G. Michelsen, MD
Emory University School
of Medicine, Atlanta, Georgia
of Beating Heart Surgery
Beating heart surgery is
characterized by the avoidance of cardiopulmonary bypass (CPB) and includes:
- OPCAB ("Off-Pump"
- MIDCAB (Minimally
Invasive Direct-Vision CAB)
Why Move From
Conventional CABG to Beating Heart?
CPB is one of cardiac surgery's
most important developments. CPB has made it possible for surgeons to
perform coronary revascularization on a still and bloodless heart. This
ability has allowed coronary revascularization to become an established
procedure that offers tremendous long-term patency rates and low mortality.
However, stopping the heart and temporarily replacing its functions
with the heart-lung machine has risks associated with it.2,3
Eighty-one percent (81%) of the surgeons polled at the 1997 CTT meeting
agreed that the elimination of CPB, rather than reduced incision size,
is the most critical issue in reducing the invasiveness of cardiac surgery.4
of Beating Heart Surgery
- 1. Beating Heart CAB
- Beating heart surgery
has been performed for years, particularly in South America, where
economic constraints (oxygenator considered cost-prohibitive) forced
the surgeons to perform many cases off-bypass. Bennetti and Buffolo
(Argentina and Brazil, respectively) have accumulated a large number
of beating heart cases and have shown that not only is it possible
to perform beating heart CABG, but it is also possible to perform
it effectively and at a reduced cost to the patient.5,6
- 2. Alternative Care.
- Cardiology techniques
and therapies (angioplasty, stents and drugs) continue to improve,
giving the cardiologist non-surgical alternatives for patient treatment.
Surgeons are finding they must compete by offering an improvement
on their "best technique"; a left internal mammary artery
(LIMA) graft to the left anterior descending coronary artery (LAD).
With beating heart surgery they can combine results (long-term patency)
with a quicker return of the patient to his normal activities and
perhaps even a smaller scar (in the case of MIDCAB).
- 3. Morbidity of Conventional
- In addition to the morbidity
related to myocardial infarction (MI), particularly alarming is the
high incidence of neurological dysfunction. The occurrence of strokes
and neuropsychological dysfunction are very disabling for the patient
and are costly to the healthcare system.
|Figure 1. Conventional CABG: Morbidity (MI
Ð Myocardial Infarction; CVA Ð cerebrovascular accident; NPD Ð neuropsychological
dysfunction; ARF Ð acute renal failure)
to Beating Heart Surgery
There are several advantages
to beating heart surgery from the anesthesiologist's perspective:
- The patient is extubated
early, is not severely anemic, is awake and breathing on his/her own.
- There are no cannulation
sites in large vessels which can potentially bleed.
- Less hemodilution.
- Coagulopathies are uncommon.