Off-pump Coronary Surgery Research Articles

Outcome of Plasma Fibrinogen Level and Postoperative Bleeding Following OPCAB Surgical Patients

Background: Bleeding is a major concern after cardiac surgery and also a significant cause of morbidity and mortality. Postoperative mediastinal bleeding in patients undergoing cardiac surgery is still one of the most common complications. Objective: To find out Outcome of Plasma Fibrinogen Level and Postoperative Bleeding Following OPCAB Surgical Patients. Methods: This comparative cross-sectional study was carried out at the Department of Cardiac Surgery in BSMMU hospital from March, 2017 to August, 2019. The study population was 60, with 2 (two) groups having 30 patients in each. Patients from both the groups underwent OPCAB. Statistical analysis of different characteristics between the patients of both groups was done to draw a conclusion. Results: This study total sixty (60) patients who underwent off-pump coronary artery bypass graft surgery were evaluated in this study. Postoperative care at ICU was given to the patients of both groups as per standard hospital protocol. The findings of the study obtained from data analysis presented in the following pages. Among the study population mean age in group A was 55.43±8.53 years and in group B was 59.63±6.86 years. The difference in age between two groups was statistically significant (p<0.05). There was no statistical significance of gender between the two study groups (p>0.05). The mean BMI in group A was 24.13±2.49 kg/m² and that in group B was 24.62±3.71 kg/m². The findings were statistically not significant (p>0.05). Shows the comparison of postoperative variables between group A and B patients. Amount blood loss in 1st 12 hours immediate after surgery in group A and B were 185.67±35.20 ml and 219.67±57.32 ml respectively. Post-operative blood transfusion in group A and B were 2±0.53 units and 2.5±0.68 units respectively, which was statistically significant (p<0.05. There were no postoperative thromboembolic events, cardiac ischemic incidents, re-exploration and mortality. The most valuable predictor for increased postoperative bleeding after OPCAB. Conclusion: In conclusion the efficacy were no postoperative thromboembolic events, cardiac ischemic incidents, re-exploration and mortality. Pearson co-efficient correlation test showed an inverse relationship between plasma fibrinogen level and postoperative bleeding following OPCAB. Fibrinogen concentration level was associated with increased postoperative bleeding in patients undergoing off-pump coronary artery bypass grafting surgical patients

Comparison of Early Outcome of Off-pump and Conventional Coronary Artery Bypass Graft Surgery in Patients with Multivessel Coronary Artery Disease and Left Ventricular Dysfunction

Introduction: Left ventricular dysfunction is an important predictor of in-hospital mortality. Due to the theoretical and practical advantages to avoid the harmful effects of cardiopulmonary bypass (CPB), many cardiac surgeons are using Off-pump Coronary Artery Bypass (OPCAB)as an effective alternative to conventional CABG (CCAB) even in patients with reduced left ventricular (LV)ejection fraction. Objectives: This study performed in the National Institute of Cardiovascular Diseases (NICVD) evaluated the early outcomes of OPCAB in terms of mortality and major post-operative morbidities and compared them with that of CCAB in patients with multivessel coronary artery diseases and reduced left ventricular (LV) function.
 Methods: Total 120 patients with multivessel coronary artery disease with reduced left ventricular ejection fraction (d”50%)were allocated into two groups: a) 60 patients who underwent OPCAB and b) another 60 patients who underwent conventional CABG between January 2013 and December 2015. Pre-operative, peroperative and early post-operative variables were recorded, compiled and compared.
 Results: All risk factors and co-morbidities were homogenously distributed between the two groups. Majority of the patients had triple vessel disease. Nearly three-quarter (73.3%) of patients in OPCAB group and 80% in CCAB group received 3 grafts (p=0.470). The mean total operative time (268.5 ± 33.5vs. 296.3 ± 34.8minutes, p < 0.001), intubation times(8.6±0.3 vs. 12.3±0.5 hours, p<0.001), blood losses (377.8378 ± 45 ml vs. 602 ± 60 ml, p < 0.001); requirements for blood and blood products (689.7±21.1 vs. 1199.3±34.5ml, p < 0.0010),intensive care unit stays (31.7±0.9 hours versus 41.6±1.5 hours; p<0.001) and hospital stays (8.2 ± 0.2days vs.10.3 ± 0.3days, p < 0.001)were all significantly lower in the OPCAB group.
 Conclusion: OPCAB is a safe and effective operative revascularization procedure for patients with multivessel coronary artery disease and left ventricular dysfunction and is associated with reduced morbidity. However, a larger and omized trial with long-term followup may show the real benefits of OPCAB.
 Bangladesh Heart Journal 2020; 35(1) : 20-27

