title: Occlusion versus shunting during MIDCAB: effects on left ventricular function and quality of anastomosis.
abstract: BACKGROUND
  Minimally invasive direct coronary artery bypass is an established clinical procedure for revascularization of the left anterior descending coronary artery. Mechanical stabilization and temporary occlusion is currently used to perform the anastomosis of the internal thoracic artery to the left anterior descending coronary artery. However, critical reduction of cardiac function can occur as a result of temporary ischemia. The purpose of this study was to evaluate whether ischemic sequelae can be avoided by using temporary intraluminal shunts and whether this alters early outcome.
  
  
  METHODS
  Thirty-five patients underwent minimally invasive direct coronary artery bypass revascularization using a mechanical stabilizer. In group A (n = 20), the anastomotic site was temporarily occluded by tourniquets. In group B (n = 15), temporary intraluminal shunts were inserted into the anastomotic site without any occlusion of the left anterior descending coronary artery. Anastomosis of the internal thoracic artery to the left anterior descending coronary artery was performed in an identical fashion. A Swan-Ganz catheter was inserted, and transesophageal echocardiographic measurements were obtained for analysis of left ventricular (LV) function. Regional wall motion, cardiac index, stroke volume index, systolic and diastolic LV diameters, and fractional area change were measured during four periods: at the start of the operation (baseline), placement of the stabilizer (stabilization), left anterior descending coronary artery occlusion (occlusion) or insertion of temporary intraluminal shunts (shunt), and 30 minutes after reperfusion (reperfusion). Angiograms were obtained 4 to 6 days postoperatively.
  
  
  RESULTS
  In group A, LV performance, cardiac index, stroke volume index, and fractional area change decreased during occlusion whereas systolic diameters increased. Almost two myocardial segments per patient developed severe hypokinesia in the perfusion area. These changes disappeared after 30 minutes of reperfusion, with increased LV function. In group B, LV function remained stable whereas hypokinetic wall motion was only detected in 2 patients. Early angiograms revealed 90% of the grafts were patent in group A versus 100% in group B. The need for percutaneous intervention during the first 6 months was 20% in group A versus 6.7% in group B.
  
  
  CONCLUSIONS
  The use of temporary intraluminal shunts resulted in reduced acute ischemia and revealed wall motion abnormalities and maintained LV function. Furthermore, this technique suggests an improvement of early graft patency and a lower reintervention rate within the first 6 postoperative months. Thus, use of temporary intraluminal shunts appears to be superior to the occlusion technique early after minimally invasive direct coronary artery bypass procedures.
authors.affiliation: Department of Thoracic, Cardiac and Vascular Surgery, Eberhard-Karls-University, Tübingen, Germany. asmenon@med.uni-tuebingen.de
authors.forename: Ares K
authors.initials: AK
authors.lastname: Menon
authors.forename: Johannes M
authors.initials: JM
authors.lastname: Albes
authors.forename: Martin
authors.initials: M
authors.lastname: Oberhoff
authors.forename: Karl R
authors.initials: KR
authors.lastname: Karsch
authors.forename: Gerhard
authors.initials: G
authors.lastname: Ziemer
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical / Q000379:methods*; D002315:Cardiopulmonary Bypass; D001026:Coronary Artery Bypass / Q000379:methods*; D003324:Coronary Artery Disease / Q000601:surgery*; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000503:physiopathology / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D009200:Myocardial Contraction / Q000502:physiology; D017202:Myocardial Ischemia / Q000503:physiopathology / Q000517:prevention & control*; D010043:Outcome and Process Assessment, Health Care; D012189:Retrospective Studies; D016277:Ventricular Function, Left / Q000502:physiology*