Table Of ContentMedical
Intelligence
Unit
Off Pump Coronary
Artery Bypass Surgery
Raymond Cartier, M.D.
Professor of Surgery
University of Montreal
Department of Cardiac Surgery
Montreal Heart Institute
Montreal, Quebec, Canada
Boca Raton London New York
CRC Press is an imprint of the
Taylor & Francis Group, an informa business
OFF PUMP CoRONARY ARrnRY BYPASS SuRGERY
Medical Intelligence Unit
First published 2005 by Landes Bioscience
Published 2018 by CRC Press
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© 2005 by Taylor & Francis Group, LLC
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ISBN 13: 978-1-58706-075-5 (hbk)
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Library of Congress Cataloging-in-Publication Data
Off pump coronary artery bypass surgery I [edited by] Raymond Cartier.
p. ; em.-- (Medical intelligence unit)
Includes bibliographical references and index.
ISBN 1-58706-075-2
I. Coronary artery bypass. I. Cartier, Raymond, 1955-II. Series: Medical intelligence unit (Unnum-
bered : 2003)
[DNLM: I. Coronary Artery Bypass. WG 169 0317 2004]
RD598.35.C67037 2004
617.4' 12--dc22
2004026259
A mon frere Paul, pour ce quil m'a appris et permis d'apprendre.
To my brother Paul, for what he taught me and allowed me to learn.
Tay or & Francis
Taylor &Francis Group
http://taylorandfrancis.com
CONTENTS
Preface................................................................................................................xi
Foreword..........................................................................................................xiii
1. Historical Considerations.................................................................................1
Raymond Cartier
2. Cardiopulmonary Bypass and Inflammation..............................................14
Frangois Dagenais
Pathophysiology of Cardiopulmonary Bypass..............................................14
Hemostasis.............................................................................................................15
Inflammatory Response Related to CPB...................................................... 15
Impact of the Inflammatory Response on Organ Function
after CPB........................................................................................................ 16
3. Potential Benefit of OPCAB Surgery..........................................................22
Marzia Leache and Raymond Cartier
Inflammatory Response and Oxidative Stress..............................................22
Myocardial Protection........................................................................................24
Pulmonary Physiology........................................................................................24
Brain Physiology.................................................................................................25
Renal Physiology.................................................................................................26
Hypercoagulability..............................................................................................26
Results of Randomized Studies........................................................................26
4. Principles of Stabilization and Hemodynamics in OPCAB Surgery.....31
Raymond Cartier
What Is the Surgeon Looking for?..................................................................31
Current Techniques............................................................................................31
Myocardial Mobilization and Hemodynamics.............................................32
Systolic and Diastolic Function during OPCAB Surgery..........................34
Adjunctive Techniques.......................................................................................35
5. Anesthetic Management for OPCAB..........................................................40
Patrick Limoges, Robert Blain and Peter Sheridan
Pre-Operative Period..........................................................................................40
Premedication......................................................................................................41
Intra-Operative Period.......................................................................................41
Monitoring the OPCAB Patient......................................................................41
Prevention of Hypothermia..............................................................................42
Induction of Anesthesia.....................................................................................42
Hemodynamic Management............................................................................43
Hemodynamic Management Related to Specific Territories
of Revascularization........................................................................................43
Blood Salvaging Strategies.................................................................................45
Fluid Replacement..............................................................................................45
Immediate Post-Operative Period...................................................................46
Post-Operative Analgesia...................................................................................46
6. Indications and Surgical Strategies
for OPCAB.......................................................................................................49
Nicolas Diirrleman and Raymond Cartier
Approaching the Left Anterior Descending Artery (LAD)
and Diagonal Artery.......................................................................................49
Approaching the Posterior Descending Artery (PDA)................................51
Approaching the Right Coronary Artery (RCA).........................................52
Approaching the Obtuse Marginal Artery (OMA)......................................52
Coronary Artery Anastomosis...........................................................................52
Surgical Strategies.................................................................................................55
Special Situations.................................................................................................56
Blood-Saving Strategy........................................................................................58
7. Effects of Vascular-Interrupting and Hemostatic Devices
on Coronary Artery Endothelial Function in Beating
Heart Coronary Artery Bypass Surgery.......................................................63
