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Ann Thorac Surg 2003;75:1132-1139
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Perfusion-assisted direct coronary artery bypass provides early reperfusion of ischemic myocardium and facilitates complete revascularization

^a The Division of Cardiothoracic Surgery, Emory University School of Medicine and the Carlyle Fraser Heart Center, Crawford Long Hospital, Atlanta, Georgia, USA

Accepted for publication October 14, 2002.

^* Address reprint requests to Dr Cooper, Division of Cardiothoracic Surgery, Emory University School of Medicine, 550 Peachtree St, NE, Atlanta, GA, USA
e-mail: william_cooper{at}emoryhealthcare.org

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
BACKGROUND: Perfusion-assisted direct coronary artery bypass (PADCAB) was developed to initiate early reperfusion of grafted coronary artery segments during off-pump operations to resolve episodes of myocardial ischemia and avoid its sequelae. This case series outlines intraoperative findings and clinical outcomes of our first year clinical experience with PADCAB.

METHODS: From November 1999 to November 2000, 169 PADCAB and 358 off-pump coronary artery bypass procedures were performed at the Emory University Hospitals. The decision to use PADCAB was predicated on surgeon preference. Perfusion pressure and flow, amount of intracoronary nitroglycerin, and total perfusion time and volume were recorded at the time of operation.

RESULTS: One off-pump coronary artery bypass patient required emergent conversion to cardiopulmonary bypass. Two PADCAB patients had ischemic ventricular arrhythmias during target vessel occlusion that resolved once active perfusion had begun. Perfusion pressure in PADCAB grafts was on average 44% higher than mean arterial pressure (p < 0.001). Nitroglycerin, infused locally by PADCAB, was used in 67 patients to resolve ischemic episodes and increase initial coronary flows. The mean number of diseased coronary territories and grafts placed was 2.8 ± 0.5 and 3.4 ± 0.7, respectively, in the PADCAB group, and 2.3 ± 0.8 and 2.7 ± 1.0, respectively, in the off-pump coronary artery bypass group (p < 0.001 for both comparisons). More PADCAB patients received lateral wall grafts than off-pump coronary artery bypass patients (83.4% vs 59.4%; p < 0.001). Hospital death and postoperative myocardial infarction were not different between groups.

CONCLUSIONS: PADCAB can provide suprasystemic perfusion pressures and a means to add vasoactive drugs to target coronary vessels. PADCAB provides early reperfusion of ischemic myocardium and facilitates complete revascularization of severe multivessel coronary artery disease.

	Introduction

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Drs Lattouf and Craver disclose that they have a financial relationship with Medtronic. Drs Puskas and Guyton disclose that they have a financial relationship with both Medtronic and Quest Medical.

 

Off-pump coronary artery bypass (OPCAB) decreases hospital cost, postoperative length of hospital stay, transfusion requirement, and morbidity compared with on-pump coronary artery bypass (ONCAB) without compromising early graft patency [1]. Hemodynamic instability during vessel occlusion or heart manipulation continues to be a major concern of surgeons performing OPCAB [2–5]. The trend toward fewer grafts, especially high, lateral wall grafts, in OPCAB compared with ONCAB may be a manifestation of this concern [2, 5–7]. Fortunately, in experienced hands, emergent cardiopulmonary bypass (CPB) after unsuccessful OPCAB is a rare event [8]. Various techniques providing early perfusion to target segments to reduce ischemic dysfunction have included the use of intraluminal stents and arterial shunts and the construction of proximal anastomoses before distal anastomoses. We have previously described a technique of selective graft perfusion by a servo-controlled pump that can regulate the blood flow and pressure within the grafted segment and allow suprasystemic perfusion of the target vessel [9] in off-pump coronary artery bypass. Perfusion-assisted direct coronary artery bypass (PADCAB) provides a means to introduce drug additives, such as vasodilators or cardioprotectants, to the perfusate. Perfusion-assisted direct coronary artery bypass (PADCAB) can preserve hemodynamic stability by resolving ischemic dysfunction during beating heart coronary artery bypass [9, 10]. In addition, PADCAB overcomes the fixed resistance of intravascular shunts, especially during hemodynamic instability and hypotension [11].

