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Eur J Cardiothorac Surg 2004;25:978-984
© 2004 Elsevier Science NL

Evaluation of serial haemodynamic changes during coronary artery anastomoses in patients undergoing off-pump coronary artery bypass graft surgery: initial experiences using two deep pericardial stay sutures and octopus tissue stabilizer

Helen Ki Shinna, Young Jun Ohb, Seung Ho Kimb, Jong Hwa Leeb, Choon Soo Leea, Young Lan Kwakb*

a Department of Anaesthesiology and Pain Medicine, Inha University College of Medicine, Inchon, South Korea
b Department of Anaesthesiology and Pain Medicine, Anaesthesia and Pain Research Institute, College of Medicine Yonsei University, 134 Shinchon-Dong, Seodaemun-Gu, Seoul 120-752, South Korea

Received 15 December 2003; received in revised form 12 February 2004; accepted 27 February 2004.

* Corresponding author. Tel.: +82-02-361-7224; fax: +82-02-364-2951
e-mail: ylkwak{at}yumc.yonsei.ac.kr


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: This study was designed to evaluate the serial haemodynamic changes during coronary artery anastomoses using two deep pericardial stay sutures and octopus tissue stabilizer in patients undergoing initial experiences of off-pump coronary artery bypass graft surgery (OPCAB) using continuous cardiac output and mixed venous oxygen saturation (SvO2) monitoring. Methods: With IRB approval, thirty patients undergoing OPCAB were studied. Pulmonary artery catheter (PAC) for continuous cardiac output and SvO2 monitoring was inserted before anaesthesia. Haemodynamic measurements were recorded after pericardiotomy for baseline value. During each coronary artery anastomosis, haemodynamic variables were measured at 1,3,5,10, and 15 min after the application of tissue stabilizer and after the removal. Vasopressors were used to maintain mean arterial pressure (MAP) higher than 60 mmHg. Results: MAP and heart rate (HR) were maintained without significant change during the anastomoses of all three arteries. Cardiac index (CI), and SvO2 decreased significantly after stabilizer application in all three arteries. CI was below 2.5 l/min/m2 and SvO2 was under 70% during left circumflex artery (LCX) anastomosis. The decrease in CI and SvO2 were significantly greater during LCX anastomosis. The increase in mean pulmonary artery pressure (MPAP) and pulmonary capillary wedge pressure (PCWP) was significant only in left anterior descending artery (LAD). Central venous pressure (CVP) increased significantly during the anastomosis of all three coronary arteries. The differences in MPAP, PCWP and CVP among the three coronary arteries were not statistically significant. The highest dose of vasoconstrictor was used during LCX anastomosis. Conclusions: When the coronary anastomoses were performed with two deep pericardial stay sutures and octopus tissue stabilizer on the beating heart, CI and SvO2 decreased significantly during all coronary artery anastomoses immediately after the stabilizer application and the degree of reduction in CI and SvO2 increased with time, though MAP was maintained constantly. CI and SvO2 during LCX anastomosis were consistently below normal values. Therefore close monitoring and proper managements are needed during graft anastomoses.

Key Words: Continuous cardiac output monitoring • Mixed venous oxygen saturation • Off-pump coronary artery bypass graft surgery


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Recently, the performance of off-pump coronary artery bypass graft surgery (OPCAB) has been expanded because of the advantage of avoiding cardiopulmonary bypass (CPB)-related complications and improvements in surgical skill as well as surgical instruments [1–6]. This surgical procedure might be mostly used in patients with cerebrovascular disease, calcification or atheromatous plaque in the ascending aorta, or in case of advanced heart failure [7]. However, haemodynamic instability throughout the positioning, stabilization and interruption of coronary flow is still important factors limiting the performance of OPCAB and numerous studies for the changes in haemodynamic values and management of haemodynamic instability has been performed [8–10]. Most studies concerning the OPCAB measured the haemodynamic variables during OPCAB only once and there has been no report about the progress of haemodynamic change during coronary artery anastomosis. This study presents and compares serial haemodynamic changes during coronary anastomoses in OPCAB using continuous cardiac output (CO) and mixed venous oxygen saturation (SvO2) monitoring.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
2.1. Patients
Thirty patients with coronary artery disease planned to undergo OPCAB consented to participate in this prospective study. After Institutional Review Board approval, informed consent was obtained from patients. Patients who had clinically significant preoperative hepatic or renal dysfunction, thrombocytopenia, coagulopathy, or uncontrolled arrythmia were excluded.

