Cirugía coronaria sin circulación extracorpórea

La cirugía de revascularización coronaria (CABG) es el estándar de tratamiento para la revascularización de la enfermedad de la arteria coronaria izquierda y/o de tres vasos. La cirugía coronaria sin bomba (OPCAB) evita el uso de derivación cardiopulmonar y puede mejorar los resultados a largo plazo al reducir las tasas de lesión miocárdica perioperatoria, accidente cerebrovascular (ACV), deterioro neurocognitivo y mortalidad de causa cardiaca. En la actualidad, se han llevado a cabo diversos ensayos clínicos desde la popularización del OPCAB en la década de los 90. Sin embargo, hasta el momento no se ha demostrado ningún beneficio del OPCAB en comparación con la cirugía tradicional a pesar de las reducciones favorables a corto plazo en los requerimientos de transfusión y otras complicaciones postoperatorias. Además, OPCAB se asocia con una revascularización miocárdica menos eficaz y no previene por completo las complicaciones tradicionalmente asociadas con la circulación extracorpórea (CEC). Este artículo revisa la evidencia actual de OPCAB en comparación con CABG tradicional en cuanto a los resultados clínicos a corto y largo plazo. Se analizan los resultados de la cirugía coronaria sin circulación extracorpórea (CEC) , comparándola con la cirugía convencional (con CEC). La revascularización coronaria sin CEC presenta resultados similares a la convencional, siempre que se cumplan determinadas condiciones en la selección de los pacientes. Una de ellas, muy importante, es la mayor experiencia del cirujano con el procedimiento.

The results of coronary artery revascularization performed without extracorporeal circulation (off pump) are compared to those of the traditional ("on pump") procedure. Compliance with selective conditions are required to obtain similar results. The most important being the experience of the surgeon performing the off pump procedure.

Reoperation after Coronary Artery Bypass Grafting; On-Pump Beating Heart Minimally Invasive Mitral Valve Replacement for Single Leaflet Device Attachment after MitraClip Placement / 日本心臓血管外科学会雑誌

A 50-year-old man with a history of coronary artery bypass grafting (CABG) 5 years prior to presentation underwent MitraClip placement for severe mitral regurgitation. Subsequently, he underwent on-pump beating heart endoscopic minimally invasive cardiac surgery (MICS) for mitral valve replacement for acute heart failure secondary to single leaflet device attachment. Endoscopic MICS via a right small thoracotomy approach is useful for reoperation after CABG in patients with a high risk of graft injury. Beating-heart surgery may be an effective option to avoid the risks associated with prolonged cardiac arrest time in patients with low left ventricular function.

Discussion on the influencing factors of beating heart coronary artery bypass grafting / 中国胸心血管外科临床杂志

@#Objective To explore the factors affecting the operation of coronary artery bypass grafting with heart beating and improve the effect of the operation. Methods From January 2012 to June 2016, 898 patients with coronary heart disease who received cardiovascular surgery in the Second Affiliated Hospital of Jilin University were analyzed retrospectively. All patients only underwent coronary artery bypass grafting with beating heart. Among them, 797 patients underwent the off-pump coronary artery bypass grafting (an OPCABG group, 592 males and 205 females, with an average age of 60.5±8.4 years); another 101 patients received on-pump beating heart coronary artery bypass grafting (an OPBH group, 77 males and 24 females, with an average age of 61.5±8.2 years). Results The average number of grafts in the OPCABG group was 3.36±0.74, and in the OPBH group was 3.71±0.69 (P<0.05). The postoperative ventilation time (10.8±9.5 hvs. 20.6±12.3 h), ICU stay (28.8±15.5 h vs. 37.4±30.8 h), hospital stay (10.9±4.8 d vs. 14.8±8.6 d), mortality (1.1% vs. 3.0%), the utilization rate of intra-aortic balloon pump (2.4% vs. 8.9%) and extracorporeal membrane oxygenation (0.5% vs. 5.0%) were significantly different between the OPCABG group and OPBH group (all P<0.05). Twelve patients died after surgery, and the total bloodless operation ratio was 91.3%. Conclusion The results show that most patients can achieve good results with the help of apical fixation and myocardial fixator, improved surgical techniques and methods, good anesthesia management as well as flexible and accurate use of vasoactive drugs. But extracorporeal circulation is necessary in the patients with large left ventricle, low ejection fraction and hemodynamic instability after intraoperatively moving the heart.

