Off-pump Coronary Artery Bypass Patients Research Articles

Relationship between preoperative FT3 levels and new-onset atrial fibrillation after off-pump coronary artery bypass grafting.

Postoperative atrial fibrillation (POAF) is the most common arrhythmia after cardiac surgery. While thyroid dysfunction can predict POAF, the association between preoperative serum free triiodothyronine (FT3) levels and POAF in patients undergoing off-pump coronary artery bypass (OPCAB) grafting remains unclear. This study aimed to investigate the relationship between preoperative FT3 levels and POAF in OPCAB patients. This prospective observational study included patients with sinus rhythm and no history of atrial fibrillation or thyroid disease who underwent OPCAB and FT3 testing at the Tianjin Chest Hospital from June 2021 to March 2023. The relationship between FT3 level and POAF was evaluated using restricted cubic spline. Cox proportional hazards regression models were used to analyze the associations between FT3 concentration categories [low T3 syndrome (LT3S) (FT3 below the normal range), low normal FT3 (3.10-4.59 pmol/L), high normal FT3 (4.60-6.80 pmol/L)] and POAF, adjusting for potential confounders. Stratified analyses were performed to assess effect modification by gender and age (<60 vs. ≥60 years old). Among 875 patients, 259 (29.6%) developed POAF within 2 days after surgery. Restricted cubic spline analysis showed an S-shaped association between FT3 concentration and POAF risk. Compared to the low normal FT3 group, LT3S was associated with an increased risk of POAF [hazard ratio (HR), 1.41; 95% confidence interval (CI): 1.90-2.19], while high normal FT3 was associated with a decreased risk (HR, 0.72; 95% CI: 0.51-0.99). The association between FT3 and increased POAF risk was more pronounced in patients aged ≥60 years (HR, 1.41; 95% CI: 1.89-2.22). Preoperative FT3 levels most likely could predict POAF risk after OPCAB, especially in patients aged 60 years and older. Measuring FT3 preoperatively may identify high-risk patients benefiting from close monitoring and prophylactic treatment. Further investigation of thyroid hormone replacement therapy for LT3S is warranted.

The effect of ulinastatin on acute kidney injury in patients undergoing off-pump cardiac bypass surgery

BackgroundUlinastatin, an anti-inflammatory and antioxidant trypsin inhibitor, has shown potential in mitigating acute kidney injury (AKI) and reducing serum creatinine levels after various surgeries. This retrospective study aimed to evaluate the effects of ulinastatin on AKI in patients undergoing off-pump coronary artery bypass (OPCAB) surgery.MethodsWe hypothesized that the administration of ulinastatin could prevent AKI in OPCAB. Electrical medical records were reviewed to identify OPCAB patients between January 2015 and June 2020. The utilization of ulinastatin was randomly determined and applied during this period. Acute kidney injury was defined according to the KDIGO guideline, and its incidence was compared between the ulinastatin administration group and the control group. To investigate the effect of ulinastatin on renal function, multivariate logistic regression analysis was used to calculate propensity scores for each group.ResultsA total 454 OPCAB were performed, and after following inclusion and exclusion process, 100 patients were identified in the ulinastatin group and 303 patients in the control group. Using 1:2 propensity score matching, we analyzed 100 and 200 patients in the ulinastatin and control groups. The incidence of AKI was similar between the groups (2.5% for the control group, 2.0% for the ulinastatin group, p > 0.999). However, the serum creatinine value on the first post-operative day were significantly lower in the ulinastatin group compared to the control group (0.774 ± 0.179 mg/dL vs 0.823 ± 0.216 mg/dL, P = 0.040), while no significant differences were observed for the other time points (P > 0.05). The length of ICU stay day was significantly shorter in the ulinastatin group (2.91 ± 2.81 day vs 5.22 ± 7.45 day, respectively, P < 0.001).ConclusionsUlinastatin did not have a significant effect on the incidence of AKI; it demonstrated the ability to reduce post-operative serum creatine levels at first post-operative day and shorten the length of ICU stay.

Blood Products Utilization Status in Off-Pump Cardiac Surgery Patients.