Investigation of the Effect of Preoperative Hypoalbuminemia, Blood Urea Nitrogen and Creatinine Levels on Postoperative Atrial Fibrillation on Off-Pump Coronary Bypass Surgery Patients.

Postoperative atrial fibrillation (PoAF) is one of the most common complications to occur after open heart surgery. It has been shown that hypoalbuminemia accompanies some cardiovascular disorders. The present study evaluates the effects of pre-procedural albumin, blood urea nitrogen (BUN), and creatinine levels on PoAF. The data of 81 patients who underwent off-pump coronary artery bypass graft (CABG) surgery was evaluated. Patients who developed atrial fibrillation (AF) in the first 48 hours post surgery constituted the PoAF (+) group, while those without AF constituted the PoAF (-) group. The pre-procedural hematological parameters of patients in both groups were included in the analysis. The PoAF (+) group was comprised of 57 patients (70.3%) with a mean age of 65.5 ± 9.8 years, while the PoAF (-) group was comprised of 24 patients (29.7%) with a mean age of 60.6 ± 9.6 years. A comparison of the demographic characteristics of the two groups showed that age (P = .036), frequency of renal failure (P = .007), and frequency of DM (P = .001) were higher in the PoAF (+) group. An examination of the laboratory data revealed a negative correlation between Hct (P = .001) and albumin (P = .000) levels and presence of PoAF. Also, the MPV (P = .02), BUN (P = .007), and Cr (P = .043) values were higher in the PoAF (+) group. The present study, whose focus was on the effects of albumin levels on the occurrence of PoAF, found that low levels of pre-procedural albumin, as one of the major proteins in the blood, is a risk factor for the development of PoAF.

Association of Preoperative HbA1c Level with Incidence of New-onset Atrial Fibrillation during Early Postoperative Period after Off-Pump Coronary Artery Bypass Grafting Surgery in Diabetic Patients

Background: Diabetes mellitus is an independent risk factor for coronary artery disease and it adversely affects the postoperative outcome after CABG surgery. Adequate control of diabetes for a longer period, which can be assessed by HbA1c, before OPCAB may reduce development of postoperative atrial fibrillation and thus improve outcome.
 Methods: This was an observational study included sixty diabetic patients purposively who underwent isolated off pump coronary artery bypass procedure in NICVD. Total sample contained 60 diabetic patients, which were divided in two equal groups. Grouping was Group I – 30 Diabetic patients with preoperative HbA1c <7% and Group II – 30 Diabetic patients with preoperative HbA1c ≥7% and all of whom underwent isolated OPCAB. Postoperative atrial fibrillation and other complications were recorded and compared in two groups of patients.
 Results: Most postoperative atrial fibrillation (AF) developed in higher age group 61-70 years (61.5%). Postoperative complications were higher in group II. Postoperative AF was significantly higher in diabetic patients having preoperative HbA1c ≥7% compare to diabetic patients with HbA1c <7% in early postoperative period after OPCAB. Age (61-70 years) (OR=1.872, p=0.018), preoperative HbA1c ≥7% (OR=19.029, p=0.002) and hypertension (OR=1.091, p=0.019) was found significantly associated with increased development of postoperative atrial fibrillation.
 Conclusion: Our study revealed that higher preoperative HbA1c level was associated with increased incidence of new onset atrial fibrillation after OPCAB. So, it can be used as a reliable indicator for adequate control of diabetes preoperatively among patients selected for isolated elective OPCAB in future.
 Cardiovasc. j. 2020; 12(2): 113-119

Prevention and management of suture piercel of intra-coronary shunt at off-pump coronary bypass surgery.

