Abstract
BackgroundCardiopulmonary bypass (CPB) with aortic cross-clamping and cardioplegic arrest remains the method of choice for patients requiring standard myocardial revascularization. Therefore, very high-risk patients presenting with acute coronary syndrome, unstable angina, onset of cardiac decompensation and requiring emergency multiple myocardial revascularization, can have a poor outcome. The on-pump beating heart technique can reduce the mortality and the morbidity in such a selected group of patients and this report describes our clinical experience.MethodsOut of 290 patients operated for CABG from January 2005 to January 2006, 25 (8.6%) selected high-risk patients suffering from life threatening coronary syndrome (mean age 69 ± 7 years) and requiring emergency multiple myocardial revascularization, underwent on-pump beating heart surgery. The mean pre-operative left ventricle ejection fraction (LVEF) was 27 ± 8%. The majority of them (88%) suffered of tri-vessel coronary disease and 6 (24%) had a left main stump disease. Nine patients (35%) were on severe cardiac failure and seven among them (28%) received a pre-operative intra-aortic balloon pump. The pre-operative EuroScore rate was equal or above 8 in 18 patients (73%).ResultsAll patients underwent on-pump-beating heart coronary revascularization. The mean number of graft/patient was 2.9 ± 0.6 and the internal mammary artery was used in 23 patients (92%). The mean CPB time was 84 ± 19 minutes. Two patients died during the recovery stay in the intensive care unit, and there were no postoperative myocardial infarctions between the survivors. Eight patients suffered of transitorily renal failure and 1 patient developed a sternal wound infection. The mean hospital stay was 12 ± 7 days. The follow-up was complete for all 23 patients survived at surgery and the mean follow-up time was 14 ± 5 months. One patient died during the follow-up for cardiac arrest and 2 patients required an implantable cardiac defibrillator. One year after surgery they all had a standard trans-thoracic echocardiogram showing a mean LVEF rate of 36 ± 11.8%.ConclusionStandard on-pump arrested heart coronary surgery has higher mortality and morbidity in emergencies. The on-pump beating heart myocardial revascularization seems to be a valid alternative for the restricted and selected cohort of patients suffering from life threatening coronary syndrome and requiring multiple emergency CABG.
Highlights
Use of cardiopulmonary bypass (CPB) with aortic crossclamping and cardioplegic arrest remains the method of choice for patients requiring standard myocardial revascularization
Despite low-risk patients requiring standard coronary artery bypass grafting (CABG) having a poor risk to develop intraoperative and postoperative complications from the use of CPB and cardioplegic arrest, the subgroup of high-risk patients suffering from acute coronary syndrome with unstable angina and severe cardiac failure is extremely sensitive to emergency surgery: clinical and experimental trials present in literature confirm that use of CPB and cardioplegic arrest are strictly related with a multitude of pathogenic mechanisms responsible for the higher intraoperative and postoperative risk [1,2,3], but, on the other hand, patients suffering from unstable angina and undergoing emergency CABG are expected to derive the greatest benefits from multiple myocardial revascularization
In the present study we describe our clinical experience with the on-pump beating heart coronary surgery for emergency multiple myocardial revascularization
Summary
Use of cardiopulmonary bypass (CPB) with aortic crossclamping and cardioplegic arrest remains the method of choice for patients requiring standard myocardial revascularization. Despite low-risk patients requiring standard CABG having a poor risk to develop intraoperative and postoperative complications from the use of CPB and cardioplegic arrest, the subgroup of high-risk patients suffering from acute coronary syndrome with unstable angina and severe cardiac failure is extremely sensitive to emergency surgery: clinical and experimental trials present in literature confirm that use of CPB and cardioplegic arrest are strictly related with a multitude of pathogenic mechanisms responsible for the higher intraoperative and postoperative risk [1,2,3], but, on the other hand, patients suffering from unstable angina and undergoing emergency CABG are expected to derive the greatest benefits from multiple myocardial revascularization. The on-pump beating heart technique can reduce the mortality and the morbidity in such a selected group of patients and this report describes our clinical experience
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