Background: Transfusion support has an essential role in coronary artery bypass graft (CABG). The time-honored gold standard for CABG is the on-pump procedure (ONCAB); however, off-pump coronary artery bypass (OPCAB) is also a safe, cost-benefit procedure with fewer blood transfusion requirements. This study was performed to evaluate transfusion patterns in OPCAB due to the diversity of transfusion practices. Materials and Methods: This retrospective study was performed to determine the transfusion rate and triggers in OPCAB patients. Medical files of all patients undergoing OPCAB surgery at Sanandaj Tohid Hospital in 2014 were reviewed. Patients' demographics data, preoperative laboratory tests (PT, aPTT, Hb, Hct, Platelet count), underlying medical conditions, and their possible relation to further transfusions and the ward department in which the transfusion had taken place were extracted. SPSS 16 Chicago software, T-student Test, One Way Anova, and χ2 exam were applied for data analysis. P values ≤0.05was considered significant. Results: Among 91 elective OPCAB patients: 28(30.8%) women and 63(69.2%) men with mean age of 64.80±9.02 years, 63(69.23%) received a blood product. Mean utilization of PRBC, FFP, Platelet, and Cryoprecipitate were 2.17±2.044, 2.46±2.86, 2.86±3.80 and 0.40±2.10 units, respectively. ICU revealed the highest consumption rate for all products. Female sex (p<0.001), Hypertension (P=0.002), and low hemoglobin(P=0.004) were noted as predictive factors for transfusion. Conclusion: This study concluded that the transfusion rate in OPCAB is still very high in Iran (regarding a study in a countryside hospital) and that the highest utilization rate is seen in the ICU.

Predictive Value of the Changes in Neutrophil-Lymphocyte Ratio for Outcomes After Off-Pump Coronary Surgery.

The neutrophil-to-lymphocyte ratio (NLR) is an extensively analyzed prognostic inflammatory index in cardiac patients. The degree of change in NLR values before and after surgery (delta-NLR) can represent the inflammatory response induced by surgery and serve as a meaningful prognostic biomarker in surgical patients; however, this has not been well investigated. We aimed to investigate the predictive value of the perioperative NLR and delta-NLR for outcomes of off-pump coronary artery bypass (OPCAB) surgery by evaluating "days alive and out of hospital (DAOH)", a novel patient-centered outcome. In this single-center retrospective study, perioperative data, including NLR data, from 1322 patients were analyzed. The primary endpoint was DOAH at 90 days postoperatively (DAOH 90), and the secondary endpoint was long-term mortality. Linear regression analysis and Cox regression analysis were performed to identify independent risk factors for the endpoints. In addition, Kaplan-Meier survival curves were plotted to assess long-term mortality. The median NLR values significantly increased from 2.2 (1.6-3.1) at baseline to 7.4 (5.4-10.3) postoperatively, with median delta-NLR values of 5.0 (3.2-7.6). Preoperative NLR and delta-NLR were independent risk factors for short DAOH 90 in the linear regression analysis. In Cox regression analysis, delta-NLR, but not preoperative NLR, was an independent risk factor for long-term mortality. When patients were divided into two groups according to delta-NLR, the high delta-NLR group had a shorter DAOH 90 than the low delta-NLR group. Kaplan-Meier curves showed higher long-term mortality in the high delta-NLR group than in the low delta-NLR group. In OPCAB patients, preoperative NLR and delta-NLR were significantly associated with DAOH 90, and delta-NLR was an independent risk factor for long-term mortality, indicating their role in risk assessment, which is essential for perioperative management.

Changes in transcranial near-infrared spectroscopy values reflect changes in cardiac index during cardiac surgery.

To determine whether changes in transcranial near-infrared spectroscopy (NIRS) values reflect changes in cardiac index (CI) in adult cardiac surgical patients. Single-center prospective post hoc analysis. University hospital. One hundred and twenty-four adult patients undergoing cardiac surgery. In each patient, several CI measurements were taken, and NIRS values were collected simultaneously. We used a hierarchical linear regression model to assess the association between NIRS values and CI. We calculated a crude model with NIRS as the only factor included, and an adjusted model, where mean arterial pressure, end-tidal CO2 , and oxygen saturation were used as confounding factors. A total of 1301 pairs of NIRS and CI values were collected. The analysis of separate NIRS and CI pairs revealed a poor association, which was not statistically significant when adjusted with the chosen confounders. However, when the changes in NIRS from baseline or from the previous measurement were compared to those of CI, a clinically and statistically significant association between NIRS and CI was observed also in the adjusted model. Compared to the baseline and to the previous measurement, respectively, the regression coefficients with 95% confidence intervals were 0.048 (0.041-0.056) and 0.064 (0.055-0.073) in off-pump coronary artery bypass patients and 0.022 (0.016-0.029) and 0.026 (0.020-0.033) in patients who underwent cardiopulmonary bypass. In an unselected cardiac surgical population, the changes in NIRS values reflect those in CI, especially in off-pump coronary artery bypass patients. In this single-center post hoc analysis of data from a prospectively collected database of cardiac surgery patients, paired measurements of cardiac output and NIRS revealed that while there was a no correlation between individual paired measurements, a small correlation was found in changes in the two measurements from baseline values. This highlights a potential to utilize changes in NIRS from baseline to suggest changes in cardiac output in cardiac surgical populations.