Prevention and management of suture piercel of intra-coronary shunt at off-pump coronary bypass surgery.

Anomalous Left Coronary Artery Originating from the Right Coronary Sinus with an Interarterial Course: a Case Report and Literature Review

Abstract Introduction: The diagnosis of coronary artery anomalies (CAAs) can be challenging due to the highly variable manifestations and symptoms. CAAs occur in less than 1% of the population. Multidetector cardiac computed tomography angiography (CTA) provides excellent spatial and temporal resolution for the imaging of CAAs. This case report describes an anomalous origin of the left main coronary artery. Case presentation: A 64-year-old woman with atypical chest pain underwent coronary CTA. The CT demonstrated that the left coronary artery was originating from the right coronary sinus and had an interarterial course with an approximately 50% stenosis at the segment between the great arteries. Invasive coronary angiography confirmed hemodynamically significant stenosis of the interarterial segment. The patient underwent off-pump coronary artery bypass graft surgery. Conclusion: Left coronary artery originating from the right coronary sinus with an interarterial course increases the risk of sudden cardiac death. In these patients, surgical revascularization is recommended. However, timely diagnosis, especially in those with mild symptoms, remains challenging. Coronary CTA is a robust tool to diagnose CAA and provides valuable information to support the clinical decision making in this patient population.

Off-pump coronary artery surgery with clamshell incision

Cardiovascular Surgery and Interventions publishes original articles on topics in cardiovascular surgery, cardiovascular anesthesia and cardiology. These encompass all relevant clinical, surgical and laboratory studies, editorials, current and collective reviews, technical know-how papers, case reports, interesting images, “How to Do It” papers, correspondence and commentary.

Fibrinolysis and the Influence of Tranexamic Acid Dosing in Cardiac Surgery

The present study aimed to determine whether underlying disease, performed surgery, and dose of tranexamic acid influence fibrinolysis measured with D-dimer levels. Retrospective analysis. Single institution (Department of Cardiac Surgery and Section of Clinical Hemostaseology at the Düsseldorf University Hospital). The study comprised 3,152 adult patients undergoing elective cardiac surgery between February 2013 and October 2016. Two doses of tranexamic acid during surgery were administered. D-dimer levels were analyzed at the start of surgery and before protamine administration. D-dimer levels at the start of surgery were compared according to disease. Intraoperative D-dimer development was analyzed according to the type of surgery and within 2 cohorts with different tranexamic acid doses. Interindividual variability was pronounced for D-dimer levels at the start of surgery, with significant differences among patients with coronary artery disease, valve disease, and aortic disease and patients undergoing heart transplantation compared with patients receiving a left ventricular assist device (p < 0.01). Aortic dissection, endocarditis, and extracorporeal life support were associated with higher D-dimer levels (p ≤ 0.01). With tranexamic acid at a fixed dose, intraoperative D-dimer levels decreased in on-pump and off-pump coronary bypass surgery, valve surgery, and left ventricular assist device surgery (p ≤ 0.02), but levels increased in aortic surgery and heart transplantations (p < 0.01). A decrease or increase in D-dimer levels during surgery was influenced significantly by a higher or lower tranexamic acid dose (p ≤ 0.01). D-dimer testing allows for the assessment of individual fibrinolytic activity in cardiac surgery, which is influenced by disease type, surgery type, and dose of tranexamic acid. The assessment of the fibrinolytic status may have the potential to facilitate dose-adjusted antifibrinolytic therapy in the future.

Association Between Postoperative Body Temperature and All-Cause Mortality After Off-Pump Coronary Artery Bypass Graft Surgery: A Retrospective Observational Study.