Beating Heart Mitral Valve Replacement via Right Thoracotomy for Ischemic Mitral Valve Regurgitation after Coronary Artery Bypass Surgery / 日本心臓血管外科学会雑誌

Reoperative valve surgery is known to be more complex and associated with increased morbidity and mortality, especially for patients with patent coronary artery bypass grafts. A 69-year old man with a history of coronary artery bypass grafting was referred to our hospital with breathing difficulties and a heart murmur. Bypass grafts were all patent, but due to severe ischemic mitral valve regurgitation, we performed beating heart mitral valve replacement via right thoracotomy. The procedure was performed with video assistance, and both the anterior and the posterior chordae tendineae were preserved. The postoperative course was uneventful. He was discharged 7 days after surgery without any complications. This technique is a safe and feasible option for a mitral valve reoperation that avoids graft injuries, minimizes the risks of bleeding, and shortens the operative time.

Study of heart and lung protection in thoracoscopic mitral valve replacement operation on beating-heart / 重庆医学

Objective To investigate the clinical significance of thoracoscopy combined with beating-heart technique to provide a certain reference for selecting clinical operation mode.Methods Forty patients with chronic rheumatic mitral stenosis receiving thoracoscopic mitral valve replacement surgery in the cardiothoracic surgery department of our hospital from September 2012 to September 2015 were included in this study and divided into the experimental group(beating-heart group,20 cases) and control group(arrested heart group,20 cases).The operative time,CPB time,enzymology indicators,RI and operative complications were analyzed and compared between the two groups.Results One case in each group died of postoperative low cardiac output syndrome.Other cases successfully completed the operation without serious operative complications such as low cardiac output syndrome,serious cardiac arrhythmia and air embolism.Two groups had no statistically significant difference in the operation time and time of CPB (P＞0.05),but the ICU staying duration had statistical difference between the two groups(P＜0.05).The levels of CK-MB,cTnI,LDH,TNF-α,IL-6,IL-8 and RI were significantly increased in two groups(P＜0.05),while the levels in the experimental group were significantly lower than those in the control group(P＜0.05).Conclusion Thoracoscopic mitral valve replacement operation with beating-heart may have better protection effect on heart and lung than thoracoscopic arrested-heart mitral valve replacement operation.

Cirugía coronaria con circulación extra corpórea y corazón batiente en pacientes de alto riesgo / On-pump beating heart coronary artery bypass grafting surgery for high risk patients

Background: The technique for coronary surgery involves the use of extra corporeal circulation (On-pump) and cardioplegia. In high-risk patients this surgery has high morbidity and high mortality. Surgery On-pump beating heart is an alternative for those cases. We describe our experience with this technique. Patients and Methods: 11 patients were operated between 2007 and 2008. Ten men (mean 59.5 years). Four patients with evolving myocardial infarction, 2 patients with left main coronary artery lesion and all with three-vessel lesion. Ejection fraction (EF) averaged was 31.5 percent. Four surgeries were considered urgent. Results: All procedures were completed with the technique, 3.1 by pass were performed per patient and all received an internal mammary artery. Mechanical ventilation averaged 13.6 hours. Removal of IABP between first and second day. Stay in ICU 4.82 days. There were no perioperative infarctions or stroke. One patient had renal failure. Postoperative hospital stay was 10.6 days. Postoperative echocardiogram (2 months) showed an average EF of 38.3 percent (NS). Conclusions: In this series, high-risk coronary patients were operated On-pump beating heart. This technique allowed complete revascularization, good immediate outcome and ventricular function improved in the medium term.