The association of body composition assessment with hospital length of stay in off-pump coronary artery bypass patients.

Bioelectrical impedance analysis is a widely available, non-invasive method for body composition assessment. To elucidate the perioperative body composition alterations and their prognostic utility for hospital length of stay (LOS) in low risk, off-pump coronary artery bypass (OPCAB) patients. Fifty patients undergoing elective OPCAB were included in the study. Body composition assessments were performed 1 day before the scheduled surgery and on the 6th postoperative day. Patients were grouped into < 9 days (n = 29, 58%) and ≥ 9 days (n = 21, 42%). Multivariate logistic regression analysis was performed to create a body composition-based screening panel for prolonged hospital stay. No significant differences in anthropometric measurements, clinical characteristics or occurrence of postoperative complications were detected between the study groups. Patients with longer hospitalization had significantly higher content of fat mass (FM%) and fat mass index (FMI), and significantly lower content of fat free mass (FFM%) baseline parameters (p = 0.011, p = 0.04 and p = 0.012, respectively). High FM% values had 15-fold, low FFM% values had 13-fold and high FMI values had 7-fold higher risk of experiencing longer stay in the hospital (p = 0.001, p = 0.001 and p = 0.005, respectively). The combined panel of three variables (higher FM%, lower FFM% and higher FMI) had 16-fold higher risk of longer hospitalization (adjusted OR = 16.40; 95% CI: 3.52-76.34; p = 0.0004). Preoperative high FM and low FFM content are independent predictors of prolonged hospital length of stay in normal- and increased-BMI patients after OPCAB.

Right ventricular volume-strain loops using 3D echocardiography-derived mesh models: proof-of-concept application on patients undergoing different types of open-heart surgery.

Right ventricular (RV) function can be quantified by right heart catheterization-derived pressure-volume loops. While this technique is invasive, echocardiography-based volume-strain loops (VSLs) potentially reflect a non-invasive alternative. In this study, an approach to generate VSLs from volume and multidimensional strain data of 3D echocardiography-derived RV mesh models is evaluated with regard to feasibility and reproducibility. In a retrospective cohort study design, 3D intraoperative transesophageal echocardiograms of twenty-three patients undergoing aortic valve surgery (AVS) and eighteen patients undergoing off-pump coronary artery bypass (OPCAB) grafting were available prior to sternotomy and after sternal closure. RV meshes were generated using 3D speckle-tracking. Custom-made software quantified the meshes' volumes, global longitudinal (RV-GLS) and global circumferential strain (RV-GCS) for VSL generation. Linear regression of systolic VSLs yielded slopes, intercepts and systolic areas. Polynomial regression of two orders was used to analyze systolic-diastolic coupling at 10% increments of the RV end-diastolic volume (RVEDV). Reproducibility was analyzed by fourfold double-measurements of four datasets. VSL calculation was feasible from all included 3D datasets. RV-GLS remained unaltered, but RV-GCS worsened in AVS [abs. diff. (∆) 3.9%, P<0.01] and OPCAB patients (∆4.5%, P<0.001). While RV-GCS systolic areas were markedly reduced at the end of AVS (∆268mL%, P<0.01) and OPCAB (∆185mL%, P<0.001), RV-GCS slopes did not change. Systolic-diastolic uncoupling was not observed, but in trend, decreased diastolic RV-GCS after AVS (P=0.06) and increased diastolic RV-GCS after OPCAB (P=0.06) were observed. Intraclass correlation coefficients (0.84-0.98) and coefficients of variation (6.4-11.8%) indicated good reproducibility. RV VSL generation using 3D echocardiography-derived mesh models is feasible. Longitudinal and circumferential strain vectors yield intrinsically different VSL indices. In future investigations, VSLs of multidimensional strains could provide further insight into periprocedural changes of RV mechanics.