Inadvertent perioperative hypothermia is common in patients undergoing off-pump coronary artery bypass grafting (OPCAB). We investigated the association between early postoperative body temperature and all-cause mortality in patients undergoing OPCAB. We reviewed the electronic medical records of 1714 patients who underwent OPCAB (median duration of follow-up, 47 months). Patients were divided into 4 groups based on body temperature at the time of intensive care unit admission after surgery (moderate-to-severe hypothermia, <35.5°C; mild hypothermia, 35.5°C-36.5°C; normothermia, 36.5°C-37.5°C; and hyperthermia, ≥37.5°C). Cox proportional hazards models were used to assess the association between body temperature and all-cause mortality. The association between early postoperative changes in body temperature and all-cause mortality was also assessed by dividing the patients into 4 categories according to the body temperature measured at postoperative intensive care unit admission and the average body temperature during the first 3 postoperative days. Compared to the normothermia group, the adjusted hazard ratios of all-cause mortality were 2.030 (95% confidence interval, 1.407-2.930) in the moderate-to-severe hypothermia group and 1.445 (95% confidence interval, 1.113-1.874) in the mild hypothermia group. Patients who were hypothermic at postoperative intensive care unit admission but attained normothermia thereafter were at a lower risk of all-cause mortality compared to patients who did not regain normothermia (adjusted hazard ratio, 0.631; 95% confidence interval, 0.453-0.878), while they were still at a higher risk of all-cause mortality than those who were consistently normothermic (adjusted hazard ratio, 1.435; 95% confidence interval, 1.090-1.890). Even mild early postoperative hypothermia was associated with all-cause mortality after OPCAB. Patients who regained normothermia postoperatively were at lower risk of all-cause mortality compared to those who did not.

Risk Factors for Postoperative Events in Patients on Antiplatelet Therapy Undergoing Off-Pump Coronary Artery Bypass Grafting Surgery.

This retrospective study assessed the risk factors for adverse events following off-pump coronary artery bypass graft (CABG) surgery with dual antiplatelet therapy (DAPT). Records (between 2013 and 2017) were reviewed for patients who discontinued DAPT (clopidogrel 75 mg and aspirin 100 mg) ≤5 days before off-pump CABG. The primary outcome was the incidence of a Bleeding Academic Research Consortium (BARC) type 4 major event. Factors associated with bleeding events and perioperative myocardial ischemia were evaluated using multivariable logistic regression. The incidence of major bleeding events was 17.6% in 2012 patients. Adjusted multiple logistic regression analysis showed that the risk of postoperative bleeding increased when DAPT was discontinued <3 days before surgery (day 2: adjusted odds ratio [OR]: 1.70, 95% confidence interval [CI]: 1.09-2.64; day 1: adjusted OR: 2.37, 95% CI: 1.49-3.77; day 0: adjusted OR: 2.45, 95% CI: 1.53-3.92). The adjusted risk of mortality (OR: 13.14, 95% CI: 4.55-37.94) was increased with bleeding complications. In subgroup analysis, perioperative myocardial ischemia was related to increased blood loss (adjusted OR: 1.10, 95% CI: 1.02-1.18). Aspirin and clopidogrel should optimally be discontinued >3 days before CABG to reduce the risk of bleeding complications, myocardial ischemia, and death.

The Relationship between the HATCH Score, Neutrophil to Lymphocyte Ratio and Postoperative Atrial Fibrillation After Off-Pump Coronary Artery Bypass Graft Surgery.

Patients who underwent OPCABG between January 2014 and January 2019 were included in the study. Preoperative and postoperative data retrospectively were obtained. Patients who did not develop PoAF during the postoperative hospitalization period constituted Group 1; those who did were classified as Group 2. Ninety-seven patients (69 males and 28 females) with a mean age of 54.4 ± 11.1 years constituted Group 1, and 26 patients (17 males and 9 females) with a mean age of 61±12.6 years constituted Group 2. Significant differences were observed between the 2 groups, in terms of age and HATCH scores (P = .025 and P < .001, respectively). NLR, number of distal anastomoses, intensive care unit (ICU) stay times, and total hospitalization times were significantly higher in Group 2 (P = .021, P = .021, P < .001, P < .001, respectively). HATCH score was identified as an independent predictor of AF development following OPCABG surgery (OR: 2.125, 95 % CI: 1.296-3.482, P = .003). In light of our study, HATCH scores of all patients preoperatively may be calculated so that preventive precautions are taken for high-risk patients.

