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Ann Thorac Surg 2008;86:1914-1918. doi:10.1016/j.athoracsur.2008.07.003
© 2008 The Society of Thoracic Surgeons
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Original Articles: Pediatric Cardiac

Efficacy and Safety of On-Pump Beating Heart Surgery

Ansheng Mo, MDa,b,*, Hui Lin, MDb, Zhaoke Wen, MMb, Weijun Lu, MMb, Xiaomao Long, MDb, Yifang Zhou, MMb

a The Medical College of Wuhan University, Wuhan, China
b Department of Cardiothoracic Surgery, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China

Accepted for publication July 1, 2008.

* Address correspondence to Dr Mo, Department of Cardiothoracic Surgery, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530021, China (Email: moansheng{at}163.com).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: Beating-heart surgery with warm blood perfusion, instead of cardioplegic solution, has been widely accredited to be a feasible technique in the cardiac operation. However, few studies have addressed the efficacy and safety of on-pump beating-heart surgery, especially with large numbers of patients. In this study, the efficacy and safety of on-pump beating-heart surgery was evaluated by surveying 701 patients with cardiac disease.

Methods: Preoperative risk factors, intraoperative techniques, and postoperative complications were documented and evaluated in 701 consecutive patients (from January 1, 2002, to December 30, 2006) who underwent beating-heart surgery with continuous antegrade or retrograde warm blood perfusion at The People's Hospital of Guangxi Zhuang Autonomous Region.

Results: Among the 701 patients with beating-heart surgery, antegrade perfusion was used in 556 patients (79.32%); retrograde perfusion was used in 40 patients (5.71%); and retrograde perfusion followed by antegrade perfusion was performed in 93 patients (13.27%). Cardioplegic arrest was required in 12 patients (1.71%) for inadequate visualization. In 4 of 701 patients (0.57%) low cardiac output syndrome occurred. Hemoglobinuria occurred in 16 patients (2.28%). No air embolization or permanent high-degree atrioventricular block occurred in these patients. The crude mortality of the surveyed patients was 2.43% (17 of 701).

Conclusions: Our results indicate that on-pump beating-heart surgery is a relatively safe and reliable technique for treatment of cardiac diseases.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Hypothermic cardioplegia techniques, inducing myocardial protective effects by reducing oxygen consumption, were introduced and applied in cardiac operation. These techniques were well accepted in the initial stage, but later it was observed that hypothermic cardioplegia techniques led to subsequent cardiac impairment, especially ischemia–reperfusion injury. Researchers sought to find other strategies to improve this situation. In 1991, a new technique, warm-heart surgery, was introduced by Lichtenstein and associates [1], in which beating-heart surgery was feasible. Thereafter, mitral valve replacement was successfully accomplished with a beating heart under mild hypothermic cardiopulmonary bypass by Wei and colleagues in 1993 [2]. In 1996, aortic valve replacement was performed with a beating heart under mild hypothermic cardiopulmonary bypass by Hui and coworkers [3]. At present, beating-heart surgery has been widely practiced. However, there are few studies addressing the efficacy and safety of on-pump beating-heart surgery, especially with large numbers of patients. In the present study, the efficacy and safety of on-pump beating-heart surgery was evaluated by surveying 701 patients with cardiac disease.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
We surveyed 701 patients who underwent on-pump beating-heart surgery at The People's Hospital of Guangxi Zhuang Autonomous Region from January 1, 2002, to December 30, 2006. The patients' preoperative variables and surgical procedures are summarized and listed in Tables 1 and 2, Go respectively. All the procedures were carried out with the legal consent of the individual patient and with the approval of the ethics committee.


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  		Table 1 Preoperative Variables of the Patients
 

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  		Table 2 Procedures Performed
 
Cardiopulmonary Bypass
After heparinization, the heart was cannulated as routine. The mean arterial blood pressure was maintained at 50 to 80 mm Hg by a pump with the flow rate of 3.0 to 3.4 L · min–1 · m–2 in the initiation of cardiopulmonary bypass, 2.4 to 3.0 L · min–1 · m–2 during cardiopulmonary bypass, and 2.8 to 3.4 L · min–1 · m–2 in rewarming. A vent was placed into the left ventricle or atrium through the right superior pulmonary vein for the purpose of decompression during the operation. The hematocrit was maintained at 18% to 24%, and the temperature was maintained at 32° to 34°C.

