Superior outcomes in patients undergoing surgery with a minimized extracorporeal
circulation compared to off pump revascularization
Thorsten Wittwer, Anton Sabashnikov, Yeong-Hoon Choi, Parwis Rahmanian, Mohammed Zeriouh, Thorsten Wahlers.
Heart Center, University Hospital of Cologne, Cologne, Germany.
Conventional coronary artery bypass grafting (CABG) with extracorporeal circulation (ECC) is associated with adverse effects as systemic inflammatory response (SIRS) leading to decreased systemic vascular resistance (SVR) and hemodynamic instability. Owing to the technical improvements in the past decades modern “less invasive” methods of minimized on-pump approaches and off-pump-coronary-artery-bypass (OPCAB) procedures have been established who can potentially avoid the negative side effects of ECC. The aim of this study was to compare both less invasive approaches focusing on perioperative outcome particularly with regard to hemodynamic characteristics.
In this prospective randomized clinical trial 120 patients referred for CABG were assigned either to OPCAB- or to ECC-procedure with utilization of a minimized circuit (Mini-HLM, ROCsafeTM). Patient demographics, preoperative characteristics and postoperative outcome were analyzed. Hemodynamic data (cardiac index, central venous saturation, central venous pressure, pulmonary capillary wedge pressure, pulmonary and systemic vascular resistance and arterial pressure) were measured at seven time points perioperatively.
Mean age was 65,6 ± 10,8 years, and 18,3 % of patients were female. There were no differences regarding preoperative morbidities between the two groups. The operating time was significantly longer in the Mini-HLM group (178,3 ± 32,9) compared to the OPCAB group (133,2 ± 32,7, p< 0,001) with a significant higher number of grafts in the Mini-HLM group (3,11 ± 0,7 vs. 1,78 ± 0,7, p< 0.001). There were no significant differences in perioperative hemodynamic criteria inotropic support, hospital (p=0,534) and intensive care unit stay (p=0,88), ventilation time (p=0,113), blood loss (p=0,57), transfusion requirements, postoperative atrial fibrillation rate (p=0,706) and neurocognitive disturbance (p=0,297). There were no deaths and no myocardial infarctions observed in both groups.
Conceptional advantages of minimized ECC systems result in perioperative hemodynamics and clinical outcome completely comparable to OPCAB procedures. As an advantage, Mini-HLM combines all OPCAB-benefits with low morbidity and mortality while allowing for more complete revascularization. Therefore, particularly in patients with complex multivessel disease the use of the Mini-HLM may help to improve functional outcome. However, larger clinical series are necessary to validate these preliminary results.
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