Feasibility of off-pump coronary artery grafting for patients with impaired left ventricular ejection fraction: A retrospective cohort study from a single institutional database.

Despite substantial advances in surgical practice, the management of patients with impaired left ventricular ejection fraction (LVEF) remains challenging. Furthermore, evidence on the outcomes of off-pump coronary artery bypass (OPCAB) surgery in this population is inconsistent. We conducted the present study to compare the short- and long-term outcomes of OPCAB in patients with different ejection fractions. This retrospective cohort study used data from the Hua-Shan Cardiac Surgery and included consecutive patients aged ≥ 18 years who underwent OPCAB procedures during 2016-2019. The patients included in the study were followed up until death or the end of data collection. Patients with different ejection fractions were matched 1:2 using propensity score matching. Factors associated with short-term outcomes were determined using logistic regression, and Kaplan-Meier survival analyses for the differences in all-cause death were generated. The two propensity score matched groups consisted of 40 left ventricular dysfunction (LVD) and 80 normal left ventricular function (NLVF) patients. No significant intergroup differences were observed in the postoperative outcomes for the occurrence of left heart failure (22.5% in LVD vs. 5.0% in NLVF, p = .009). Age (odds ratio = 1.11, 95% confidence interval = 1.04-1.18) but not the preoperative LVEF was shown to be a strong predictor of short-term events in logistic regression analyses. Kaplan-Meier curves displayed similar freedom from all-cause death (p = .119) or cardio-death (p = .092) between groups. The immediate postoperative outcomes and long-term outcomes were similar between the groups, indicating that OPCAB is a safe and effective choice for patients with LVD.

Off-Pump Coronary Artery Bypass Reduces Cardiac Death in Patients with Peripheral Arteriopathy.

The aim of this study was to investigate whether the use of off-pump coronary artery bypass (OPCAB) may enhance early outcomes in subjects with peripheral artery disease (PAD) undergoing coronary artery bypass grafting (CABG). We employed a propensity-score (PS) method to compare early postoperative results of OPCAB and on-pump CABG patients with associated PAD. The study population consisted of 1,961 patients: 284 in the OPCAB and 1,677 in the on-pump CABG group. The inverse probability of treatment weighting was used as PS method. The incidence of death (1.2% [95% confidence interval, CI: -0.9 to 3.3%], p = 0.262), stroke (2.2% [95% CI: -1.4 to 5.7%], p = 0.235), acute kidney disease (1.5% [95% CI: -3.8 to 6.8%], p = 0.586), limb ischemia (3.2% [95% CI: -0.6 to 7.0%], p = 0.315), and low output syndrome (1.2% [95% CI: -0.9 to 3.3%], p = 0.262) did not differ between the two groups. On the other hand, the rate of cardiac death (1.2% [95% CI: -0.1 to 2.3%], p = 0.038) was significantly higher in on-pump CABG group. The OPCAB procedure considerably reduced the occurrence of cardiac death after coronary revascularization. This finding might suggest that the OPCAB procedure should be considered as the first option in patients with higher cardiovascular risk scores. Further research is warranted.

Paraoxonase 1 low activity and SYNTAX score may predict postoperative complications after coronary artery surgery.

Coronary artery bypass grafting (CABG) seems to present a powerful trigger of oxidative stress (OS) and acute inflammatory response. This study aimed to estimate the effects of off-pump coronary artery bypass (OPCAB) grafting on the OS that is commonly observed in patients undergoing operation under cardiopulmonary bypass (CPB). Additionally, we aimed to examine the relationship between and paraoxonase 1 (PON1) activity and the degree of stenosis, severity and complexity of the atherosclerotic lesions, estimated by SYNTAX score (SS). Study group of 107 patients scheduled for CABG were divided into CPB and OPCAB group. Blood samples for OS markers measurement were collected at six-time intervals: before skin incision (t1), immediately after surgery (t2), 6h (t3), 24h (t4), 48h (t5) and 96h after cessation of the operation and surgical trauma (t6). SS was calculated. A significant decrease in lipid hydroperoxides (LOOH) and advanced oxidation protein products (AOPP) levels after both types of surgeries were observed, whereas PON1 reduction was observed higher in the CPB than in the OPCAB group. A significant inverse correlation between SS values and PON1 activity, preoperatively and during the early postoperative hours after surgery [in t2, t3 time intervals (p<0.05 for all)] was found. ROC analysis showed that for CPB patients, Model with all OS parameters showed excellent accuracy (AUC=0.957, p<0.001) for prediction postoperative complications. Decrease in PON1 activity during the early post-operative phases was related to higher SS. This relationship was more convincing in CPB, compared with OPCAB patients. Moreover, integrated models of OS status parameters have the capability to predict the development of postoperative complications.