Blood flow assessment by transit time flow measurement and its prognostic impact in coronary bypass surgery.

The competitive coronary flow is influenced by the severity of the stenosis and may affect graft patency. Transit time flow measurement (TTFM) enables intraoperative graft evaluation and cardiac magnetic resonance (MRI) allows for graft evaluation during follow-up. Competitive flow and target vessel diameters were determined in 35 patients undergoing off-pump coronary bypass graft surgery (CABG) and correlated to TTFM. Cardiac function, ischemia, and graft flow were evaluated using cardiac MRI during the follow-up period to determine the impact of above-mentioned parameters on graft patency. Competitive flow led to reduced mean graft flow (MGF) and increased pulsatility index (PI) in arterial grafts. This effect to was not observed in veins. Smaller target coronary arteries (<1.5 mm) were associated with reduced MGF, more pronounced in veins, which presented increased PI and shortened diastolic flow fraction (DF). No death and no re-hospitalization for acute coronary syndrome occurred. Borderline values of TTFM (mean MGF 13±4 mL/min; PI 3.8±1) in left internal mammary artery (LIMA) were mainly observed due to increased native anterior descending artery (LAD) flow. These LAD's collateralized occluded right coronaries (RCA). The corresponding LIMA to LAD grafts showed a bypass flow increase at cardiac MRI follow-up. Two graft occlusions occurred: one in LIMA-to-LAD bypass with borderline TTFM, which did not collateralize the RCA and one in a vein graft with borderline TTFM bypassed on a narrow vascular target. Competitive flow has an impact on arteries contrary to veins. Veins are at risk for occlusion when grafted to smaller targets. Borderline LIMA flow should be considered as potentially dangerous, if satisfactory explanations are missing, e.g. in the absence of a large coronary target without flow competition.

Effect of remote ischaemic conditioning on coagulation function as measured by whole blood impedance aggregometry and rotational thromboelastometry in off-pump coronary artery bypass surgery: A randomised controlled trial

IntroductionRemote ischaemic conditioning (RIC) has been shown to prevent platelet activation during ablation for atrial fibrillation. RIC has also been associated with more postoperative transfusion in the off-pump coronary artery bypass graft surgery (OPCAB) patients. We evaluated the effects of RIC on coagulation function in OPCAB patients. MethodsA total of 58 patients undergoing OPCAB were randomised to the RIC or control group. In the RIC group, four cycles of 5 min of ischaemia and 5 min of reperfusion were applied twice to the upper arm after the induction of anaesthesia (preconditioning), and after the completion of coronary anastomoses (postconditioning). Whole blood impedance aggregometry (Multiplate®) and rotational thromboelastometry (ROTEM®) were performed before the induction of anaesthesia, at the end of surgery, and at postoperative day 1. ResultsThe trend towards a decrease in adenosine diphosphate-induced whole blood aggregation at the end of surgery was greater in the RIC group than in the control group, but this effect was not statistically significant (−10.4 [18.1] vs. −5.7 [24.8] U, P = 0.424). In ROTEM® analysis, the EXTEM area under the velocity curve was lower in the RIC group than in the control group at the end of surgery (3567 [1399–5794] vs. 5693 [4718–6179] mm∗100, respectively; P = 0.030). A tendency of larger perioperative blood loss was identified in the RIC group. ConclusionsAlthough some parameters indicated a tendency for hypocoagulation in the RIC group at the end of surgery, most effects were not statistically significant. RIC does not significantly affect perioperative platelet aggregability and coagulation in patients undergoing OPCAB.

