Anaesthesia for Off-pump Coronary Artery Bypass Surgery Virin.

Sidhu FRCP FRCA Consultant in Anaesthesia and Intensive Care. Sri. Varaday FRCA Specialist Registrar in Anaesthesia Abstract Despite the developments in cardiopulmonary bypass (CPB) equipment and technique, CABG surgery performed on CPB may be associated with deleterious effects. This has renewed interest in Off-pump CABG (OPCAB) surgery. The development of mechanical stabilizers and using a median sternotomy allows grafting of multiple vessels. A balanced anaesthetic technique of moderate dose of opioids, propofol and volatile agents (sevoflurane or isoflurane ) is usual. The use of TOE monitoring is common and mixed venous oxygenation is useful. OPCAB grafting may be associated with ischaemia and major haemodynamic instability when the heart is displaced during grafting of the inferior, lateral and especially, the posterior aspect of the heart. Specific advantages of the technique include a reduction in blood loss and transfusion requirements, shorter period of ventilation, ICU stay and potential cost-saving. Pulmonary function appears to be better and the incidence post-operative cognitive function appears to be better at least in the shortterm. Advantages in terms of renal function and the incidence of stroke are not as yet universally accepted. The technique may be unsuitable in patients with poor ventricular function requiring multiple grafts and in patients with certain patterns of coronary disease. The procedure is technically demanding for the surgeon and OPCAB performed in low volume centres is associated with a greater mortality. Early graft patency and outcome is at least equivalent although, the long term remains uncertain. The main advantage of the technique is likely to be in the high risk patient with significant co-morbidities. Keywords: anaesthesia , cardiac, off-pump coronary artery bypass; monitoring, transoesophageal echocardiography. Off-pump coronary artery bypass (OPCAB) surgery is performed on a beating heart without the use of cardiopulmonary bypass. The first work relating to coronary artery bypass graft on a beating heart was carried out in 1910 by Carrel, and the first successful surgery using cardio pulmonary bypass was performed in 1953 by Gibbon. The initial morbidity and mortality on cardiopulmonary bypass was high, allowing the development of coronary artery surgery without it. In 1967, Kolessov reported a series of six cases in which the internal mammary artery was anastomosed to the left anterior descending artery on the beating heart. With the development of bubble oxygenators and cardioplegia in the late 1960s, coronary artery surgery performed on cardiopulmonary bypass became the technique of choice. Despite developments in cardiopulmonary equipment design and technique, it was still associated with some deleterious effects. In 1996, Calafiore introduced minimally invasive direct coronary artery bypass surgery (MIDCAB) through a left anterior short thoracotomy incision or mini-sternotomy, which renewed interest in offpump surgery. This technique was improved by the use of stabilizers designed to immobilise a target area of the heart. However, its main limitation was that access

was limited to the left anterior descending and proximal right coronary arteries. This has resulted in an increase in popularity of OPCAB through a median sternotomy, allowing access to multiple vessels, the avoidance of one-lung ventilation (mandatory for MIDCAB) while retaining rapid access to cardiopulmonary bypass in difficult or failed procedures. OPCAB presents new challenges for the surgeon and anaesthetist. Exposure and stabilization of coronary arteries Complete revascularization of the heart by accessing all coronary territories requires adequate exposure and stabilization of target coronary arteries. The left anterior descending and proximal right coronary arteries are exposed with minimal cardiac displacement and haemodynamic compromise using surgical packs. The circumflex, diagonal, posterior descending artery and distal right coronary artery are more difficult to expose. The application of slings, pericardial sutures and the placement of surgical packs help to displace and elevate the heart anteriorly providing adequate exposure. A Trendelenburg tilt with rotation of the operating table to the right and opening the right pleura reduces haemodynamic compromise due to compression of the heart against the right pleura, while performing anastomosis on the posterior and lateral walls. Exposure of the posterior descending artery may require a steep Trendelenburg tilt, such that the apex of the heart is almost pointing towards the ceiling! In order to prevent bleeding from the open coronary artery during anastomosis, the target vessel is occluded with slings (or microvascular clamps). The resultant ischaemia is better tolerated if the technique of ischaemic preconditioning is used, whereby the target vessel is occluded for five minutes and then reperfused for three. This allows better tolerance of the more prolonged ischaemia during suturing and relates to better preservation of ATP levels, conferring myocardial protection. A humidified carbon dioxide blower is used to prevent blood obscuring the arteriotomy site. Alternatively and especially in patients with poor collateral blood supply intra-coronary shunts may be used to maintain perfusion, display the suture line and reduce back-bleeding. A double limb shunt is the most popular. Mechanical stabilizers have greatly contributed to the feasibility of beating heart surgery, allowing good quality anastomotic suturing. Stabilization of the target site is accomplished by using stabilizers such as the Octopus Systems (Medtronic, USA) (Figure 1a), which offer secure, stable access to all coronary arteries. Stabilization of the tissue at the grafting site is achieved by the flexible arm and turret-mounted design of the Octopus device. The malleable suction pods assure easy application, such that the site is lifted and not depressed, thus avoiding impairment of ventricular filling. In addition, the Star-Fish (Figure 1b) may be used to lift, position and hold the apex of the beating heart. Anaesthetic technique The most important anaesthetic considerations are the prevention of haemodynamic instability and ischaemia. The technique lends itself to early extubation and ambulation. Preoperative assessment should include a review of the angiogram and a discussion with the surgeon of the order of grafting. Adequate premedication is required and tachycardia avoided.