A retrospective comparison of on- and off-pump coronary artery bypass surgery undergoing fast track protocol

Introduction Fast track treatment, especially in a specialized recovery area, is a safe alternative for patients with low to moderate risk after surgery and leads to a reduced ventilation time as well as a shorter stay in the intensive care unit especially.1The benefit of fast track in off-pump vs on-pump coronary artery bypass patients is unclear. The aim of the study was the comparison of on- vs off-pump coronary artery bypass surgery undergoing fast track protocol. Primary endpoints are ventilation time and primary fast track failure. Primary fast track failure is defined as unplanned transfer from the recovery area to the intensive care unit or back to the operating theatre. Secondary endpoints include length of stay in recovery area, intermediate care unit and hospital, postoperative complications and secondary fast track failure (patients transferred from intermediate care or ward back to the intensive or intermediate care unit). Methods This retrospective observational study was performed in a single centre heart centre. Between September 2012 and December 2018 n= 3505 consecutive patients after coronary artery bypass surgery underwent fast track protocol. Patients after on-pump coronary artery bypass surgery were compared with patients after off-pump coronary artery bypass surgery using propensity score matching. Matching criteria included: age, gender, BMI, logistic Euroscore, preoperative ejection fraction, co-existing diseases, operative time and risk factors. Values are expressed as percentage or mean value ± standard deviation. Results After propensity score matching 926 patients were included in each group. There were no significant differences in demographic data after matching. Time to extubation showed no significant difference between both groups (on-pump 75 (55-120) min vs off-pump 80 (55-120) min, p=0,973). Primary and secondary fast track failure were also not significantly different between the groups with 8.2% vs 6 % and 12.9% vs 12.3% in on-pump vs off-pump group. There were no significant differences between both groups in terms of postanaesthetic care length of stay (on-pump 265 (83) min vs off-pump 270 (85) min, p=0,702), intermediate care length of stay (on-pump 53,6 (56) h vs off-pump 50 (56) h, p=0,316) and hospital length of stay (on-pump 9,9 (5,3) d vs off-pump 9,6 (5,4) d, p=0,256). Postoperative complications were comparable except for a significant difference in postoperative bleeding. Patients receiving off-pump coronary artery bypass surgery had a significant (p Discussion In conclusion, on- and off-pump coronary artery bypass surgery seem to be comparable in terms of fast track success. Any difference between the two approaches may be only attributed to the difference in the preoperative risk profile and length of surgery.

Cardiac Output Values and Correlation of Renal Injury with Neutrophil Gelatinase-Associated Lipocalin Levels in Off-Pump Coronary Artery Bypass Patients.

ObjectiveTo investigate the correlation between cardiac output values and renal neutrophil gelatinase-associated lipocalin (NGAL) levels as a biomarker of renal ischemia.MethodsForty patients, who underwent off-pump coronary artery bypass (OPCAB) surgery and in whom the positioning of the heart was fixed with simple suspension sutures without a mechanical stabilizer, were included in the study. Continuous cardiac output (CO) measurements were recorded using the arterial pressure waveform analysis method (FloTrac sensor system) in the perioperative period. CO was recorded every minute during non-anatomical cardiac positioning for left anterior descending artery (LAD), diagonal artery (D), circumflex artery (Cx), and right coronary artery (RCA) bypasses. Serum NGAL samples were analyzed in the preoperative, perioperative, and postoperative periods.ResultsThe CO values measured at various non-anatomical cardiac positions during distal anastomosis for LAD, D, Cx, and RCA were significantly lower than pre- and postoperative values measured with the heart in normal anatomical position (3.45±0.78, 2.9±0.71, 3.11±0.56, 3.19±0.81, 5.03±1.4, and 4.85±0.78, respectively, P=0.008). There was no significant difference between CO values measured at various non-anatomical cardiac positions during distal anastomosis. Although there was no significant correlation between NGAL levels and age, duration of surgery, preoperative CO, D-CO, RCA-CO, and postoperative CO measurements, there was a significant correlation between NGAL levels and LAD-CO (P=0.044) and Cx-CO (P=0.018) at the postoperative 12th hour.ConclusionFull revascularization may be achieved by employing the OPCAB technique while using simple suspension sutures without a mechanical stabilizer and by providing safe CO levels and low risk of renal ischemia.