Preoperative left stellate ganglion block: Does it offer arrhythmia-protection during off-pump CABG surgery? A randomized clinical trial

ABSTRACT Background Cardiac arrhythmias are not uncommon during and after coronary artery bypass graft cardiac surgeries. Preliminary studies showed the preventive effects of stellate ganglion block upon cardiac arrhythmias; however, this could be the 1st study focusing upon intraoperative arrhythmias during offpump coronary artery bypass graft surgery as a main goal. Methods This is a randomized controlled trial. The study involved forty adult patients undergoing elective offpump coronary artery bypass graft surgery. Twenty patients received left SGB with 10 ml of 2% lidocaine before induction of anesthesia (B group), and twenty patients as a control group (A group). Intraoperative and 24-hours postoperative electrocardiogram and hemodynamics were monitored, in addition to the mean postoperative 24-hours inotropic score. Results There was a significantly higher incidence of intraoperative arrhythmias in the control group in the form of bradyarrhythmia (25%), supraventricular tachycardia (30%), atrial fibrillation (5%), ventricular tachycardia (10%), and ventricular fibrillation (5%) in comparison to the block group where atrial fibrillation occurred only in 4 patients (20%) with the p value of 0.007. Mean arterial blood pressure and heart rate showed significantly lower values in the SGB group intraoperatively. Postoperative mean 24-hour inotropic score and hemodynamics showed insignificant differences. Conclusion Preoperative left stellate ganglion block can decrease incidence of arrhythmias during offpump coronary artery bypass graft surgeries. The technique showed a safe profile upon hemodynamics during the study period.

Effect of Off-Pump Coronary Artery Bypass Graft Surgery on Transthoracic Echocardiographic Right Ventricular Function in Indian Patients

Background: The importance of the right ventricle as a determinant of exercise capacity and its significant prognostic value in the evaluation of surgical outcomes has been largely proven. In this study, we sought to explore the effect of off-pump coronary artery bypass surgery (OPCAB) on right ventricular (RV) function by the different methods of RV functional assessment on transthoracic echocardiography. Materials and Methods: This is a prospective cohort study. All patients undergoing elective OPCAB were included in the study from July 1, 2016, to October 1, 2016 after an informed consent. Their preoperative, postoperative day 4, and postoperative 2-month transthoracic echocardiographic RV and left ventricular functions were evaluated and analyzed. Results: A total of 48 patients undergoing OPCAB were included in this study. The mean age of the cohort was 57.2 ± 8 years. About 85.4% (41) were males. Overall, there is a significant time effect observed in RV ejection fraction (RVEF), with a significant decline from preoperative to postoperative value and a significant increase from postoperative day 4 to postoperative 2-month value. Although RVEF was lower throughout the study in patients with events than those without events, this difference was not statistically significant. Conclusion: In this Indian cohort of patients undergoing OPCAB, there is a significant drop in RVEF, RV tissue Doppler, tricuspid annular peak systolic excursion on postoperative day 4, and also a significant increase in these values over the next 2 months though not reaching the basal value. Hence, suggesting that the drop in RV function is temporary and recovers over time in patients undergoing OPCAB. Patients with events had a lower RVEF when compared to those without events suggesting prognostication.

Role of central venous - Arterial pCO2 difference in determining microcirculatory hypoperfusion in off-pump coronary artery bypass grafting surgery.

Background:Cardiac surgery is frequently associated with macro and microcirculatory hypoperfusion. Patients with normal central venous oxygen saturation (Scvo2) also suffer from hypoperfusion. We hypothesized that monitoring central venous-arterial pco2 difference (dCO2) could also serve as additional marker in detecting hypoperfusion in cardiac surgery patient.Methods:This is a prospective observational study. Patients undergoing off-pump coronary artery bypass grafting included in this study. The dCO2 was measured postoperatively. The patients with a ScvO2 ≥70% were divided in to 2 groups, the high-dCO2 group (≥8 mmHg) and the low-dCO2 group (<8 mmHg).Results:The 65 patient had scvO2 ≥70%. Out of these, 20 patients were assigned to the high dCO2 group and 45 patients to the low dCO2 group. Patients with high dco2 had higher lactate levels after ICU admission. They also had significantly prolonged need for mechanical ventilation (14.90 ± 10.33 vs 10 ± 9.65, P = 0.0402), ICU stay (5.05 ± 2.52 d vs 3.75 ± 2.36 d, P = 0.049) and hospital stay (12.25 ± 5.90 d vs 8.57 ± 5.55 d P = 0.018). The overall rate of post-operative complications was similar in both the group.Conclusion:The present study demonstrates dCO2 as an easy to assess and routinely available tool to detect global and microcirculatory hypoperfusion in off-pump CABG patients, with assumed adequate fluid status and ScvO2 as a hemodynamic goal. We observed that high dCO2 (>8 mmHg) was associated with decreased DO2I, increased oxygen extraction ratio, the longer need for mechanical ventilation and longer ICU stay.