Roland G. Demaria and Louis P. Perrault
Hemostatic Devices and the Endothelium....................................................64
Clinical Studies....................................................................................................67
8. Systematic OPCAB Surgery for Multivessel Disease
with the CoroN^o Cor-Vasc Device............................................................71
Raymond Cartier
Patient Population...............................................................................................71
The OPCAB Surgical Technique....................................................................71
Surgical Strategies................................................................................................73
Anesthetic Management....................................................................................73
Inflow Maneuver..................................................................................................73
The CPB Surgical Technique...........................................................................73
Statistics.................................................................................................................73
Results.....................................................................................................................74
9. Understanding the Mechanisms of Hemodynamic
and Echocardiographic Changes during OPCAB Surgery.......................82
Pierre Couture, Andri Denault, Patrick Limoges, Peter Sheridan
and Denis Babin
Hemodynamic Changes after Mobilization and Stabilization.................83
Monitoring Myocardial Ischemia....................................................................90
10. Cerebral Complications Following Coronary Artery Bypass
Grafting Surgery.............................................................................................97
Marzia Leache and Raymond Cartier
Classification Based on Cerebral Outcomes..................................................97
Predictive Factors..............................................................................................100
Mechanisms of Injury.......................................................................................100
Other Factors Influencing Neurological Outcome
after CABG Surgery.....................................................................................100
11. OPCAB Surgery in High Risk-Patients.....................................................110
Jehangir J. Appoo and Raymond Cartier
OPCAB in Patients with Impaired LVEF.................................................110
OPCAB in Patients Undergoing Reop Surgery..........................................Ill
OPCAB in the Elderly......................................................................................112
Risk Adjusted Comparison Between OPCAB and CCAB ................... 113
Intra-Aortic Balloon Pump in High-Risk OPCAB Patients................. 114
OPCAB Surgery in Acute Coronary Artery Syndrome (ACS).............115
12. Pitfalls in Off-Pump Coronary Artery Bypass Surgery...........................119
Nicolas Durrleman and Raymond Cartier
The Enlarged Aorta......................................................................................... 119
The Occluded Vessel........................................................................................121
The Dominant Right Coronary Artery (RCA)...........................................122
The Dominant Left Main................................................................................122
Ischemic Mitral Insufficiency (IMI) .............................................................122
Mobilization Techniques and Myocardial Injuries.................................. 124
Graft Patency......................................................................................................124
Hemodynamic Instability and Acute Conversion.....................................125
Post-Operative Thromboembolic Complications.....................................125
Training...............................................................................................................126
13. Sutureless Coronary Artery Bypass Grafting:
Experimental and Clinical Progress............................................................130
Kenton J. Zehr
Historical Perspective and Impetus for the Development
of Mechanical Anastomoses...................................................................... 130
The Evolution of a Sutureless System for Anastomoses...........................132
Current Status of Other Facilitated Techniques..................................... 141
14. The Future of Coronary Artery Surgery: Quo Vadimus?.......................147
Ray C.'J. Chiu
Index................................................................................................................151
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EDITOR
Raymond Cartier, M.D.
Professor of Surgery
University of Montreal
Department of Cardiac Surgery
Montreal Heart Institute
Montreal, Quebec, Canada
Chapters 1, 3, 4, 6, 8, 10-12
CONTRIBUTORS
Jehangir J. Appoo, M.D. Fran$ois Dagenais, M.D.
University of Alberta Assistant Professor of Surgery
Division of Cardiac Surgery Laval University
University of Alberta Hospital Division of Cardiac Surgery
Edmonton, Alberta, Canada Laval Hospital
Chapter 11 Quebec City, Quebec, Canada
Chapter 2
Denis Babin, M.S.C., R.T.
University of Montreal Roland G. Demaria, M.D.
Department of Anaesthesiology Assistant Professor of Surgery
Montreal Heart Institute University of Montpellier
Montreal, Quebec, Canada Department of Cardiovascular Surgery
Chapter 9 Arnaud de Villeneuve Hospital
Montpellier, France
Robert Blain, M.D. Chapter 7
Assistant Professor of Anaesthesiology
University of Montreal Andr^ Denault, M.D.
Department of Anaesthesiology Associate Professor of Anaesthesiology
Montreal Heart Institute University of Montreal
Montreal, Qu£bec, Canada Department of Anaesthesiology
Chapter 5 Montreal Heart Institute
Montreal, Quebec, Canada
Ray C.-J· Chiu, M.D. Chapter 9
Professor of Surgery
McGill University Nicolas Diirrleman, M.D.
Division of Cardiovascular Surgery Assistant Professor of Surgery
Montreal General Hospital University of Montpellier
Montreal, Quebec, Canada Department of Cardiovascular Surgery
Chapter 14 Arnaud de Villeneuve Hospital
Montpellier, France
Pierre Couture, M.D. Chapters 6, 12
Assistant Professor of Anaesthesiology
University of Montreal
Department of Anaesthesiology
Montreal Heart Institute
Montreal, Quebec, Canada
Chapter 9