Auto-antibodies to protein Z in patients undergoing off-pump coronary artery bypass surgery – preliminary results

Background: Considerable attention has been focused over the past several years on the protein Z (PZ) system. However, little is known about the role of auto-antibodies to PZ (anti-PZ) in cardiac surgery patients.&lt;br&gt;Aim: In the present pilot study, we investigated plasma levels of anti-PZ in patients undergoing off-pump coronary artery bypass (OPCAB) surgery.&lt;br&gt;Material and methods: Thirty patients with coronary artery disease scheduled for OPCAB surgery were enrolled in this study. Plasma levels of anti-PZ IgM and anti-PZ IgG were measured before surgery and one week after surgery using enzyme-linked immunosorbent assay.&lt;br&gt;Results: None of the subjects were shown to have positive results for anti-PZ IgM and anti-PZ IgG either before and one week after OPCAB surgery.&lt;br&gt;Conclusions: These results suggest that anti-PZ autoantibodies are not an effective component of the PZ system in OPCAB patients.

DOES PREOPERATIVE PULMONARY ARTERY HYPERTENSION AFFECT LONG-TERM SURVIVAL AFTER OFF-PUMP CORONARY ARTERY BYPASS SURGERY?

Preoperative pulmonary hypertension (HTAP) increases perioperative morbidity and mortality after coronary surgery. How it is affected by revascularization and how it impacts on long-term survival remain questionable. Off-pump coronary artery bypass (OPCAB) patients offer a unique model to specifically study the effect of preoperative HTAP because no extra-corporal circulation is used. The purpose of our study is to evaluate long-term effect of preoperative HTAP after OPCAB surgery.

Hybrid, Transcatheter Aortic Valve Implantation (TAVI) and Total Arterial Off-Pump Coronary Artery Bypass (OPCAB) in a Patient with Severe Aortic Valve Regurgitation – A Case Report

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been shown to be an effective growing strategy for severe, symptomatic aortic valve stenosis (AS) in patients who are either not ideal candidates or who are at intermediate or high surgical risk for surgical aortic valve replacement. Hybrid TAVI and off-pump coronary artery bypass graft (OPCAB) have been previously reported in high-risk patients with severe AS and coronary artery disease (CAD). TAVI data for severe aortic valve regurgitation (AR) is limited and currently considered an off-label application. Reports on hybrid TAVI for severe AR and OPCAB in patients with severe co-morbid CAD are limited. We report a hybrid TAVI and OPCAB in a 64-year-old female, with severe AR, severe left ventricular systolic dysfunction and CAD with a low take-off of the left main (LM) and porcelain aorta. CASE REPORT: The patient is a 64-year-old morbidly obese Filipino female with porcelain aorta and post-percutaneous coronary intervention with drug-eluting stent implantation for multivessel CAD with LM involvement and was admitted for refractory heart failure. Her 2D echocardiography demonstrated a dilated left ventricle with 19% left ventricular ejection fraction (LVEF) and severe AR. Computed tomography angiography demonstrated porcelain aorta, a low take-off of the left main with good femoral access. Hybrid TAVI with 26 mm Corevalve was done via the transfemoral approach after OPCAB of the left internal mammary artery to left anterior descending artery. Valve-in-valve transcatheter aortic valve replacement was required due to low valve implantation and severe paravalvular leak (PVL). Follow-up echo at 22 months demonstrated no PVL, 1.6 cm2 effective orifice aortic valve area, 12.4 mmHg mean gradient and 50% LVEF. She remains asymptomatic and in functional class I. CONCLUSION: Hybrid TAVI and OPCAB in patients with severe valvar AR, porcelain aorta and CAD represents a feasible and effective option of care. There are few reports in the literature documenting the effectiveness or feasibility of this approach for such patients.

