Assessment of cardiac autonomic regulation and ventricular repolarization after off-pump coronary artery bypass grafting.
BACKGROUND
Altered autonomic regulation precipitates cardiac arrhythmias and increases the risk of sudden cardiac death. This risk is further increased by changes in ventricular repolarization. Autonomic regulation is deranged in patients after myocardial on-pump revascularization. We aimed to clarify how off-pump coronary artery bypass grafting (CABG) affects postoperative cardiac autonomic regulation and ventricular repolarization within 4 weeks after CABG.


METHODS
Forty-two patients (mean age, 61.9 +/- 9.3 years; mean EURO score 2.6 +/- 1.9) were electively admitted for off-pump CABG. The electrocardiographic and respiratory waveform recordings were performed in the afternoon in the supine position for 10 minutes. Autonomic modulation was assessed using heart rate variability analysis. Power spectra were computed from 5-minute stable RR intervals using Fourier Transform analysis. Total power of spectra was defined in the range of 0.01 to 0.40 Hz, high-frequency power within 0.15 to 0.40 Hz, and low-frequency power within 0.04 to 0.15 Hz. Normalized power was defined as a ratio of power in each band/total power. The high- and low-frequency power as well as their normalized values indicated cardiac vagal and sympathetic modulation, respectively. Ventricular repolarization was assessed using QT interval, QT interval variability, and QT-RR interdependence analysis. QT intervals were determined from the beginning of the 5-minute segments. QT interval variability was evaluated by a T-wave template-matching algorithm. Pearson correlation between length of RR and QT interval was applied to study QT-RR characteristics. The results were tested for significance using the Fisher exact test, nonpaired t test, and analysis of variance; a P <.05 was considered significant.


RESULTS
The frequency of arrhythmic events and heart rate increased from the fourth to the seventh postoperative day and returned to preoperative levels 4 weeks after CABG. Heart rate variability measures indicating autonomic modulation remained depressed even 4 weeks after the procedure. QT variability index increased from -1.2 +/- 0.5 to -0.8 +/- 0.4 on the fourth day after the operation (P <.05) and returned to -1.0 +/- 0.5 4 weeks after CABG (P = not significant). QT-RR correlation decreased from 0.41 to 0.23 (P <.05) and remained significantly impaired as long as 4 weeks after CABG.


CONCLUSIONS
Observed faster heart rates until 1 week after off-pump CABG imply excessive adrenergic activation, which is comparable to on-pump CABG procedure rates. The results indicate profound autonomic derangement and loss of rate-dependent regulation after off-pump CABG even 4 weeks after operation. Restituted repolarization as assessed by QT variability index 4 weeks postoperatively corresponded with decreased frequency of rhythm disturbances 4 weeks after CABG. The loss of coupling between QT and RR intervals shows increased electrical instability postoperatively, which may serve as an additional promoter for postoperative arrhythmias, especially at higher heart rates.
Kalisnik
Jurij M
JM
Department of Cardiovascular Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia. jurij-matija.kalisnik@mf.uni-lj.si
Avbelj
Viktor
V
Trobec
Roman
R
Ivaskovic
Daroslav
D
Vidmar
Gaj
G
Troise
Giovanni
G
Gersak
Borut
B
D000368:Aged; D001145:Arrhythmias, Cardiac / Q000209:etiology / Q000503:physiopathology*; D001341:Autonomic Nervous System / Q000503:physiopathology*; D001342:Autonomic Nervous System Diseases / Q000209:etiology / Q000503:physiopathology*; D047549:Coronary Artery Bypass, Off-Pump / Q000009:adverse effects*; D005260:Female; D006329:Heart Conduction System / Q000503:physiopathology*; D006339:Heart Rate; D006352:Heart Ventricles / Q000503:physiopathology*; D006487:Hemostasis; D006801:Humans; D008297:Male