Operating room set up Early extubation requires the maintenance of normothermia. The operating room is kept warm (up to 24degree C.) to avoid radiant heat loss. The head should be covered with drapes. A warming mattress and fluid warmer are used. A forced-air warming blanket is used over the lower half of the body once the saphenous vein has been harvested. The heartlung machine and perfusionist should be available immediately, but it is usually unnecessary to have the machine primed. Facilities for defibrillation, cardiac pacing and intra-aortic balloon pump counterpulsation should also be available immediately. For multiple vessel OPCAB a cell saver reduces homologous blood transfusion. Monitoring Standard cardiac monitoring is used. The ECG may be distorted during cardiac displacement; in particular, the amplitude and ST segment changes may be reduced. Simultaneous monitoring of lead II and leads V4 & V5 increases the detection of ischemia. Automated ST segment trending is useful. Pulmonary artery pressure monitoring may be used in high-risk patients with severe left ventricular dysfunction. Continuous cardiac output monitoring is considered insensitive for routine use. The response time is too slow to detect sudden changes following manipulation and tilting of the heart; it is more useful as a trend monitor. Right atrial pressure (and pulmonary artery pressures) are distorted during tilting of the heart. Continuous monitoring of mixed venous oxygenation usefully detects abrupt changes in cardiac output and the adequacy of tissue oxygenation. TOE is useful in the detection of regional wall motion abnormalities (RWMA) and thus early ischaemic changes. During OPCAB, the heart is displaced or lifted and standard TOE views may be lost. The use of stabilizers may produce artefacts of RWMA. However, a baseline TOE allows their assessment with particular attention to the areas supplied by the vessel to be grafted. A TOE examination following the completion of the anastomosis allows RWMA to be re-checked. Persistent RWMA are of prognostic value for post-operative complications. Despite lifting the heart TOE views are often still interpretable and useful for evaluating diastolic function, mitral and tricuspid regurgitation that often occurs with heart elevation. TOE may detect the presence of a patent foramen ovale (and thus explain refractory hypoxemia should it supervene) and an intracavitatory thrombus. The latter is a contraindication to beating heart surgery. The morbidity from TOE is low (<0.2%) and it is now considered a valuable tool for monitoring and used almost routinely. Anaesthesia Induction and maintenance of anaesthesia are determined by local extubation protocols. A balanced anaesthetic technique using limited doses of opioids, volatile agents and propofol is popular. Isoflurane and sevoflurane have been shown to confer ischaemic preconditioning. A thoracic epidural anaesthetic technique (TEA) provides cardiac sympathectomy, attenuates the stress response, reduces anaesthetic requirements promotes early extubation and provides excellent postoperative analgesia. The risk of spinal haematoma formation can be reduced by siting the epidural catheter well before surgery. However, only in the context of early extubation has a combined TEA technique shown to have a better outcome than general anaesthesia alone.