A Comparison of Different Doses of Dexmedetomidine for Myocardial Protection in Percutaneous Coronary Interventional Patients

Introduction: Dexmedetomidine has been shown to have a myocardial protective effect in off-pump coronary artery bypass patients. However, the same dosage of dexmedetomidine could not elicit a myocardial protective effect in percutaneous coronary intervention patients. The aim of this study was to assess the effect of different doses of dexmedetomidine when used for myocardial protection in percutaneous coronary interventional patients. Methodology: 240 patients (Group D1, treated with dexmedetomidine [n=80]; Group D2, treated with dexmedetomidine [n=80]; and the control group [C; n=80]) were enrolled in the study. Dexmedetomidine was administered over 15 minutes in the respective doses in Groups D1 and D2 at the start of the procedure, while normal saline was given to patients in Group C. Maintenance of dexmedetomidine/NS was started at 0.5 µg/kg/hour in the groups until 30 minutes post-procedure. Creatine phosphokinase (CPK) and CPK-MB, heart rate (HR), mean blood pressure (MAP), and sedation score were noted at baseline (T0), 6 hours (T1), 12 hours (T2), and 24 hours (T3) after the loading dose. Results: MAP and HR significantly decreased in D1 and D2 compared to C (p&lt;0.05). None of the patients in D1 had a reduction in MAP &lt;20% and HR &lt;50 bpm; however, 3 patients in D2 had a clinically significant reduction in MAP, and 5 patients had HR &lt;50 bpm. The patients in D2 were more sedated compared to patients in D1 and C. The difference in CPK and CPK-MB was significant at 6 hours, 12 hours, and 24 hours in D2. Conclusion: Dexmedetomidine 2 µg/kg provides myocardial protection compared to 1 µg/kg, but at the cost of a clinically significant decrease in MAP and HR. Patients who received dexmedetomidine 2 µg/kg were more sedated compared to patients receiving 1 µg/kg, warranting greater care during and post-procedure.

Comparing Intraoperative Flow Measurement in Both off-Pump Coronary Artery Bypass and on-Pump Coronary Artery Bypass Graft Patients

AbstractBackground: Patent bypass grafts are fundamental to successful coronary artery bypass grafting. We studied the use of transit-time flow measurement to determine its ability to detect technical errors in grafts, to measure the mean flow norms, and to compare flow in both on-pump and off-pump CABG procedures.Aim of Study: To compare conduit flow in a standardized type of CABG and OPCAB using the Left Internal Mammary Artery (LIMA) and vein grafts.Patients and Methods: This study was conducted on 60 patients requiring coronary artery bypass surgery classified into 2 equal groups:•Group A: (Conventional CABG), who were approached through on pump CABG.•Group B: (OPCAB), whom approached without cardiopul-monary bypass machine.Results: There was no statistical difference between the two groups in baseline pre-operative characteristics regarding their age, sex, NYHA class and EF%.In Group (A), the MGF was (39.51±5.26) and PI values were (2.33±0.64). While in Group (B), the MGF was (32.71± 6.47) and PI measurements were (2.71±1.22). The MGF for the occluded grafts in Group A was (14.33±3.21) ml min and (12.75±2.87) in Group B (p=.522). The corresponding PI values were (8.03±1.0) for Group A and (8.85±1.67) for Group B (p=0.489).Conclusions: TTFM technique is a highly valuable equip-ment. Mean flow is lower in the OPCAB group with higher pulsatility index than the conventional CABG group, which raises suspicion about the long term patency of OPCAB grafts.

Comparison of Ultrafast Tracking Anesthesia versus Conventional Strategy in Postoperative Management of Off-Pump Coronary Artery Bypass Surgery

Abstract Introduction Conventional strategy in the postoperative ventilation was a long-established practice in former times but now fast tracking is an acknowledged technique. This study was embarked to assess the impact of ultrafast tracking on patient recovery and length of stay in intensive care unit (ICU) compared with conventional methods in off-pump coronary artery bypass (OPCAB) patients. Methods Fifty patients were enrolled in each group. Exclusion criteria were patients with ejection fraction &gt; 30%, hemodynamically unstable, on intra-aortic balloon pump, associated valvular heart disease, and intraoperative conversion to on-pump coronary artery bypass grafting. Ultrafast tracking of anesthesia (UFTA) protocol included induction with low dose fentanyl, propofol, and vecuronium. Maintenance of anesthesia was done with sevoflurane, fentanyl, and atracurium whereas analgesia was done with tramadol and paracetamol. Results Statistical analysis was done with SPSS 21.0 program. Fischer’s test, chi-square test, independent t-test/Mann–Whitney U tests were used for calculations. Extubation time was statistically significant (p = 0.0001). Shift to ward was 3.96 ± 0.73 days in UFTA group and 4.34 ± 0.66 days in conventional group which proved statistically significant (p = 0.0073). No patients in both groups had postoperative myocardial infarction, stroke, low cardiac output, or mediastinitis. Renal failure and mortality were 2% in conventional group. Hypothermia, pacemaker dependency, blood transfusion, inotrope score, atrial fibrillation, re-exploration, and reintubation were monitored. No reintubation occurred in UFTA group. Conclusion UFTA appears to be safe and effective in OPCAB patients with early shift from ICU without any major complications.