We report here our first year experience with PADCAB compared with contemporaneous OPCAB at the Emory University Hospitals, detailing intraoperative findings and clinical outcomes.

	Material and methods

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From November 1999 to November 2000 at the Emory University Hospitals, intraoperative data were collected from patients undergoing OPCAB and PADCAB, including mean arterial pressure, selective graft perfusion pressure and flow, number of distal anastomoses, the use of nitroglycerin in the perfusate, and total volume and time of PADCAB perfusion. The decision to use PADCAB was made by the surgeon preoperatively. Conversion to PADCAB was not performed once an OPCAB procedure had begun. Clinical factors including severe multivessel coronary artery disease requiring three or more grafts, left ventricular dysfunction, or cardiomyopathy influenced the decision to use PADCAB. The PADCAB procedure was not used for one-vessel or two-vessel bypasses or for grafts that were only to anterior wall targets, and PADCAB was often avoided in patients with renal or pulmonary insufficiency. Placement of an intraaortic balloon pump (IABP), either preoperatively, intraoperatively, or postoperatively was at the discretion of the surgeon. Criterion for placing an IABP preoperatively in OPCAB and PADCAB included emergent transfer from the cardiac catheterization laboratory to the operating room with ongoing ischemia or hemodynamic compromise, ongoing myocardial ischemia or pump insufficiency refractory to maximal medical therapy in nonemergent procedures, complex coronary artery disease with reduced ventricular function, and other comorbid conditions in a patient who would benefit from avoiding CPB [12].

The PADCAB circuit was used as previously described [9, 13] using the myocardial protection system cardioplegia and perfusion delivery system (Quest Medical, Inc, Allen, TX) (Fig 1). Epivascular echocardiography was performed in all patients who were older than 65 years of age, had left main disease, or had peripheral vascular or cerebrovascular disease to assess the extent of arteriosclerosis in the ascending aorta. Intraoperative transesophageal echocardiography was another standard procedure used to monitor new wall motion abnormalities during heart manipulation or vessel occlusion.

View larger version (51K): [in this window] [in a new window]   Fig 1. The perfusion-assisted direct coronary artery bypass circuit in which aortic blood is obtained from the aortic cannula (A) and taken to the Quest myocardial protection system (MPS) cardioplegia and perfusion device. The MPS actively pumps the blood and drug treatments to the multiple perfusion set (B) and then to the vein or arterial grafts (C) once the distal anastomoses are completed and the circuit is connected. The infusion pressure in the grafts is monitored by the MPS by a feedback line (D) located at the proximal portion of the multiple perfusion set. (LIMA = left internal mammary artery.)

Typically in the PADCAB group, the first graft was a saphenous vein or radial artery to a coronary artery of adequate size, usually the right coronary artery or one of its branches with a severe proximal stenosis (Table 1). In the OPCAB group, the left internal mammary artery was placed to the left anterior descending coronary artery more frequently as the first graft in multivessel coronary artery bypass. The target vessel was snared with a silicon vessel loop to create a reversible coronary occlusion. Grafting sequence varied among surgeons, but specific strategies were common among all surgeons: (1) collateralized or occluded vessels were grafted before collateralizing vessels and (2) targets that required less heart manipulation were generally grafted before ones that required extensive heart manipulation. There was a significant difference in the placement of the first coronary graft between the PADCAB and the multivessel OPCAB (Table 1) (p < 0.001). Using PADCAB, there was no need to perform proximals first or to use intraluminal shunts. In the OPCAB cohort, the proximals first technique was used in 6% of procedures and the intraluminal shunts were used in 2% of procedures to provide early reperfusion.

