• Chanaka Rajakaruna, Chris Rogers, Katie Pike, Hazaim Alwair, Alan Cohen, Sally Tomkins, Gianni D Angelini, and Massimo Caputo.
• Section of Cardiac Surgery, Yale School of Medicine, New Haven, CT, USA.
• Interact Cardiovasc Thorac Surg. 2013 May 1;16(5):602-7.

ObjectivesOff-pump coronary artery bypass (OPCAB) surgery is a technically more demanding strategy of myocardial revascularization compared with the standard on-pump technique. Thoracic epidural anaesthesia, by reducing sympathetic stress, may ameliorate the haemodynamic changes occurring during OPCAB surgery. The aim of this randomized controlled trial was to evaluate the impact of thoracic epidural anaesthesia on intraoperative haemodynamics in patients undergoing OPCAB surgery.MethodsTwo hundred and twenty-six patients were randomized to either general anaesthesia plus epidural (GAE) (n = 109) or general anaesthesia (GA) only (n = 117). Mean arterial blood pressure (MAP), heart rate (HR) and central venous pressure (CVP) were measured before sternotomy and subsequently after positioning the heart for each distal anastomosis.ResultsBoth groups were well balanced with respect to baseline characteristics and received a standardized anaesthesia. The MAP decreased in both groups with no significant difference (mean difference (GAE minus GA) -1.11, 95% CI -3.06 to 0.84, P = 0.26). The HR increased in both groups after sternotomy but was significantly less in the GAE group (mean difference (GAE minus GA) -4.29, 95% CI -7.10 to -1.48, P = 0.003). The CVP also increased in both groups after sternotomy, but the difference between the groups varied over time (P = 0.05). A difference was observed at the third anastomosis when the heart was in position for the revascularization of the circumflex artery (mean difference (GAE minus GA) +2.09, 95% CI 0.21-3.96, P = 0.03), but not at other time points. The incidence of new arrhythmias was also significantly lower in the GAE compared with the GA group (OR = 0.41, 95% CI 0.22-0.78, P = 0.01).ConclusionThoracic epidural with general anaesthesia minimizes the intraoperative haemodynamic changes that occur during heart positioning and stabilization for distal coronary anastomosis in OPCAB surgery.

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