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CAB: Why do it?

CAB: Why do it?. CAB. Incidence of CAD Treatment options pharmacologic options percutanious procedures open surgery. History of CAB. Pre 1950 all patients died Late 1960’s some survival hearts were fibrillating the quick or the dead! 1970-80 coming of age use of cardioplegia

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CAB: Why do it?

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  1. CAB: Why do it?

  2. CAB • Incidence of CAD • Treatment options • pharmacologic options • percutanious procedures • open surgery

  3. History of CAB • Pre 1950 • all patients died • Late 1960’s • some survival • hearts were fibrillating • the quick or the dead! • 1970-80 • coming of age • use of cardioplegia • survival expected!

  4. History of CAB • 1980-90’s • improved techniques, equipment • improved survival • increased complexity of cases • 2000 and beyond • more technology • more biology • more physiology

  5. CAB & CPB • Maintains circulatory flow with non-pulsatile flow. • Requires full heparinization and cardioplegia. • Still heart. • Despite decreased mortality with CPB, it is an important predictor of increased morbidity/mortality after revascularization.

  6. CPB

  7. Complications of CAB & CPB • CNS • Myocardial • Renal • Coagulation • Pulmonary • Financial

  8. CAB & CPB • Patient risk factors for increased morbidity following CPB: • Age > 70 years • Carotid artery stenosis • Atheromatous/calcified aorta • Underlying comorbidities • LV dysfunction

  9. CAB & CPB • CNS • TIA’s and stroke 2-3% • Neurocognitive changes • Risk factors • cerebral vascular disease • PVD • DM • Renal failure • MI • HTN • Age > 70

  10. CPB ? Ischemia-reperfusion Complement activation Endotoxin Proinflammatory cytokines Cellular activation (PMN, endothelial cells, platelets, …) Oxygen free radicals Proteases Arachidonic acid metabolites NO Endothelins PAF Tissue injury Multiple organ dysfunction Reprinted from Chest 1997.

  11. CAB & CPB • Renal • Serum Cr > 1.5 mg/dL • independent risk for mortality • independent risk for bleeding • independent risk for pulm complications • independent risk for cardiac complications

  12. Off Pump Coronary Revascularization(OPCAB)

  13. OPCAB • Concepts: Anesthesia • Physiology • Techniques • monitoring • drugs • contortion

  14. OPCAB • Concepts: Surgical • Techniques • Stabilizers • Anastamosis • Assist Devices

  15. OPCAB

  16. OPCAB • Patency • Emory 125 pts • results show comparable patency rates • Mayo 50 pts • higher incidence of graft problems • ascribed to “spasm”, “heparin reversal”

  17. OPCAB • Low EF • early results, safe and effective • Emergency Procedures • early results, safe and effective

  18. OPCAB • Outcome • CNS • Myocardial • Renal • Pulmonary • Coagulation • Costs

  19. OPCAB • CNS • Germany 20 patients OPCAB • Decreased number embolic events • Better performance on post-op cognitive tests • Decreasd S-100 levels • No difference stroke/TIA • Hawaii 68 OPCAB vs 69 CPB • Decreased number microemboli • No difference stroke/TIA.

  20. OPCAB • Renal • Bristol UK • 50 pts total • renal glomerular function • CrCl, urine microalbumin/Cr • renal tubular function • N-acetyl glucosaminiase • OPCAB better function than CPB

  21. OPCAB • Renal • Duke • 55 OPCAB 635 CPB • no difference in post op renal function

  22. OPCAB • SIRS and Myocardial Injury • LMU, Germany 13 patients OPCAB • Decreased levels TNFaplha, NO, CRP. • IL-6 levels high in both groups. • Decreased inotropes . • End point 96hours post-op • No difference in post-op intubation time, ICU stay, blood loss, post-op EF.

  23. OPCAB • SIRS and Myocardial Injury • Hong Kong, 18 OPCAB • Lower levels Il-8, Il-10, ck-mb, and Troponin I. • Endpoint 48 hours. • No difference ICU stay, ventilation time.

  24. OPCAB • Acute Aortic Dissection • Montreal • OPCAB 3/308 vs 1/2723 (p.00001) • risks related to HTN on cross clamp

  25. OPCAB • Elderly • UWO 30 OPCAB > 70 • LOS ICU 24 vs 36 hrs • discharge 6.3 vs 7.7 days • low Q syndrome 10 % vs 30% • Cost lower by $1000 !

  26. OPCAB • Elderly • Harrisburg • 142 pts > 70 OPCAB • only 2 conversions to CPB • no IABP • no CVA • no inotropes

  27. OPCAB • High Risk Pts • 242 OPCAB vs 483 CPB • age >80 (28/58), EF < 25% (13/26), renal insuff (27/46), COPD (33/43) • COPD < vent 0/33 vs 4/43 • renal comps < 1/28 vs 9/58 • CNS events < 2/28 vs 8/58 • overall mortality .4% vs 2.7% • OPCAB < transfusions, reoperations

  28. OPCAB • Morbidity • Minneapolis • morbidity 2.3% CPB vs 2.7% OPCAB • no significant differences • Cleveland (100 pts) • OPCAB 2% morbidity • no renal failure, stroke, sternal infections • shorter LOS (1 day)

  29. OPCAB • Morbidity • Hawaii • 68 CPB 69 OPCAB • OPCAB had less transfusions, vent, LOS • same mortality

  30. OPCAB • Morbidity • Minneapolis • 350 OPCAB 3171 CPB • low risk 1.1% CPB vs 1.4% OPCAB • medium risk 7% CPB vs 6% OPCAB • high risk 28.5% CPB vs 7.7% OPCAB • OPCAB > angina, interventional procedures

  31. OPCAB • Cost • Germany • 125 OPCAB • lower costs vs CPB, Endo-CAB, PA-CAB • Salt Lake • no difference ( 40 OPCAB/ 40 CPB) • Univ Mass Medical School • < vent, blood transfusions,LOS • costs 20 % less than ONCAB

  32. Conclusions • General: • Safe with equivalent short-midterm patency rates. • Evolving surgical technique. • Anesthetic considerations/montioring. • High risk patients with most benefit. • Neurological: • Stroke outcome?

  33. Conclusions • Renal: • Unclear results in literature. • SIRS: • Unclear clinical implications. • Costs: • Sicker the better.

  34. CPB IS DEAD?

  35. CASE • ES underwent three vessel saphenous vein grafts, no difficulty coming off pump. • Transferred to CVICU on milrinone and aprotonin. • First 24 hours patient required epinephrine. • Post-op creatinine increased to 2.2, dx with ARF on top of CRI. • Post-op day 6 trx for empiric pneumonia.

  36. CASE • Post-op day 9 dx with DVT and pulmonary embolus. • Extubated 5/11/01

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