Implementation of Enhanced Recovery After Surgery (ERAS) protocol in off-pump coronary artery bypass graft surgery. A prospective cohort feasibility study.

Coronary artery bypass graft (CABG) is the most commonly performed cardiac surgery procedure. Although some complications related to the cardiopulmonary bypass circuit are avoided during off-pump CABG (OP-CABG) procedures, prolonged mechanical ventilation and severe postoperative pain are still important issues. This prospective cohort study aimed to assess the impact of the institutional Enhanced Recovery After Surgery (ERAS) protocol in patients undergoing OP-CABG. This protocol contained several modifications to the perioperative period, among which bilateral erector spinae plane block, remifentanil infusion, and patient-controlled analgesia (PCA) with oxycodone were the most important factors (ERAS group). The ERAS group was compared with the retrospective cohort (same surgeon) before the ERAS protocol was implemented (standard care group). The outcomes measured included the postoperative mechanical ventilation time, ICU and hospital stay, postoperative drainage time, postoperative troponin T level, pain severity evaluated via a numerical rating scale, and the total consumption of opioids in both groups of patients. Overall, 57 patients were analyzed - 29 in the ERAS group and 28 in the standard care group. The time of mechanical ventilation, thoracic drainage, and ICU and hospital stay was shorter in the ERAS group than in the standard care group. The pain was less intense in the ERAS patients, and the postoperative opioid demand was reduced. Moreover, the increase of the postoperative troponin T concentration was lower in the ERAS group. Our study showed that ERAS protocol implementation could improve patient outcomes after OP-CABG surgery.

Adenosine as cardioprotective in off-pump coronary artery bypass grafting

ObjectiveTo assess the effect of adenosine as a cardioprotective drug and its role in attenuating ischemia-reperfusion injury during off-pump coronary artery bypass surgery.BackgroundCardioprotective drugs have long been investigated for use during off-pump coronary artery bypass surgery to attenuate ischemia-reperfusion injury and limit hemodynamic instability. Adenosine has been investigated due to its cardioprotective effect that is mediated through A1 and A3 adenosine receptors. Stimulation of these receptors reproduces the infarct-limiting effect of ischemic preconditioning.MethodsAfter approval of the local ethics committee and informed written consent, fifty patients undergoing elective off-pump coronary artery bypass grafting were prospectively studied. The adenosine group received an infusion of Adenoscan at a rate of 50 μg/kg/min for 15 min. The control group received normal saline at the same rate and volume calculated. Pulmonary artery catheter was introduced through the right internal jugular vein. Cardiac output measurements were obtained. Cardiac index, stroke volume, systemic vascular resistance, pulmonary vascular resistance, right ventricular stroke work index, and left ventricular stroke work index were derived. Hemodynamic measurements were recorded together with blood levels of troponin I and CK-MB fraction to detect perioperative myocardial necrosis. Postoperative duration of mechanical ventilation, ICU stay together with inotropic support quantification using inotropic score were recorded.ResultsFifty patients were included in the study. In the adenosine group, the infusion of adenosine resulted in a significant reduction in mean pulmonary artery pressure after stopping drug infusion (18 ± 2.2 mmHg versus 31 ± 4.1 mmHg). There was a recorded increase in cardiac index in the adenosine group that started 15 min after adenosine infusion and lasted for 12 h postoperatively (p < 0.001). Also, adenosine infusion resulted in a reduction in pulmonary vascular resistance that exceeded the reduction in systemic vascular resistance which resulted in a decrease in pulmonary vascular resistance/systemic vascular resistance ratio (0.14 in adenosine group 15 min after injection versus 0.28 in control group) and (0.11 in adenosine group 12 h postoperatively versus 0.26 in control group). The cTroponin I measured 6 h postoperatively was less in the adenosine group compared with the control group (5.8 ± 2.8 ng/ml versus 16.5 ± 3.9 ng/ml).ConclusionAdenosine infusion during off-pump coronary artery surgery may improve cardiac index, reduce the need for inotropes, and have cardioprotective effect.