2.2. Anaesthesia
All recent cardiac medications except digoxin and diuretics were given till the morning of surgery. As premedication, morphine 0.05 mg/kg IM was injected an hour before the surgery. In the operating room, EKG leads II and V5 were monitored and the radial artery was cannulated for continuous monitoring of arterial blood pressure and blood gas analysis. For continuous cardiac output and SvO2 monitoring, pulmonary artery catheter (PAC; Swan-Ganz, CCOmbo®, Baxter Healthcare Co., Irvine, CA, USA) was inserted through the right internal jugular vein before anaesthesia. Anaesthetic technique was standardized for all patients. Anaesthesia was induced with 2.0–3.0 mg of midazolam, 1.0–3.0 µg/kg of sufentanil, and 50 mg of rocuronium and maintained with 0.2–0.5 vol% of isoflurane and continuous intravenous infusion of 0.5–1.5 µg/kg/min of sufentanil and vecuronium. Ventilation was controlled with oxygen–air mixture (FiO2 0.6) to maintain end-tidal CO2 in 35–38 mmHg. Isosorbide dinitrate 0.5 µg/kg/min was started after induction. Transesophageal echocardiography (TEE) was monitored at short-axis midpapillary muscle view. When the view was not clear due to the displacement of the heart, four or five-chamber view was used. To prevent hypothermia, the temperature of the operating room was kept above 25 °C and all the fluid was warmed. Warm humidifier was connected to the breathing circuit. Patients were also warmed with warm mattress and after the venous harvest, lower limbs were wrapped with aseptic forced air blanket. After median sternotomy, adequate amount of fluid (1.5–2.0 l) was given and head down position was made during anastomosis. In case of hypotension, norepinephrine was given to maintain mean systemic arterial pressure (MAP) above 60 mmHg. After the dissection of left internal mammary artery (LIMA), 1 mg/kg of intravenous heparin was injected and activated clotting time was maintained over 250 s during the anastomosis. To expose the lateral side of the heart and elevate the apex, two deep pericardial stay sutures were placed between atrioventricular groove and left inferior pulmonary vein. This stay suture moved the heart to expose the coronary artery to be anastomosed and then suction type tissue stabilizer (Octopus Tissue Stabilizer System, Medtronic Inc., Minneapolis, MN, USA) was applied. Intracoronary endoluminal shunt was used during anterior descending coronary (LAD) anastomosis and proximal right coronary artery (RCA) anastomosis.

2.3. Haemodynamic monitoring
For each coronary artery anastomosis, heart rate (HR), MAP, central venous right atrial pressure (CVP), pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), CO, and SvO2 were recorded as haemodynamic variables. Cardiac index (CI), stroke volume index (SVI), left ventricular stroke work index (LVSWI), and systemic and pulmonary vascular resistance index (SVRI and PVRI, respectively) were calculated according to general formulas. Haemodynamic measurements were recorded after pericardiotomy for baseline value (T0), at 1,3,5,10, and 15 min after the application of tissue stabilizer (T1, T3, T5, T10, T15, respectively) during each coronary artery anastomosis, after the removal of stabilizer (Tp), and after sternal closure (Tst). The amount of norepinephrine used to maintain MAP for each anastomosis was also recorded.

2.4. Statistical analysis
All haemodynamic variables were expressed as the mean value±SD. Haemodynamic changes for each coronary anastomosis were compared to baseline measures using repeated measures of ANOVA. The comparisons of variables between coronary arteries were analyzed with one-way ANOVA. Percent changes of CI and SvO2 for baseline values in each coronary artery were analyzed with linear regression. A P value of <0.05 was considered as statistically significant. Data were analyzed with SPSS for Windows, release 10.0 (SPSS Inc., Chicago, IL, USA).


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
Demographic data are listed in Table 1.


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  		Table 1. Demographic data

 
Haemodynamic data during coronary artery bypass graft anastomosis are shown in Tables 2 and 3. During LAD anastomosis, the HR and MAP did not change and the MPAP, PCWP, and CVP at T1–T15 significantly increased compared with T0. The CI, SVI, and LVSWI at T3–T15 and the SvO2 at T1–T15 significantly decreased and the SVRI at T15 significantly increased compared with T0 during LAD anastomosis.


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  		Table 2. Haemodynamic data during coronary artery graft anastomosis-1

 

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  		Table 3. Haemodynamic data during coronary artery graft anastomosis-2

 
During LCX anastomosis, the HR at T5 and T10 and the PCWP at T10 significantly increased compared with T0 and the HR decreased only at T1 compared with T0 recovered to baseline value. The CVP at T1–T15 and SVRI at T3–T15 also significantly increased and the CI, SvO2, SVI, and LVSWI at T1–T15 significantly decreased compared with T0 during LCX anastomosis.

