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Eur J Cardiothorac Surg 2001;20:655-656
© 2001 Elsevier Science NL
Letter to the Editor |
Department of Cardiothoracic Surgery, Yorkshire Heart Centre, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, West Yorkshire, UK
Received 28 April 2001; received in revised form 2 May 2001; accepted 1 June 2001.
Corresponding author. Tel.: +44-113-243-2799; fax: +44-113-28092
e-mail: dumbor{at}ngaage.freeserve.co.uk
Key Words: Offpump coronary artery bypass grafting • Complete myocardial revascularisation • Total arterial revascularisation • Ventricular fibrillation
Two publications in the March 2001 issue of the European Journal of Cardio-thoracic Surgery [1,2] adds to the growing body of evidence in favour of off-pump coronary artery bypass (OPCAB) in high risk situations. Varghese and associates [1] reported an excellent outcome in a retrospective review of 35 patients operated non-electively by OPCAB. Two factors that may have contributed to the impressive result are noteworthy. Firstly, the mean number of diseased coronary arteries (2.74) correspond to the mean number of grafts (2.8). This implies that most of the patients had complete myocardial revascularisation. This is particularly important because incomplete myocardial revascularisation is common with OPCAB [2,3]. Growing concern of an inappropriate trade-off, of the benefits of complete myocardial revascularisation for the ‘dubious’ advantages of OPCAB remains a setback to the rapid global acceptance of OPCAB [4].
Secondly, Varghese et al. achieved 100% arterial revascularisation in the study population and 77.3% total arterial revascularisation in patients younger than 70 years, thereby securing the advantages of arterial revascularisation with OPCAB even in high risk patients.
The only mortality in their series had a poor left ventricular function (PLVF), and developed perioperative myocardial infarction (MI) and postoperative ventricular fibrillation (VF). The pathophysiological association between PLVF and/or MI, and VF is inadequate myocardial perfusion perpetuating ischaemic myocardial injury [5]. Since no operative details of this patient was given, one wonders if this patient had incomplete revascularisation.
A personal experience in the management of a 62-year-old man in cardiogenic shock from massive anteriolateral MI, and failed thrombolysis and percutaneous transluminal coronary angiosplasty, lends credence to this fact. This patient was transferred for surgical revascularisation mechanically ventilated, on multiple inotropes and intraaortic balloon pump. Coronary angiography had confirmed left main stem stenosis (70%), proximal left anterior descending artery (LAD) stenosis (90%), occluded circumflex artery, and normal non-dominant right coronary artery. At OPCAB performed as a salvage procedure 72 h after MI, only the LAD and the first diagonal arteries were grafted. The circumflex artery was infarct-related, to an extensive anterolateral area and was not grafted because of haemodynamic instability.
In the early postoperative period, he developed multifocal ventricular ectopics that was controlled with amiodarone infusion. On the 14th postoperative day (a day before planned hospital discharge), he developed monomorphic, direct current shock-resistant VF not amenable to amiodarone and lignocane infusions. An implantable cardioverter defibrillator was inserted and he remains well, 1 year later.
Complete myocardial revascularisation is fundamental in surgical treatment of ischaemic heart disease and although sometimes this cannot be achieved, especially in very high-risk patients, it should always be the goal even in OPCAB. It is not illusionary to think that the promising results of OPCAB can be stultified by incomplete myocardial revascularisation. Increasingly, OPCAB is being performed in very high-risk situations and the maximally derivable benefit from this burgeoning practice may well lie in complete myocardial revascularisation and the use of arterial grafts, whenever possible.
It would be interesting to know the mid-term and/or long-term results in this cohort of patients.
References
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