Introducción: La técnica habitual para la cirugía coronaria incluye el uso de circulación extracorpórea (CEC) y cardioplejia. En pacientes de alto riesgo esta cirugía tiene alta morbi-mortalidad. La cirugía con CEC y corazón batiente es una alternativa para estos casos. Se describe nuestra experiencia con la técnica. Pacientes y Métodos: 11 pacientes operados entre 2007 y 2008, 10 hombres (promedio 59,5 años). Cuatro pacientes con infarto en evolución, dos con lesión de tronco coronario izquierdo y todos con lesión de tres vasos. Fracción de eyección (FE) promedio 31,5 por ciento. Cuatro cirugías se consideraron de urgencia. Resultados: Todas las cirugías se completaron con la técnica. Se realizaron 3,1 puentes/paciente y todos recibieron una arteria mamaria interna. Ventilación mecánica promedio 13,6 horas. Retiro de BCIA entre primer y segundo día. Estadía en unidad de cuidados intensivos 4,82 días. No hubo infartos perioperatorios, ni accidentes vasculares encefálicos. Un paciente presentó falla renal. Alta promedio 10,6 días. Ecocardiograma post operatorio (2 meses) mostró FE promedio de 38,3 por ciento (NS). Conclusiones: En esta serie, los pacientes coronarios de alto riesgo fueron intervenidos utilizando CEC y sin detener el corazón. La técnica permitió una revascularización completa, buen resultado inmediato y mejoría de la función ventricular en el mediano plazo.

A Case of Aortic Valve Replacement Performed on a Beating Heart / 日本心臓血管外科学会雑誌

A 75-year-old man was admitted to our hospital because of severe aortic stenosis associated with fainting spells. He had undergone coronary artery bypass grafting at the age of 66, and had progressive aortic stenosis for 9 years. Ultrasound showed left ventricular hypertrophy and a calcified aortic valve. The aortic valve area was 0.34 cm² and the mean pressure gradient was 56 mmHg. Multi detector-row computed tomography showed patent bypass grafts (LITA-LAD, SVG-OM-PL, and SVG-RCA) and a persistent left superior vena cava (PLSVC). Coronary angiography revealed total occlusion of all the 3 native coronary arteries, therefore, antegrade cardioplegic perfusion was impossible. Retrograde perfusion was also impossible because of the PLSVC. We had to clamp the LITA and infuse the cardioplegic solution through the SVG graft to obtain cardioplegic arrest. Performing aortic valve replacement (AVR) on a beating heart facilitates the operation, because it negates the need to clamp the patent bypass graft and the PLSVC. We exposed a minimal area of the operating field, ascending aorta, and right atrium. Cardiopulmonary bypass was established by cannulating the ascending aorta and right atrium. The right pulmonary vein was cannulated for left ventricular venting. The ascending aorta was cross clamped on the proximal side of the SVG. AVR was thus performed using the standard approach on the beating heart with coronary perfusion through the bypassed graft. The postoperative course was uneventful, and the patient was discharged 15 days postoperatively. Redo surgery is more complex than primary surgery and is associated with higher mortality and morbidity. Beating heart surgery is one of the optional methods in such a complex case.

Primeros resultados comparativos de dos vías de abordajes de cirugía de revascularización coronaria mínimamente invasiva / First comparative results from two-ways surgical approaches of minimally-invasive coronary revascularization

INTRODUCCIÓN. El objetivo de esta investigación fue exponer y comparar los resultados de 2 vías de abordaje diferentes (toracotomía anterior izquierda y esternotomía media longitudinal) para revascularización miocárdica con corazón latiendo, practicadas en el Hospital Hermanos Ameijeiras entre septiembre de 2007 (cuando se introdujo en el centro la técnica mediante toracotomía) y enero del 2008. MÉTODOS. Se realizó un estudio prospectivo y descriptivo longitudinal para comparar resultados según la vía de abordaje quirúrgico para revascularización miocárdica mínimamente invasiva: vía habitual, por esternotomía media longitudinal (29 operados; 65,9 por ciento) y vía nueva y no habitual por toracotomía anterior izquierda (15 operados; 34,1 por ciento). RESULTADOS. El promedio de derivaciones realizadas fue de 3,31 mediante esternotomía y de 3 por toracotomía. Requirió transfusiones el 96,6 por ciento y el 26,7 por ciento de los pacientes operados por esternotomía y toracotomía, respectivamente, lo cual fue estadísticamente significativo. El uso de fármacos inotrópicos y de balón de contrapulsación intraórtico no fue estadísticamente significativo. El tiempo quirúrgico usual en ambas técnicas fue de 5 a 7 h, mientras que el tiempo de intubación fue significativamente mayor en los pacientes operados por esternotomía (11-14 h frente a 3-6 h en la toracotomía). Igual fue significativa la estadía, mayor en la esternotomía (3-4 días frente a 1-2 días en la toracotomía). La hemorragia posoperatoria fue significativamente mayor en la esternotomía. No hubo diferencia estadística cuando se compararon las complicaciones y la mortalidad. CONCLUSIONES. La vía de abordaje por toracotomía para la revascularización miocárdica es una técnica alternativa, efectiva y segura. Observamos que es posible realizar una revascularización miocárdica completa sin comprometer la seguridad del procedimiento y la calidad de las anastomosis. Los costos son algo menores por esta vía que por la habitual, e igualmente son significativos los resultados en cuanto a estadía hospitalaria y uso de hemoderivados, por lo cual proponemos continuar trabajando en la estabilización de esta nueva vía de cirugía coronaria en nuestro servicio(AU)