Using PADCAB after completion of the distal anastomosis, the proximal end of the graft was immediately connected to a delivery line from the myocardial protection system using a multiple perfusion set (Medtronic DLP). One to three grafts were sequentially perfused in each patient. The target perfusion pressure for each graft was 100 mm Hg. If there was evidence of myocardial ischemia detected by ST-segment elevation changes on continuous electrocardiogram or new wall motion abnormality on transesophageal echocardiography, or both of these, or if the flow through a single graft was below 80 mL/min, the perfusion pressure was increased to 120 mm Hg. Nitroglycerin (NTG, 10 µg/mL) was added to the perfusate if the increase in perfusion pressure did not resolve the ischemia or increase graft flow. The delivery rate of NTG was 100 µg/min for each graft.

The proximal anastomoses of the radial artery and saphenous vein were created to the ascending aorta using a partial occlusion clamp. If evidence of severe arteriosclerosis in the ascending aorta (grade III or higher) on epivascular ultrasonography was discovered, the proximal anastomoses of the radial artery and saphenous vein were made to the left internal mammary artery. Perfusion to the grafted segments was halted during formation of the proximal anastomoses.

Preoperative chronic renal insufficiency was defined as a creatinine level above 2.0 mg/dL. Postoperative myocardial infarction was defined as ST-segment elevation changes in two or more contiguous leads or the appearance of a new Q-wave on a postoperative electrocardiogram. Postoperative acute renal insufficiency was defined as either an increase in the postoperative creatinine level above 2.0 mg/dL if the preoperative creatinine level was normal, or a need for hemodialysis if the patient had preoperative chronic renal insufficiency. Postoperative cerebrovascular accident was defined as a central neurologic deficit that persisted greater than 72 hours. The diagnosis of postoperative cerebrovascular accident was confirmed by a thorough neurologic examination by consultant neurologists and computed tomography or magnetic resonance imaging of the brain. Postoperative coagulopathy was defined as clinically significant bleeding that required medical intervention or blood product transfusion, or both.

Statistics
The mean and standard deviation were calculated for independent and dependent variables and are reported in the text, tables, and figures. The unpaired Student’s t test and ² analysis were used to compare continuous variables between groups. A ² analysis of contingency was used to compare several groups and categories as appropriate. Statistical analysis was performed using SigmaStat 2.0 for Windows (SPSS, Inc, Chicago, IL). A p value of less than 0.05 was considered significant.

	Results

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The preoperative characteristics of PADCAB and OPCAB patients are shown in Table 2. There were more patients who were female, hypertensive, and had previous catheter based coronary interventions in the OPCAB group (p < 0.05). The PADCAB cohort had a greater number of diseased coronary territories than the OPCAB cohort (p < 0.001) reflecting multiregional coronary disease that required multivessel CAB. There were no other significant differences in preoperative characteristics between groups.

Intraoperative findings are found in Table 3. The PADCAB patients had a greater number of bypass grafts compared with OPCAB (p < 0.001). The proportion of patients with lateral wall grafts was significantly greater in the PADCAB group (p < 0.001). The average number of lateral wall grafts was also greater in the PADCAB cohort compared with the OPCAB cohort (p < 0.001). In general, both groups had complete revascularization as the number of bypass grafts exceeded the number of diseased coronary territories in both groups.

Perfusion pressure in the PADCAB circuit significantly exceeded mean arterial pressure (p < 0.001) (Table 4). Perfusion flow averaged 88 ± 34 mL/min in the grafts connected to the PADCAB circuit. Sixty-seven of 169 PADCAB patients (40%) received an average of 31.9 ± 32.0 mL of NTG by the PADCAB circuit through the grafts to enhance myocardial perfusion. There was no decrease in mean systemic arterial pressure during the delivery of the NTG through the grafts. Total time connected to the PADCAB circuit averaged 55.7 ± 21.9 minutes. Total PADCAB volume infused averaged 5,118 ± 3,471 mL.