Heart Perfusion
Antegrade perfusion
The aorta was unclamped throughout the cardiopulmonary bypass, so that perfusion of the coronary ostium was through the arterial cannula and reaching the aortic root.

Retrograde perfusion
After the venae cavae were snared and total cardiopulmonary bypass was initiated, a retrograde perfusion catheter was inserted into the coronary sinus and positioned by its balloon and pursestring suture. Then perfusate from the cardiopulmonary bypass was delivered through the catheter with the aorta cross-clamped. During retrograde perfusion, the perfusion flow rate was maintained at 200 to 300 mL/min and the coronary sinus pressure was maintained at 45 to 60 mm Hg. Perfusion adequacy was monitored by electrocardiography, blood returning from the coronary ostium, and myocardial color.

Air Embolism Prevention
In antegrade perfusion, a suction catheter was placed into the left atrium or left ventricle through the right superior pulmonary vein or interatrial septum to achieve decompression. The mean arterial pressure was kept greater than 60 mm Hg for adults and 50 mm Hg for children. In retrograde perfusion, aortic cross-clamping was performed to obviate air embolization. After intracardiac manipulation, the patients were placed in a Trendelenburg position, and cardiopulmonary bypass perfusion pressure was kept greater than 70 mm Hg to eliminate the risk of air embolization.

Removal of air from the left heart
After the intracardiac procedures were completed, the left heart was filled with blood to extrude the air through the opening mitral valve, ventricular septal defect, or atrial septal defect. In case of interatrial septum incision, the interatrial septum was closed with a continuous suture. Simultaneously, the lung was briefly inflated to help with removal of air. Moreover, a suction vent was placed in the ascending aorta.

Removal of air from the right heart
After the intracardiac procedures, the right heart was closed with a continuous suture. Removal of air was performed by filling the heart with blood. In addition to that, massage was also used to remove air from the right heart.

Aortic Valve Replacement
The right superior pulmonary vein was cannulated for left ventricular venting. Coronary sinus perfusion was carried out with mild hypothermia blood after the aorta was cross-clamped and incised. The rest of the procedure was performed as normal. When the aortic valve replacement was accomplished, filling of the left heart and aorta with blood was performed to exclude the air. Meanwhile, a suction vent was placed in the ascending aorta. After the aortotomy was completed, the retrograde perfusion catheter and the aortic cross-clamp were removed.

Aortic Root Procedures
The heart was cannulated through the left femoral artery and the superior and inferior venae cavae. The heart was kept beating by retrograde perfusion while the aorta was cross-clamped. Then, the rest of the surgery proceeded following standard aortic root procedures. After the aortic root procedures were completed, standard air removal maneuvers were performed.

Mitral Valve Surgery
The aorta was not cross-clamped, and the perfusion of the myocardium was maintained. After snaring the venae cavae, mitral valve replacement was performed through a transseptal incision. After the intracardiac procedures, the mitral valve prosthesis was kept opened with a Foley catheter and then the left ventricle and atrium were filled with blood to exclude the air from the chambers. In some cases, the tricuspid valvuloplasty (De Vega type) was performed before removing air from the right heart.

Combined Aortic and Mitral Valve Surgery
Retrograde perfusion followed by antegrade perfusion was performed in combined aortic and mitral valve surgery. Antegrade perfusion was restored and the mitral valve prosthesis was fixed under antegrade perfusion after intermittent suture lines were placed at the mitral annulus, and the aortic valve replacement was completed.

Combined Valve and Coronary Artery Bypass Grafting Surgery
After coronary revascularizations were performed with or without the pump, the mitral valve procedures or aortic valve procedures were done as described above.

Repair of Paravalvular Leakage After Mitral Valve Replacement, Removal of a Left Atrial Thrombus, and Left Atrium Tumor Resection
Air embolism prevention and air removal procedures were performed as described previously. To eliminate the risk of embolization, a suction catheter was placed through the right superior pulmonary vein into the left atrium only after the cardiopulmonary bypass was started.