INTRODUCTION.The objective of present paper was to expose and to compare the results from two-ways different approaches (left anterior thoracotomy and longitudinal medium sternotomy) for myocardial revascularization with the heart beating carried out in the Hermanos Ameijeiras Clinical Surgical Hospital between September, 2007 (when this technique was introduced by thoracotomy ) and January, 2008. METHODS. A longitudinal, descriptive and prospective study was conducted to compare the results depending on the surgical approach for minimally invasive myocardial revascularization: usual route, by longitudinal medium sternotomy (29 operated on, 65,9 percent) and the new rout and unusual by left anterior thoracotomy (15 operated on, 34,1 percent). RESULTS. The average of shunts carried out was of 3,31 by sternotomy and of 3 by thoracotomy. The 96,6 and the 26,7 percent of operated on sternotomy and thoracotomy, respectively need blood transfusions which was statistically significant. The use of inotropic drugs and of intra-aortic balloon counterpulsation hasn't statistical significance.The usual surgical time in both techniques was of 5 to 7 h, whereas the intubation was greater in patients operated on using sternotomy (11-14 h versus 3-6 h in the thoracotomy). The hospital stay was greater in the cases of sternotomy ( 3-4 days versus 1-2 days in those of sternotomy. There weren't statistical difference when complications and mortality were compared. CONCLUSIONS. The approach route using thoratocomy for myocardial revascularization is a alternative, effective and safe technique. It is possible to carry out a complete myocardial revascularization without compromising the procedure safe and he anastomoses quality. The costs are less using this route than with the usual one and the results are similarly significant as regards hospital stay and the use of hemoderivatives, thus, authors propose to continue working in the stabilization of this new route or coronary surgery in our service(AU)

Treating atrial fibrillation in beating heart during surgery using bipolar radiofrequency ablation system / 中国综合临床

Objective To investigate the feasibility and efficacy of treating atrial fibrillation(AF)in beating heart surgery using bipolar Radiofrequency Ablation(RFA)system. Methods Treating AF in beating heart under normal temperature CBP surgery with bipolar RFA following the circuit of maze operation,2 - 6 times each place,until sinus rhythm appeared,then perform AVR or MVR in the stopped beating heart. Results All 18 cases survived the surgery. Sinus rhythm appeared in all cases. The average treating time was 28 minutes. Conclusions Application of bipolar RFA in the treatment of AF in beating heart is a safe and efficacy method. It is recommended to be applied widely.

A Cervical Epidural Block Combined with Light General Anesthesia in Takayasu's Arteritis: A case report / 대한마취과학회지

Takayasu's arteritis is a chronic and occlusive inflammatory disease of uncertain etiology affecting medium to large sized arteries. We anesthetized a patient who had Takayasu's arteritis affecting both common carotid arteries, the left anterior descending coronary artery, and the left subclavian artery. During beating heart coronary artery bypass graft and aorto-carotid bypass graft we chose a cervical epidural block combined with light general anesthesia as an anesthetic technique. We managed the patient successfully with consistant hemodynamic stability. The operation was done without cardiopulmonary bypass and the patient was returned to consciousness immediately after the end of the operation. We extubated the endotracheal tube in the operating room without pain. The patient maintained hemodynamic stability in the intensive care unit and we controlled the pain via a cervical epidural catheter with morphine and 0.1% bupivacaine.