During RCA anastomosis, the HR at T1–T15 significantly increased and MAP decreased only at T1 and MPAP and PCWP did not change compared with T0. The CVP at T1–T15 significantly increased and the CI, SvO2, SVI at T1–T15 significantly decreased compared with T0 during RCA anastomosis. The LVSWI significantly decreased only at T1 and the SVRI did not change compared with T1 during RCA anastomosis.

In comparison among three coronary artery anastomosis, there was no difference in the HR and MAP, CVP at all time periods. MPAP was significantly lower in LCX at T3, and in RCA at T1 and T5 compared to LAD. CI and SvO2 from T1 to T15 were significantly lower in LCX compared to LAD. SVI was significantly lower in LCX than in LAD from T1 to T10. LVSWI of LAD at T1 was higher than that of the other two arteries. SVRI was significantly higher in LCX form T3 to Tp compared to LAD. The percent changes of CI and SvO2 of each coronary artery were compared. The percent decrease in CI and SvO2 were greater in LCX compared to that of LAD (Figs. 1 and 2) . The change of CI in LAD showed linear decrease with time (R2=0.115,P=0000). The other two arteries did not show the same pattern. The other two arteries did not show the same pattern. The total doses of norepinephrine used to maintain MAP over 60 mmHg were 96.1±126.4, 236.9±382.6, and 64.0±70.9 µg in LAD, LCX, and RCA, respectively. The amount of norepinephrine was significantly larger in LCX than in other two arteries.



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  		Fig. 1. The changes of cardiac index during each coronary artery graft anastomosis. {Delta}Cardiac index (%), (cardiac index of each period/baseline cardiac index)x100. Vertical bars are SD. T0, after pericardiotomy (baseline); T1, 1 min after stabilizer application; T3, 3 min after stabilizer application; T5, 5 min after stabilizer application; T10, 10 min after stabilizer application; T15, 15 min after stabilizer application; Tp, after stabilizer removal, post-grafting period. *P<0.05 compared to LAD.

 


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  		Fig. 2. The changes of mixed venous oxygen saturation(SvO2) during each coronary artery graft anastomosis. {Delta}SvO2 (%), (SvO2 of each period/baseline SvO2)x100. Vertical bars are SD. T0, after pericardiotomy(baseline); T1, 1 min after stabilizer application; T3, 3 min after stabilizer application; T5, 5 min after stabilizer application; T10, 10 min after stabilizer application; T15, 15 min after stabilizer application; Tp, after stabilizer removal, post-grafting period. *P<0.05 compared to LAD.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
This study was designed to evaluate the serial changes of haemodynamic variables during coronary artery graft anastomosis in patients undergoing OPCAB using two deep pericardial stay sutures and octopus tissue stabilizer. In the study, there was no further haemodynamic deterioration or improvement after the initial haemodynamic change induced by the heart positioning and application of stabilizer, except that the change in CI presented linear decrease with time during LAD anastomosis. There was no case that could not perform planned anastomosis or convert to CPB due to haemodynamic instability. In this study, 2.8±0.7 coronary arteries were bypassed. Mean time for main three coronary artery anastomosis was 49±11 min and for all anastomosis was 72±23 min. The times required to anastomose each coronary arteries are following: 19.6±3.4 min for LAD, 17.6±1.8 min for LCX and 17.9±1.8 min for RCA.

For theoretical advantages of avoiding CPB-related complications, OPCAB has been generally performed in patients with high risk factors such as old age, cerebrovascular disease, ventricular failure, renal failure [1–7]. Haemodynamic deterioration during coronary anatomosis is the main problem of the procedure and numerous studies have reported about the changes of haemodynamic values during anastomosis and the recovery of them after the anastomosis by measuring the haemodynamic variables before and after the anastomosis [8–10]. On the other hand, in this study, variables were recorded according to the time of anastomosis in each coronary artery. The CI and SvO2 significantly decreased at the beginning of the anastomosis and did not recover or further decreased during the anastomosis in all three coronary arteries although the MAP was constantly maintained. In the LCX and RCA, CI and SvO2 decreased abruptly, immediately after the placement of the stabilizer but further decrease did not occur. This change seems to be associated with mechanical interruption caused by manipulation of the heart rather than the progression of myocardial ischemia. On the other side, in the LAD, the CI decreased progressively after the beginning of the anastomosis, which seems to be associated with position of stabilizer. Goyer et al. [9] reported that MPAP and PCWP increased significantly during anastomosis of the arteries located anterior of the heart such as LAD. During anastomosis of anterior arteries, the stabilizer compresses directly the right ventricular outflow tract and the right ventricular end systolic and diastolic volume increase. As a result, the left ventricular diastolic compliance is reduced through the interventricular relationship and the PAP and PCWP increase. The right ventricular outflow tract being obstructed during LAD anastomosis may be the possible reason for the gradual decrease in CI. Another possible reason is the fact that LAD contributes to a large portion of the LV blood supply and is critical for the maintenance of the global LV function, although this may not be the main mechanism of progressive decrease in CI since blood flow to distal parts were maintained using endoluminal shunt.

