A prospective randomized study to evaluate splanchnic hypoxia during beating-heart and conventional coronary revascularization.
OBJECTIVE
Cardiopulmonary bypass (CPB) is associated with gut mucosal hypoxia, which may contribute to gastrointestinal complications. We examined gastric mucosal oxygenation together with whole-body oxygen flux in low-risk patients undergoing coronary artery bypass grafting (CABG) with and without CPB.


METHODS
Fifty-four patients undergoing primary CABG by the same surgeon were randomized into either on-pump (ONCAB, n=27) or off-pump (OPCAB, n=27) groups. The ONCAB group underwent mild hypothermic (35 degrees C) pulsatile CPB with arterial line filtration. Each patient underwent perioperative monitoring with continuous tonometry and cardiac output devices. Gastric intramucosal pH (pHi), gastric-arterial carbon dioxide partial pressure difference (CO(2) gap), whole-body oxygen delivery (DO(2)) and consumption (VO(2)) and whole-body oxygen extraction fraction were measured at sequential time-points intraoperatively and up to 6 h postoperatively. Anaesthetic management was standardized.


RESULTS
Both groups had similar demographic makeup and extent of revascularization (ONCAB 2.6+/-0.9 grafts versus OPCAB 2.5+/-0.8 grafts; P=0.55). The ONCAB group had a mean (+/-SD) CPB time of 62+/-25 min and aortic cross-clamp time of 32+/-11 min. In both groups there was a similar and progressive drop in pHi intraoperatively. Postoperatively, there was a gradual separation between the groups with ONCAB patients showing no further decline in pHi, while further deterioration was observed in the OPCAB group up to 6 h postoperatively. There was a significant difference between the groups over time (P=0.03). There was a corresponding progressive rise in CO(2) gap perioperatively in both groups, with ONCAB patients demonstrating superior preservation of gastric mucosal oxygenation in the early postoperative period. Global oxygen utilization measurements showed superior DO(2) and VO(2) in the OPCAB group throughout the study.


CONCLUSIONS
Despite superior global oxygen flux associated with beating-heart revascularization, gastric mucosal hypoxia occurred to similar extents in both groups with worsening trends for the OPCAB patients postoperatively. The splanchnic pathophysiology during beating-heart revascularization should be further explored.
Velissaris
Theodore
T
Department of Cardiac Surgery, Wessex Cardiothoracic Centre, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK. theo@velissaris.com
Tang
Augustine
A
Murray
Matthew
M
El-Minshawy
Ahmed
A
Hett
David
D
Ohri
Sunil
S
D000368:Aged; D000704:Analysis of Variance; D002315:Cardiopulmonary Bypass; D001026:Coronary Artery Bypass; D003327:Coronary Disease / Q000378:metabolism / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D005753:Gastric Mucosa / Q000098:blood supply*; D006801:Humans; D000860:Hypoxia / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D010100:Oxygen / Q000378:metabolism; D011446:Prospective Studies; D011673:Pulsatile Flow; D016896:Treatment Outcome
D010100:Oxygen