The heart surgery forum
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The heart surgery forum · Jan 2002
Comparative StudyEarly- and long-term comparison of the on- and off-pump bypass surgery in patients with left ventricular dysfunction.
The adverse effects of extracorporeal circulation increase the morbidity and mortality risk of coronary bypass surgery, especially in patients with left ventricular dysfunction. The purpose of this study was to provide a comparison of the early and long-term outcome between patient groups with left ventricular dysfunction (LVEF<40% or LVPS>or=15) operated with or without using cardiopulmonary bypass. ⋯ In spite of more than four times as many patients in the cardiopulmonary bypass group requiring inotropic support after surgery, survival and cardiac death rates were similar for both groups. Off-pump bypass surgery conserves the blood constituents. The benefits of both techniques to improve the left ventricular performance score and ejection fraction were similar, but postoperative extubation time, length of intensive care unit and hospital stay were reduced significantly in the beating heart group. With these good results of the beating heart coronary bypass surgery and considering its cost effectiveness, we concluded that coronary bypass on a beating heart can be an alternative to cardiopulmonary bypass technique in selective patient groups.
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The heart surgery forum · Jan 2002
Aortic and mitral valve surgery on the beating heart is lowering cardiopulmonary bypass and aortic cross clamp time.
The concept of cardiac surgery on the beating heart is acceptable rationale for the cardiac surgery in the next millenium. Beating heart (off-pump) coronary artery bypass grafting (CABG) techniques have led us to consider the possibility for performing the aortic and mitral valve surgery (mitral valve repairs and replacements - with or without CABG) on the beating heart with the technique of retrograde oxygenated coronary sinus perfusion. ⋯ We conclude that beating heart valve surgery (any combination) with or without CABG significantly lower the cardiopulmonary bypass and aortic cross clamp time. In addition, the advantages of beating-heart surgery are 1) the perfused myocardial muscle, 2) the heart is not doing any work, 3) no reperfusion injury, 4) the possibility for ablation of atrial fibrillation on the beating heart, and 5) testing of the mitral valve repair is done in real physiologic conditions in the state of left ventricle beating tonus. The procedure could be the procedure of choice for the valve operation or combined operations (valve operation and CABG) in high-risk patients with low ejection fractions. There is no doubt that at present day in cardiac surgery exist at least two major factors for mortality and morbidity after cardiac surgery, which are operation - related, namely cardiopulmonary bypass time and its duration and aortic cross clamp time (ischemic time of myocardium). In the last few years a number of different techniques emerged in the field of cardiac surgery, which were directed toward better results in the selected high risk patients or to minimize the deleterious effects of cardiopulmonary bypass (CPB) on the overall postoperative performance [Calafiore 1996, Tasdemir 1998]. Due to the fact, that the cardiac muscle should be protected at most during the cardiac arrest, retrograde blood cardioplegia was successfully introduced [Buckberg 1990], and more - the warm cardioplegia is being used recently [Kawasuji 1997]. The natural status of the human heart is the beating status, so it is reasonable to try to perform the operations on the beating heart. This has been done recently with the MID - CAB and OP - CAB (off-pump CABG) operations [Tasdemir 1998]. The retrograde warm blood cardioplegia has therefore led us to the premise, that with retrograde oxygenated blood perfusion it would be possible to achieve the operations on the beating heart even in the open heart surgery, such as aortic and/or mitral valve surgery. All will agree that the most damaging effect of the cardioplegia is the reperfusion injury [Allen 1997], and it is obvious that with the technique of retrograde continuous oxygenated blood perfusion this effect will be canceled. In this article, we would like to show the how-to technique for the operations on the beating heart in the case of operations on the aortic valve replacement (AVR) with mitral valve repair (MVR) or replacement MVR and with/without concomitant coronary artery bypass (CABG) surgery. The tricuspid valve repair (PTV) is normally done on the beating heart and there it is realized what problems or technical difficulties may arise during procedures on the mitral valve: the walls of the ventricles are not flattened and the exposure of the mitral valve is challenging task. Furthermore, the free walls of the ventricles with interventricular septum are in the state of the tonus, so every force applied to better expose the aortic or mitral valve is not acceptable
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The heart surgery forum · Jan 2002
Multiple off-pump coronary revascularization with "aorta no-touch " technique using composite and sequential methods.
Although off-pump coronary artery bypass grafting (OPCAB) has been widely applied in patients who are considered high risk for cardiopulmonary bypass (CPB), there is still a risk of stroke during the operation because of the ascending aortic partial clamp for proximal anastomosis. In the present study, we report the initial results of an "aorta no-touch " technique using an in-situ graft and composite and sequential grafting methods. ⋯ OPCAB performed with the aorta no-touch technique using an in-situ graft and composite and sequential grafting methods provides excellent early clinical results and graft patency.
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The heart surgery forum · Jan 2002
Total arterial off-pump coronary revascularization with only internal thoracic artery and composite radial artery grafts.
Total arterial off-pump coronary artery bypass (OPCAB) grafting with only internal thoracic artery (ITA) and composite radial artery (RA) grafts has been applied extensively to avoid cerebral complications and late vein graft failure. We evaluated the initial experience with this method by clinical and angiographic study. ⋯ OPCAB grafting with ITAs and composite RAs provides excellent early and intermediate clinical results and graft patency.
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The heart surgery forum · Jan 2002
Cardiac surgery in patients with heparin-induced thrombocytopenia using preoperatively determined dosages of iloprost.
Patients with preoperatively diagnosed type II heparin-induced thrombocytopenia (HIT) scheduled for cardiopulmonary bypass (CPB) present a challenge in their intraoperative anticoagulation management because re-exposure to heparin may result in profound thrombocytopenia, intravascular thromboses, bleeding, and even death. Iloprost, a prostacyclin analogue that reversibly inhibits platelet aggregation, has been suggested as a management approach in such cases. The purpose of this study was to assess and confirm the efficacy of a perioperative intravenous iloprost infusion in preventing thromboembolic complications in patients with type II HIT undergoing cardiac surgery and requiring the use of heparin and CPB. ⋯ Although a number of alternative anticoagulation methods, such as the use of another anticoagulant (danaparoid sodium and recombinant hirudin) or the preoperative use of a defibrinogenating agent (ancorod), have been suggested for patients with type II HIT requiring anticoagulation during CPB, the use of heparin associated with a potent platelet inhibitor such as the prostacyclin analog iloprost is, as this study confirmed, the only to-date safe and effective choice.