Dexmedetomidine for prevention of skeletal muscle ischaemia-reperfusion injury in patients with chronic limb ischaemia undergoing aortobifemoral bypass surgery: A prospective double-blind randomized controlled study.

Background:Dexmedetomidine is a selective α-2 agonist used for sedation. It has also been shown to have myocardial protective effect and prevent ischemia-reperfusion injury in off-pump coronary artery bypass patients. The aim of our study was to assess the effect of dexmedetomidine for prevention of skeletal muscle ischemia-reperfusion injury in patients undergoing aortobifemoral bypass surgery.Methodology:Sixty adult patients (Group dexmedetomidine n = 30, Group normal saline n = 30) undergoing aortobifemoral bypass surgery were recruited over 3 months. Randomization was done using a computer-generated random table. The attending anesthesiologist would be blinded to whether the drug/normal saline was being administered. He would consider each unlabeled syringe as containing dexmedetomidine and calculate the volume to be infused via a syringe pump accordingly. Dexmedetomidine infusion (1 mcg/kg) over 15 minutes was given as a loading dose, followed by maintenance infusion of 0.5 mcg/kg/h till 2 h postprocedure in Group dexmedetomidine (D) while the same volume of normal saline was given in the control Group C till 2 h postprocedure. Creatine phosphokinase (CPK) values were noted at baseline (T0), 6 h (T1), 12 h (T2), and 24 h (T3) after the procedure. Hemodynamic variables (heart rate [HR] and mean blood pressure [MAP]) were recorded at T0, T1, T2, and T3. Results were analyzed using unpaired Student's t-test, P < 0.05 was considered statistically significant.Results:MAP and HR significantly decreased in Group D as compared to control group (P < 0.05). However, the decrease was never <20% of the baseline. The CPK values at 6, 12, and 24 h were statistically significant between the two groups.Conclusion:Dexmedetomidine prevents skeletal muscle ischemia-reperfusion injury in patients undergoing aortobifemoral bypass surgery.

Evaluation of preoperative oral carbohydrate administration on insulin resistance in off-pump coronary artery bypass patients

In fasting cardiac surgery patients, preoperative carbohydrate (CHO) drink intake attenuated insulin resistance and improved cardiac metabolism, although its beneficial effects were not evident after cardiac surgery possibly due to cardiopulmonary bypass-related extreme systemic inflammation. We aimed to evaluate whether preoperative CHO intake affected insulin resistance and free-fatty acid (FFA) concentrations in off-pump coronary revascularisation. A randomised controlled trial. Primary care in a university hospital in Korea from January 2015 to July 2016. Sixty patients who underwent elective multi-vessel off-pump coronary revascularisation were randomised into two groups. Three patients were excluded from analysis and 57 patients completed study. The CHO group received oral CHO (400 ml) the prior evening and 2 to 3 h before surgery, and the control group was fasted from food and water according to standard protocol. Insulin resistance was assessed twice, after anaesthetic induction and after surgery via short insulin tolerance test. FFA, C-reactive protein and creatine kinase-myocardial band concentrations were determined serially for 48 h after surgery. Insulin sensitivity was greater (P = 0.002) and plasma FFA concentrations were lower (P = 0.001) after anaesthetic induction in the CHO group compared with the Control group, although there were no intergroup differences after surgery. The postoperative peak creatine kinase-myocardial band concentration was significantly lower in the CHO group compared with the Control group [8.8 (5.4 to 18.2) vs. 6.4 (3.5 to 9.7) ng ml, P = 0.031]. A preoperative CHO supplement significantly reduced insulin resistance and FFA concentrations compared with fasting at the beginning of the surgery, but these benefits were lost after off-pump coronary revascularisation. Despite their transient nature, these beneficial effects resulted in less myocardial injury, mandating further studies focused on the impact of preoperative CHO on myocardial ischaemia and cardiac function after coronary revascularisation. Clinicaltrials.gov identifier: NCT 02330263.