Congenital Heart Disease Surgery
In congenital heart diseases surgeries, such as atrial septal defect repair, partial anomalous pulmonary venous drainage, or single atrium repair, it was essential to keep the left atrium filled with blood so as to avoid air ingression. In cases such as small ventricular septal defect, patent ductus arteriosus, and Watt's sinus aneurysm rupture repair, a Foley catheter inflated with water was used to obtain a bloodless operative view. However, a suction catheter passing through the interatrial septum and mitral valve into the left ventricle was used in large ventricular septal defect repair, atrioventricular canal, and radical surgery for tetralogy of Fallot. The procedures of coronary artery fistula repair, corrective surgery for Ebstein's malformation, radical operation for trilogy of Fallot, surgical repair of double-chambered right ventricle, and radical resection of pulmonary valve stenosis were performed in accordance with those performed during heart arrest.

Converting to Cardioplegia Arrest
Heart arrest was induced as routine for the patients in whom the beating-heart surgery could not be performed. In 12 patients, cold cardioplegia arrest was enforced during the intraoperative period for inadequate visualization. In 7 patients with mitral valve replacement, cardioplegic solution was admitted to retrieve aortic insufficiency caused by retraction of the atrial wall or small left atrium. Air removal and incision closure were done in the beating state. In the 5 patients with tetralogy of Fallot, cardioplegia was induced to repair the ventricular septal defect. However, the right ventricular outflow tract was reconstructed in a beating heart. In this way, the period of myocardial ischemia and cardiopulmonary bypass was reduced.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Of the 701 patients with beating-heart surgery, antegrade perfusion was performed in 556 patients (79.32%), retrograde perfusion was performed in 40 patients (5.71%), and retrograde perfusion followed with antegrade perfusion was performed in 93 patients (13.27%). The ST segment of the electrocardiogram did not show obvious change during the perfusion. Cardioplegic arrest was enforced in 12 patients (1.71%) for inadequate visualization. In 4 of 701 patients (0.57%) low cardiac output syndrome occurred, and in 16 patients (2.28%) hemoglobinuria was experienced. No air embolization or permanent high-degree atrioventricular block occurred. The crude mortality of all surveyed patients was 2.43% (17 of 701) Dosages of dopamine used, complications, and the crude mortality are listed in Table 3.


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  		Table 3 Postoperative Variables of the Patients
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Traditional myocardial protection strategies, such as hypothermia, might lead to postoperative left ventricular dysfunction. It becomes more notable in patients with preoperative myocardial dysfunction or those who need time-consuming operations. For that reason, continuous antegrade or retrograde perfusion with warm blood, as an improved technique, was developed and now has been widely accepted. In beating-heart surgery, with empty beating, the cardiac workload is dramatically reduced. Nourishment derived from continuous perfusion is adequate to obviate hypoxia or arrhythmias. Evidence from both experimental and clinical studies demonstrates that beating-heart surgery is characterized with some advantages, including (1) no reperfusion injury, (2) less workload, (3) reduced cardiopulmonary bypass time, (4) testing of the mitral valve repair done in close to physiologic conditions in the state of left ventricular beating tonus, (5) easier to find small ventricular septal defect and residual leakage, and (6) direct opportunity to find conduction block. However, a few disadvantages should be noted when performing beating-heart surgery, including (1) inability to provide a bloodless surgical field in some cases, (2) increased blood cell damage, and (3) performance of open heart surgery in a beating state is technically a little more demanding than in an arrested state [2–14].

From January 1, 2002, to December 30, 2006, beating-heart surgery has been performed on 701 patients in The People's Hospital of Guangxi Zhuang Autonomous Region. The survey indicates that the outcomes are satisfactory. Based on the results of survey, we raised a few issues that should be of concern in beating-heart surgery.

First, the temperature should be adjusted flexibly during the surgery. With the initiation of cardiopulmonary bypass, the temperature of the priming solution must be maintained greater than 32°C. Then the temperature is decreased gradually in the cardiopulmonary bypass. In this way, ventricular fibrillation can be avoided. The nasopharyngeal temperature should be kept at 32° to 34°C during cardiopulmonary bypass to prevent heart arrest. Mild hypothermic perfusion is needed to reduce the heart rate (40 to 60 beats/min), cardiac contractile force, and metabolic rate. This adjustment enables the lower flows during cardiopulmonary bypass, hence attenuating red blood cell damage and permitting a nice field of view in the operation. Esmolol or magnesium are used, in some special cases, to induce adequate bradycardia effect. Gersak and Sutlik [4] and Gersak [5] performed the beating-heart surgery during normothermia ((37°C), in which the heart rate was 50 to 80 beats/min. However, Kaukoranta and colleagues [15] proposed that mild hypothermia, instead of normothermia, was preferred to maintain better heart protection.

