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Eur J Cardiothorac Surg 2001;20:214-215
© 2001 Elsevier Science NL
Letter to the Editor |
Department of Cardiothoracic Surgery, Yorkshire Heart Centre, Leeds General Infirmary, Leeds LS1 3EX, West Yorkshire, UK
Received 13 March 2001; accepted 4 April 2001.
Tel.: +44-113-2432799; fax: +44-113-3928092
e-mail: dumbor{at}ngaage.freeserve.co.uk
Key Words: Off-pump • Coronary artery bypass grafting • Haemodynamic changes • Left ventricular function
During coronary surgery with the beating heart technique, varying degrees of haemodynamic alterations occur, sometimes necessitating expeditious institution of cardiopulmonary bypass. As a result there is a valid concern among surgeons about the possible deleterious effects on patient outcome, of the haemodynamic changes that attend off-pump coronary artery bypass grafting (OPCAB). I therefore congratulate Watter et al. for their study [1] which seeks to address this concern. In this study, Watter et al. determined the adverse effects of the haemodynamic changes during OPCAB involving the three territories by:
Although they reported changes in the haemodynamics associated with the distal anastomosis in the different set-ups, these were well tolerated by their select group of patients without pharmacologic or volume support. However their conclusion deviates from their findings, and suggests that this is achievable in all OPCAB cases.
I wish to make the following observations about this study.
The positioning of the heart and stabilization of the target coronary artery during OPCAB is notorious for engendering haemodynamic deterioration [2]. A major cause of conversion to on-pump coronary artery bypass grafting in my experience, which corroborates published reports [2,3], is haemodynamic upheavals during the dislocation of the heart to expose and stabilize the target site. After this stage the haemodynamics usually improves, especially in patients with good left ventricular (LV) function who tolerate these upsets well. Cardiac output measured 5 min after this crucial stage of haemodynamic disturbance does not capture the worst possible derangement that may occur. More so, since their cohort of patients all had good LV function (ejection fraction more than 40%), they would have recovered from any haemodynamic instability at the time of recording. Continuous cardiac output monitoring provides a more reliable recording of the haemodynamics changes during different set-ups of OPCAB and eliminates the injection-to-injection variation of intermittent measurements. This would have been an advantage in this study.
Patients with poor LV function and recent myocardial infarction have an impaired capability to tolerate haemodynamic changes. These groups of patients who have been found to benefit from OPCAB [4,5], and are increasingly selected for this procedure, usually require intraoperative support to withstand any haemodynamic instability. It would put their study in the right perspective, if Watter and associates had specified that patients with good LV function tolerate haemodynamic changes during OPCAB without a deleterious outcome.
References
This article has been cited by other articles:
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  O. Reuthebuch, A. Haussler, M. Genoni, R. Tavakoli, D. Odavic, A. Kadner, and M. Turina Novadaq SPY: Intraoperative Quality Assessment in Off-Pump Coronary Artery Bypass Grafting Chest, February 1, 2004; 125(2): 418 - 424. [Abstract] [Full Text] [PDF]
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