques on pulmonary functions in patients with COPD. We also analyzed the variables of extubation period and long-term spirometric and arterial blood gases outcomes in the second postoperative month.

The shortest extubation time was obtained in group 3 as expected. This group of patients also had the shortest intensive care unit stay and total hospitalization period. The factor of this difference was considered to be the avoidance of the side effects of CPB and median sternotomy. The extubation time in group 2 was longer than that in group 3, but it was shorter than that in group 1. So both CPB and median sternotomy can be blamed separately for the prolonged extubation and intensive care unit stay.

For the MIDCABG procedure, we prefer to use one-lung ventilation according to our institutional protocol. One-lung ventilation could not be tolerated in 12 patients with pulmonary dysfunction, so two-lung ventilation was required in these patients. There were no atelectatic occurrences in this subgroup of patients. However, two patients were ventilated using only right-lung during the MIDCABG procedures because they suffered from atelectasis (2 of 9). We interpreted the reasons for postoperative atelectasis in these patients may have been related to deflation of the lung during the operation in the MIDCABG group and due to the high incidence of postoperative atelectasis connected to the deflation of lungs during cross-clamping together with the adverse effects of CPB in group I.

The preoperative FEV₁ value was accepted as a major predictor for a 5-year survey of patients with COPD [24]. We did not find any differences in the FEV₁, FEV₁/FVC, and FVC values among the three groups in the second postoperative month. The results were different when comparing the preoperative and postoperative values in each group. The FEV₁ value in the second postoperative month was similar to the preoperative value in groups 2 and 3, but it was significantly lower in group 1. Also when we compared all groups for the difference between preoperative and postoperative values, we found that the decrease in the FEV₁ was statistically significant in group 1 than it was for the other groups. For the FEV₁/FVC ratio the outcome was found to be similar in the groups. There were no differences in both groups 2 and 3 between preoperative and postoperative FEV₁/FVC values in the second postoperative month, but there was a difference in group 1. The FVC value in the second postoperative month was lower than the preoperative values in all three groups. The PaO₂ and PaCO₂ values in all three groups in the second postoperative month were not found to be statistically different from the preoperative values.

As a result, the patients operated on using CPB with sternotomy seemed to be much more influenced when compared with the patients operated on using the beating heart either with sternotomy or with minimal invasive techniques in the mean of the FEV₁, FEV₁/FVC, and FVC values. The effect of internal mammary artery harvesting upon the pulmonary function in coronary surgery was reported previously [25]. Because the left internal mammary artery harvesting was performed on all the patients in all three groups, the left internal mammary artery harvesting was not accepted as a determinant on the postoperative pulmonary functions. Thus, CPB could be assumed to be the predictor for postoperative pulmonary dysfunction of patients with COPD. Although the mean CPB time (21.6 ± 3.8 minutes) was quite short in one-vessel diseased patients, it was surprising to find out that the FEV₁, FEV₁/FVC, and FVC values at the end of the second postoperative month could not reach the preoperative values of the patients in group 1.

In conclusion, pulmonary dysfunction is still a major problem in CABG operations. Patients with COPD seem to do better after coronary revascularization if cardiopulmonary bypass is avoided. They can be operated on using the beating heart technique, which prevents the side effects of CPB on pulmonary functions. In selected patients, avoiding the side effects of both sternotomy and CPB on pulmonary functions can be performed with the MIDCABG procedure.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We especially want to thank Dilad Cebeci, MD, from the Department of Public Health and Biostatistics Medical Faculty, Marmara University, for her assistance in the statistical analyses.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

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