The advent of stabilizers has made the induction of pharmacological bradycardia, originally used to provide a relatively immobile area less important, but tachycardia should be avoided. The serum potassium should be maintained at >4.5 mmol/litre. Magnesium sulphate prevents and treats atrial and ventricular arrhythmias during OPCAB surgery and can be infused following induction of anaesthesia, prior to opening of the pericardium. Partial heparinization (1-2 mg/kg) maintaining an activated clotting time of 250300 s, checked every 30 mins. Heparin is reversed as necessary with protamine. During proximal coronary anastomosis, arterial pressure should be reduced to 90 mm Hg to reduce the risk of aortic dissection on application of aortic side-biting clamps. Fluid input may be similar to an on-pump technique. Diuretics, in small doses, may be required to correct fluid balance. Management of haemodynamic instability The main causes of haemodynamic instability during OPCAB surgery are the impairment of venous return due to chamber compression and abnormal positioning; and pump failure due to direct ventricular compression and or ischaemia during occlusion of the target arteries. Mitral valve and tricuspid valve distortion can contribute significantly to haemodynamic instability, and cardiac displacement increases the risk of intraoperative arrhythmia. The extent of the haemodynamic compromise depends on the coronary artery being anastomosed, the greatest being the circumflex artery and its branches on the posterior aspect of the heart. It is therefore prudent to revascularize vessels on the anterior aspect of the heart (ie LIMA to LAD is usually first), before any lifting (PDA, distal RCA) or rotation (diagonal, circumflex) occurs. Changes in arterial pressure and cardiac output may occur rapidly with cardiac manipulation and the anaesthetist must pre-empt these to maintain haemodynamic stability. The use of the Trendelenburg position, optimizing preload, and the use of vasopressors, inotropes, or repositioning of the heart may improve cardiac output. Occlusion of the target coronary arteries during anastomosis of grafts may result in ischaemia and arrhythmias, including ventricular fibrillation. Occlusion of the proximal right coronary artery may lead to ischaemia of the atrioventricular node and complete heart block, pacing wires are necessary before arterial occlusion. If adequate haemodynamic parameters cannot be maintained it will be necessary to convert to an on pump technique . Good communication with the surgeon is mandatory. Advantages and disadvantages of OPCAB Advantages: off pump surgery avoids the complexity and may avoid some of the deleterious effects of cardiopulmonary bypass. This includes derangements in coagulation, a nd multiple-organ dysfunction occurring through a combination of the systemic inflammatory response syndrome, flow abnormalities and emboli. The specific advantages of the technique are shown in Figure 2; Advantages in terms of renal function and the incidence of stroke have not been universally accepted. Post operative cognitive function may be better in the short-term ie < three months and pulmonary function may be better especially in patients with COPD. The incidence of atrial fibrillation is unchanged. The main advantage of the technique is likely to be in the elderly patient with significant co-morbidities.

Disadvantages: OPCAB surgery demands a high level of vigilance on the part of the anaesthetist and is technically demanding for the surgeon. Cardiovascular collapse or ventricular fibrillation may occur rapidly. The ability to respond quickly to such changes is essential, including conversion to an on-pump technique. Patients with severe left ventricular dysfunction requiring multiple grafts may be unsuitable for an off-pump technique as may patients with certain patterns of coronary artery disease (diffuse disease, calcification, intramyocardial, small targets). OPCAB performed in low, as opposed to high volume centres is associated with a significant increase in cardiac specific as well as an overall mortality. Although early graft patency and outcome is thought to be at least equivalent, the long-term remains unknown.

FURTHER READING Moises VA, Mesquita CB, Campos O et al. Importance of intraoperative transoesophagel echocardiography during coronary artery surgery without cardiopulmonary bypass. J Am Soc Echocardiogr 1998 11: 1139-44 Alston P R. Off-pump Coronary Artery Surgery and the Brain. Br J Anaesth 2000; 84: 54952. George S J. Mitral A nnulus Distortion during Beating Heart Surgery: A Potential Cause for Haemodynamic Disturbances A Three Dimensional Echocardiography Reconstruction. Ann Thorac Surg 2002; 73: 142430. Conzen PF, Fischer S, Detter C, Peak K. Sevoflurane provides greater protection of the myocardium than propofol in patients undergoing off-pump coronary artery bypass surgery. Anesthesiology 2003;99: 826-33. Chassot PG, van der Linden P, Zaugg M et al. Off-pump coronary artery bypass surgery: physiology and anaesthetic management. Br J of Anaesthesia 2004: 92:400-13 Cheng DC, Bainbridge D, Martin JE et al. Does off-pump coronary artery surgery reduce mortality, morbidity, and resource utilisation compared with conventional coronary bypass? A meta-analyses of randomized trials. Anesthesiology 2005;102: 188-203. Raja SG, Dreyfus GD. Impact of off-pump coronary artery bypass on post-operative pulmonary dysfunction: Current best available evidence. Annals of Cardiac Anaesthesia 2006;9:17-24

Figure 1 Mechanical anastomotic stabilizer

a Octopus stabilizer

b Star-Fish

Figure 2 Advantages of OPCAB Reduced systemic inflammatory response syndrome Reduced blood loss and transfusion requirements Shorter period of ventilation Reduced ICU and hospital stay Potential cost saving