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We believe that selected patients with severe multivessel coronary disease (requiring three or more grafts to coronary arteries with severe proximal stenoses), left ventricular dysfunction, or cardiomyopathy, or a combination thereof, will benefit from coronary bypass without the use of CPB, but may require early perfusion assistance during the procedure especially in the case of ongoing myocardial ischemia. Perfusion-assisted direct coronary artery bypass (PADCAB) can promote hemodynamic stability as well as restore myocardial oxygen supply and demand imbalances during vessel occlusion [11] and therefore facilitate myocardial functional recovery in the affected myocardium. This population of patients is different from those with good ventricular function or less severe native coronary disease that will have favorable outcomes with standard OPCAB. Perfusion-assisted direct coronary artery bypass (PADCAB) is a tool that provides early reperfusion and intraoperative cardiodynamic stability in those with ongoing or iatrogenically imposed ischemia.

In our first year experience with PADCAB, we were able to safely and comfortably graft lateral wall vessels and construct an overall greater number of grafts compared with a cohort of patients undergoing standard OPCAB. More patients who underwent PADCAB required and received obtuse marginal grafts, and more obtuse marginal grafts were completed per patient compared with OPCAB patients. The PADCAB patients who required multiple grafts secondary to severe multivessel disease benefited from early direct reperfusion to avoid multiple areas of regional dysfunction compared with OPCAB patients who required fewer grafts on average for complete revascularization. PADCAB permitted immediate reperfusion and cardiodynamic stabilization of 2 patients in whom vessel occlusion during the formation of the distal anastomosis caused ischemic ventricular arrhythmias. Perfusion-assisted direct coronary artery bypass (PADCAB) was particularly useful in providing early reperfusion in a patient who required emergent coronary artery bypass after failed placement of a left anterior descending coronary artery stent and had subsequently arrested. Stabilization of these patients would have been difficult with OPCAB without active perfusion assistance.

There were 2 PADCAB patients whose operations were performed early in the experience and who had ischemic ventricular arrhythmias during the formation of the final proximal anastomosis after active perfusion ceased. In these 2 patients, flow through the graft was greater than 150 mL/min and was likely supplying a large amount of collateral flow. Abrupt stoppage of the flow through the graft was thought to be responsible for the cardiodynamic compromise of these patients. After this experience, PADCAB flow in the final graft was gradually reduced to allow the heart to adjust to systemic perfusion through the completed grafts. There were no further episodes of ventricular arrhythmia or hemodynamic deterioration during creation of the proximal anastomoses in the PADCAB group after this change in perfusion strategy.

Perfusion-assisted direct coronary artery bypass (PADCAB) provides a means to infuse drug additives such as NTG during episodes of myocardial ischemia. In the present study, ST-segment elevation changes or new wall motion abnormalities, or both, were treated and resolved with suprasystemic perfusion pressures and an infusion of NTG (67 patients) in the target grafts without untoward systemic hemodynamic effects observed. The myocardial protection system has two separate chambers for drug additives with individual flow controls [13]. Other additives and cardioprotectants, including adenosine [14], L-arginine, glucose, and insulin, or sodium-hydrogen exchange inhibitors can be added to the PADCAB delivery system. The myocardial protection system can also accommodate modified reperfusion strategies, such as timed, gradual increases in perfusion pressures, which reduce postischemic injury in at-risk myocardium [15, 16].

Postoperative myocardial infarction occurred in 1.2% of PADCAB patients, which is similar to that reported in a previous OPCAB series [1] and not different from the contemporaneous OPCAB cohort. The incidence of postoperative cerebrovascular accident and renal insufficiency were similar. Hospital death was not different between groups despite the fact that the PADCAB patients had multiregional coronary disease and received more grafts.

The average intensive care unit stay in the PADCAB cohort was longer than the OPCAB cohort. The longer intensive care unit stay may reflect the more severe coronary artery disease and compromised myocardial function as evidenced by the decision to use PADCAB and a greater proportion of preoperatively placed IABPs. The longer postoperative length of stay may also reflect the severity of the coronary disease and the complexity of multivessel revascularization.