Mini-extracorporeal circulation surgery produces less inflammation than off-pump coronary surgery.

Both off-pump coronary artery bypass grafting surgery (OPCABG) and mini-extracorporeal circulation (MECC) have been associated with lower morbidity and mortality and less inflammation than conventional cardiopulmonary bypass. However, studies comparing the 2 techniques are scarce and the results are controversial. We compared the clinical outcomes and inflammatory response of low-risk patients undergoing coronary bypass grafting with MECC versus OPCABG. We conducted a prospective, randomized study in patients undergoing coronary heart surgery. Two hundred and thirty consecutive low-risk patients were randomly assigned to either receive OPCABG (n = 117) or MECC (n = 113). Clinical outcomes and postoperative biochemical results were analysed in both groups. We also analysed 19 circulating inflammatory markers in a subgroup of 40 patients at 4 perioperative time points. The area under the curve for each marker was calculated to monitor differences in the inflammatory response. No significant differences were found between groups regarding perioperative clinical complications and no deaths occurred during the trial. Plasma levels in 9 of the 19 inflammatory markers were undetectable or showed no temporal variation, 3 were higher in the MECC group [interleukin (IL)-10, macrophage inflammatory protein-1β and epidermal growth factor] and 7 were higher in the OPCABG group (growth regulator oncogene, IL-6, IL-8, soluble CD40 ligand, monocyte chemoattractant protein-1, monocyte chemoattractant protein-3 and tumour necrosis factor-α). Differences in 2 proinflammatory cytokines, IL-6 and monocyte chemoattractant protein 1, between the 2 surgical procedures were statistically significant. No clinical differences were observed between in low-risk patients undergoing MECC or OPCABG surgery, but OPCABG was associated with an increased release of proinflammatory cytokines compared with MECC. Studies in larger cohorts and in patients at higher risk are needed to confirm these findings. NCT02118025.

High-Flow Nasal Cannula Therapy With Early Extubation for Subjects Undergoing Off-Pump Coronary Artery Bypass Graft Surgery.

The effects of high-flow nasal cannula (HFNC) therapy on postoperative atelectasis and duration of oxygen therapy after off-pump coronary artery bypass graft are unknown. The purpose of this study was to compare the effects of HFNC therapy for subjects who underwent off-pump coronary artery bypass graft with the effects of standard oxygen therapy in terms of oxygen requirement and atelectasis. This prospective single-blinded randomized, controlled trial included 148 subjects who underwent off-pump coronary artery bypass graft between 2010 and 2015 with HFNC (n = 72) or without HFNC (standard O2, n = 76). The primary end point was the percentage difference in loss of lung volume between subjects with or without HFNC therapy. Secondary end points included the total amount of oxygen administered and duration of oxygen therapy with and without HFNC therapy. There were significant between-group differences in the percentage loss of lung volume (P < .001), total amount of oxygen administered (P < .001), duration of oxygen therapy (P < .001), and the need for postoperative diuretic therapy (P = .037). The amount (ρ = 0.569, P < .001) and duration (ρ = 0.678, P < .001) of oxygen administered were correlated with atelectasis volume. Using HFNC therapy after off-pump coronary artery bypass graft shortened the duration of oxygen therapy and reduced the percentage loss of lung volume and total amount of oxygen administered when compared with standard oxygen therapy.