Second, an optimal field of view of the operation is essential to ensure the operation is carried out smoothly. In beating-heart surgery, coronary blood flow is not blocked and the left-to-right shunt exists, which will lead to obscuring of the surgical field. To obtain a bloodless operative field, suction catheters are needed through which air or blood can be removed during cardiopulmonary bypass. Alternatively, an inflated Foley catheter can be used to block the blood shunt temporarily. However, cardioplegia arrest is still needed in some special conditions. Among the 701 patients, 12 cases of cardioplegia arrests were performed for inadequate visualization.

The last but not the least aspect deserving special concern is prevention of air embolism. In anterograde perfusion, air embolism may occur when the pressure of the aortic root is less than that of the left ventricle. Therefore, keeping the left ventricle vented to the atmosphere and maintaining the aortic root mean blood pressure greater than 60 mm Hg for adults and 50 mm Hg for children are necessary. In retrograde perfusion, air embolism can be avoided by aortic cross-clamping. After the intracardiac procedures are accomplished, air will be excluded by filling the chambers with blood. Usually, left ventricular decompression and air removal is achieved through the mitral valve opening or placement of a shunt. Among the 701 patients, not a single case of a stroke caused by air embolization was observed. Karadeniz and associates [16] reported that there were no significant differences on the major neurologic outcome between the patients having beating-heart surgery and those undergoing hypothermic arrested-heart surgery. Salerno and colleagues [17] prevented air embolism by inducing ventricular fibrillation and decompressing the left ventricle through the apex, which is different from the methods used by us.

In the 701 patients, antegrade perfusion was performed in most cases. Retrograde perfusion was performed only in aortic valve replacement and aortic root surgery. No significant change was found in the ST segment of the electrocardiogram during the period of perfusion. The outcome of perfusion has been controversial. It was reported that retrograde perfusion could not provide adequate myocardial protection to the right ventricle and part of the interventricular septum [18, 19]. However, some reports support the idea that retrograde blood cardioplegia reduced ischemic injury and permitted accelerated recovery for myocardial function, compared with antegrade blood cardioplegia. Jasinski and coworkers [20] found that retrograde perfusion obtained better outcomes in patients with severe proximal left anterior descending artery occlusion and extensive coronary artery disease. It could provide ideal myocardial protection for both ventricles [21]. Menasché and associates [22] reported that retrograde perfusion effectively maintained myocardial aerobic patterns in patients with aortic valve stenosis derived from left ventricular hypertrophy. The controversial results derived from different studies might be attributable to the temperatures maintained in the operation [23, 24]. The dissimilarity of the anatomy of coronary sinus drainage in different genera also affected the outcomes of perfusion [23].

It was reported that perfusion whether antegrade or retrograde alone resulted in the inhomogeneous distribution of coronary flow [25, 26]. Salerno and colleagues [17] developed the modified technique, simultaneous perfusion of both antegrade and retrograde, which retrieved the disadvantage of one-way perfusion. Recently, another revised perfusion system was introduced in beating-heart surgery, in which retrograde perfusion was achieved by a pump, and antegrade perfusion of the coronary ostia is through a Y-cannula connected to the side port of the ascending aorta cannula [27]. However, Wang and associates [28] proposed that simultaneous perfusion did not show obvious ascendancy during beating-heart valve surgery, compared with the antegrade perfusion. These investigators also believed that simultaneous antegrade and retrograde perfusion was not suitable for cases of hypertrophied hearts, in which it led to slightly impaired myocardial oxygenation and energy metabolism [29].

Beating-heart surgery could be applied to most congenital and acquired cardiovascular diseases, especially for hypertrophied hearts and high-risk patients with low ejection fractions. In our study, beating-heart surgery was performed in more than 90% of 701 patients. Cardioplegia arrest was applied during beating heart surgery for inadequate visualization in only 12 patients (1.71%). In several cases, cardioplegia and beating-heart technique were applied.

Beating-heart surgery provides an alternative method for myocardial protection in heart operation. Our results indicate that on-pump beating-heart surgery is a relatively safe and reliable technique for treatment of cardiac diseases. Compared with the traditional strategies, the randomized trial with a larger number of patients is preferred to characterize the efficacy and safety of this procedure.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

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