The patients in the PADCAB cohort received cell saver blood more frequently and with greater volumes than the OPCAB patients. The PADCAB cohort also received more units of packed red blood cells on average than the OPCAB cohort, although this difference was not significant. The PADCAB group’s increased blood product use versus the OPCAB group may be related to the administration of a full on-pump heparin dosing regimen or a systemic inflammatory response associated with the extracorporeal circuit, or both. Inflammatory mediators were not prospectively collected in this series; however quantification of plasma tumor necrosis factor and interleukins may be helpful in understanding the increased blood use in the PADCAB group. The effect of PADCAB on these mediators is currently being evaluated in a prospective, randomized study at this institution.

Conversion to CPB in recent clinical series of OPCAB ranges from 0.4% to 2.8% [8, 17–20]. There were no patients in the PADCAB and only 1 patient in the OPCAB group that required conversion to CPB caused by hemodynamic collapse. This OPCAB patient had labile systemic blood pressure during anterior vessel anastomosis and had further hemodynamic compromise during occlusion of a marginal vessel. Elective IABP placement extended the benefit of OPCAB to patients with poor or marginal preoperative ventricular function and comorbidities. The combination of elective IABP and PADCAB proved to be useful in 16 patients in a previously described series [12] and likely helped to avoid CPB in these patients.

There are few series in the literature documenting the incidence of myocardial ischemia during OPCAB. In a small series of Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) patients monitored with transesophageal echocardiography and a pulmonary artery catheter, 81% had new wall motion abnormalities and increased pulmonary artery pressures with iatrogenic occlusion of the left anterior descending coronary artery develop [21]. Another small series of MIDCAB patients showed that 9 of 14 patients had intraoperative or postoperative signs of ischemia, or both [22]. Serum markers of myocardial injury typically show an increase in values intraoperatively and postoperatively indicating intraoperative ischemia with or without evidence of new regional wall motion abnormalities [23]. Because the number of grafts performed in OPCAB is approaching that of ONCAB, the risk of creating multiple regions of myocardial ischemia or severe ischemia in a particular regional bed increases.

In the present study, 14% of PADCAB patients and 12% of OPCAB patients had evidence of intraoperative ischemia, typically during the period of vessel occlusion for target visualization. However, only the PADCAB patients received immediate intervention by graft reperfusion that could be modified with NTG or increases in perfusion pressure. During standard OPCAB, passive perfusion is given immediately after completion of the distal anastomosis only if the proximal anastomoses are performed first or pedicled grafts are used. However, in standard OPCAB, the perfusion pressure is reliant upon systemic arterial pressure and the reperfusate cannot be directly modified.

Some authors have advocated the use of intraluminal coronary shunts to provide perfusion to the target myocardium during the creation of the distal anastomosis [24, 25]. However, passive perfusion through a shunt limits myocardial perfusion at baseline and does not provide adequate myocardial oxygen supply to match demand during episodes of hypotension [11]. In the present study, intraluminal shunts were used sparingly in the OPCAB cohort and were not needed in the PADCAB cohort.

The PADCAB procedure is advantageous because it provides the surgeon the ability to reperfuse at-risk myocardium early, as well as add cardioprotective pharmacologic interventions in off-pump surgery. Early perfusion assistance in beating heart coronary bypass can preserve cardiodynamic stability as well as treat iatrogenically imposed myocardial ischemia. Additionally, PADCAB facilitates complete revascularization as evidenced by a greater proportion of patients receiving lateral wall grafts and more such grafts constructed per patient. Although an infrequent event in experienced hands [8], PADCAB may reduce the incidence of emergent conversion to CPB during attempted multivessel OPCAB.

	Acknowledgments

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The authors gratefully acknowledge the assistance of Linda Robertson, RN, and Rebecca Petersen, RN, and the continuing support of the Carlyle Fraser Heart Center. We are indebted to Jakob Vinten-Johansen, PhD, for his comments on this article.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

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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): William A. Cooper John D. Puskas Joseph M. Craver Omar M. Lattouf Robert A. Guyton Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cooper, W. A. Articles by Guyton, R. A. Search for Related Content PubMed PubMed Citation Articles by Cooper, W. A. Articles by Guyton, R. A. Related Collections Minimally invasive surgery