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Ann Thorac Surg 2001;72:2183
© 2001 The Society of Thoracic Surgeons

Correspondence

Myocardial stunning after off-pump coronary artery bypass grafting: safeguards and pitfalls: Reply

Herko Grubitzsch, MDa, Knut Ansorge, MDa, Hans-Georg Wollert, MDa, Lothar Eckel, MDa

a Heart and Diabetes Centre Mecklenburg-Vorpommern, Clinic of Thoracic and Cardiovascular Surgery, Greifswalder Str 11 A, D-17495 Karlsburg, Germany

e-mail: Grubitzsch{at}t-online.de

To the Editor

We wish to thank Dr D’Ancona and colleagues for their contriution to the discussion on how to prevent myocardial stunning after off-pump coronary artery bypass grafting (OPCAB). The suggested standard protocol consisting of (1) ischemic preconditioning and (2) intracoronary shunting may be superior in adequately preventing ischemic complications. But what does shunting prevent when myocardium is already preconditioned? Furthermore, considering the risks of these maneuvers (ie, coronary artery spasm due to repeated snaring or endothelium alterations by shunt placement) we question whether they should be applied to every constructed graft with OPCAB.

Severe sequelae of temporary coronary artery occlusion occur very rarely. In our patients myocardial stunning was present in 2 of 201 patients. According to our experience, we use shunts only if evidence of regional ischemia arises after incision in the coronary artery or if coronary artery occlusion will exceed 15 minutes. Using this protocol we have not observed any cases of postischemic left ventricular dysfunction. Because of additional advantages of shunts, such as minimizing bleeding, "exposing" intramural vessel structures or "temporarily stenting" the coronary artery, we now prefer shunts. Ischemic preconditioning is applied if snaring the coronary artery before incision leads to relevant ischemia. Again, we would like to stress, that transient ischemia does not limit subsequent ischemic regional dysfunction in a clinical setting of minimally invasive coronary artery bypass grafting [1].

Regarding intraoperative monitoring we have learned that ST segment monitoring and continuous measurement of the left atrial pressure [2] are simple but very reliable methods for evidence of regional ischemia. Changes in cardiac output usually do not occur in a close time relationship to regional ischemia because mechanisms of cardiovascular autoregulation stabilize cardiac output. Reductions in stroke volume immediately lead to increasing filling pressures.

Today, OPCAB is a safe procedure with low perioperative morbidity and mortality. Patients at risk of complications due to extracorporeal circulation especially benefit from off-pump coronary artery revascularization. Nevertheless, temporary arterial occlusion bears a risk of postischemic contractile dysfunction. Therefore, shortening ischemic periods must be a central issue in these procedures.

References

  1. Malkowski M.J., Kramer C.M., Parvizi S.T., et al. Transient ischemia does not limit subsequent ischemic regional dysfunction in humans: a transesophageal echocardiographic study during minimally invasive coronary artery bypass surgery. J Am Coll Cardiol 1998;31:1035-1039.
  2. Grubitzsch H., Ansorge K., Wollert H.G., Eckel L. Hemodynamic monitoring in patients undergoing off-pump coronary artery bypass grafting using the Octopus tissue stabilizer—left atrial pressure as a gold standard. J Cardiothorac Vasc Anesth 2000;14:105-106.

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Myocardial stunning after off-pump coronary artery bypass grafting: safeguards and pitfalls
Giuseppe D'Ancona, Harry W. Donias, Jacob Bergsland, and Hratch L. Karamanoukian
Ann. Thorac. Surg. 2001 72: 2182. [Extract] [Full Text] [PDF]

Left axillary to left anterior descending coronary artery: Reply
James A. Magovern
Ann. Thorac. Surg. 2001 72: 2183-2184. [Extract] [Full Text] [PDF]




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