The result of this study draws attention to the possible detrimental effects of sustained haemodynamic change on other major organ function, especially if the total time required for anastomosis is prolonged and haemodynamic stability gets worse. It has been well known that in the off-pump technique, for the grafting of the LCX and posterior descending artery branches through sternotomy, anterior displacement of the beating heart is required and this often causes haemodynamic compromise [11,12]. In this study, CI and SvO2 also decreased below 2.0 l/min and 70% and were constantly maintained during whole periods of LCX anastomosis. Although there were no patients having any increase in CK-MB, SGOT/SGPT, BUN/Cr or development of neurologic complications, and major organ damage was not apparent, development of subclinical organ damage could not be excluded. It is not certain as to what degree and duration of haemodynamic deteriorations must occur during anastomosis to have an effect on the development of complications. However, when considering that OPCAB is objected to high risk patients who suffer from heart failure, renal failure and cerebrovascular disease, repetitive low cardiac output status more than 10 min may have bad effects to organ function. The number of coronary artery anastomosis during OPCAB is increasing and it is necessary to manage CI, SvO2 properly. And also, further studies are needed to identify the effects of decreased CI and SvO2 on other major organ during anastomosis.

Generally, the management of patients undergoing OPCAB has been focused on the maintenance of the MAP, HR and cardiac rhythm between stable limits during coronary anastomosis [13–17]. Especially, intravenous fluid loading, head down position were recommended to compensate decreased MAP and CO [18], and the use of inotropic drugs were relatively contraindicated. The decrease in the CI is mainly attributed to mechanical dysfunction in relation to the displacement and compression of the heart during anastomosis and inotropic drugs that act on the beta-adrenergic receptors increased myocardial oxygen consumption and HR, which induces the myocardial ischemia [19–20]. However, it was found that the augmentation of preload with head down position and fluid loading was not enough to compensate the reduced CO during anastomosis in the study. Therefore, management to maintain the CO and SvO2 without subsequent adverse cardiac effects is needed and milrinone may be useful. Unlike other inotropic agents, which act on the ß-adrenergic receptors, milrinone has been reported to have little effect on the HR and myocardial oxygen consumption compared with dobutamine [15,21]. We presented prophylactic, continuous infusion of milrinone without bolus dose to successfully increase CO and decrease the degree of reduction in the CO and SvO2 during anastomosis in patients undergoing OPCAB [22]. It also has been known to increases the coronary blood flow, and prevent spasm of the IMA and arterial graft in patients with coronary artery disease [23–25].

Along with TEE, PAC, which monitors the CO and SvO2 continuously, seems to be very useful in patients undergoing OPCAB. Scott et al. [25] also reported its effectiveness in detecting rapid change of the heart function during surgical procedures. Especially, SvO2 reflects haemodynamic changes earlier compared to the CO measured every 45 s and has critical significance since it represents both delivery and consumption of oxygen. The SvO2 is dependent on actual haemoglobin, arterial oxygenation, and CO. During manipulation of the heart, changes in the SvO2 depend on changes in the CO as the level of hemoglobin and oxygen remain relatively stable. Although, measurement of the CO level is too slow for monitoring the cardiac status during the manipulation and tilting of the heart, the CO is still useful as a trend monitor during the entire surgical period, and concomitant changes of the CI and SvO2 were observed in this study.

The haemodynamic changes during OPCAB largely depend on the surgical technique and surgeon's skill and the result of this study is as our initial experience using this type of stabilizer and technique. Other techniques to expose the target coronary vessel may result in different degree of changes in haemodynamic variables and the result may not be generalized in all OPCAB.

In conclusion, when we continuously monitored the changes in CO and SvO2 during coronary anastomosis in patients undergoing OPCAB, using two deep pericardial stay sutures and octopus tissue stabilizer the CO and SvO2 decreased further with time in case of the LAD even though HR and MAP were maintained constant but the CO and SvO2 started to decrease significantly at the beginning of anastomosis and maintained constantly in the LCX and RCA. Based on this result, close monitoring with proper intervention is required to decrease the change in the CI and SvO2 at the time of coronary artery anastomosis in patients undergoing OPCAB.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

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