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Incidence of perioperative myocardial infarction on pump versus off pump CABG

Incidence of perioperative myocardial infarction on pump versus off pump CABG. By Prof. Dr Morsi Amin Dr Ahmed Shaaban. Introduction. Introduction. Off pump CABG has been performed for the first time 40 years ago.

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Incidence of perioperative myocardial infarction on pump versus off pump CABG

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  1. Incidence of perioperative myocardial infarction on pump versus off pump CABG By Prof. Dr MorsiAmin Dr Ahmed Shaaban

  2. Introduction

  3. Introduction • Off pump CABG has been performed for the first time 40 years ago. • Although conventional CABG is considered both safe and effective, the use of CBP is associated with several adverse effects. • Improved survival and freedom from adverse cardiac events after CABG for patients with CAD have already been established.

  4. Introduction • Perioperative myocardial infarction is the most important postoperative complications after coronary bypass grafting. • Biochemical markers (CK, CK-MB and troponin) are used for assessment of myocardial injury postoperatively. • PMI can be diagnosed if there is ECG changes (new Q wave) or CK-MB elevation with CK/CK-MB ratio more than 0.1

  5. Aim of the Work

  6. Aim of the Work • To determine the incidence of PMI of both conventional CABG and off-pump surgery. • To determine the risk factors in these cases and how to reach the most safe and effective surgery.

  7. Patients and Methods

  8. Patients and Methods Type of the study This is a prospective descriptive study including 60 patients undergoing coronary artery bypass grafting either on-pump or off-pump.

  9. Patients Patients and Methods Sixty patients with coronary artery disease subjected to coronary artery bypass grafting either on pump or off pump with the following inclusion and exclusion criteria.

  10. Inclusion criteria: Patients with coronary artery disease indicated for coronary artery bypass grafting operation for the first time either on-pump or off-pump Patients and Methods

  11. Patients and Methods Exclusion criteria: • Poor left ventricular function. • Patients with deep intramyocardial coronaries. • Patients require endarterectomy or vein patch. • Patients who were planned to be off pump but it was changed to on pump intraoperatively. • Redo coronary artery bypass graft. • Emergency cases. • Patients with other concomitant valve surgery

  12. Patients and Methods Patients who fulfill the inclusion criteria were divided into two groups: Group A 30 patients underwent coronary artery bypass grafting on beating heart. Group B 30 patients underwent coronary artery bypass grafting using CPB

  13. Patients and Methods Preoperative assessment • Clinical assessment • ECG • Echocardiography • Coronary angiography • Carotid duplex for all patients over 60 • Complete blood picture, liver function, kidney function tests.

  14. Patients and Methods Operative assessment • Number, types of grafts and targets. • The ratio between the numbers of the performed grafts over the number of the intended grafts, incomplete revascularization. • The use of inotropic drugs, intra aortic balloon. • Number of blood unit transfused. • Duration of the operation

  15. Patients and Methods Postoperative assessment Every patient was subjected to: • Clinical assessment for post operative morbidity. • Mechanical ventilation with the assessment of the time of ventilation • The use of inotropic drugs or intra-aortic balloon. • Occurrence of arrhythmias. • Amount of postoperative blood drainage

  16. Patients and Methods • ECG for detection of perioperative myocardial infarction if occurred. • Echocardiogram at the first day postoperative. • Total blood unit transfused. • Total ICU stay in hours. • Total hospital stay in days

  17. Patients and Methods Laboratory assessment: • ACT and coagulation profiles on arrival of the patient. • CK-MB at 4h, 12h, 24h, 48h postoperatively. • Cardiac troponin T at 4h, 12h, 24h, 48h postoperatively. • Liver and kidney function tests every 24 h for 3 days postoperatively. • Complete blood picture every 24 h.

  18. Results

  19. Results • Most of the cases were in the age group between 51-60 yrs old.

  20. Results • Mean operation time was longer in group B than A (219.8 ± 26vs.167.4±28.5min; P-value< 0.05). • Number of grafts per patients was significantly higher in group B (2.7±.83) than group A (1.4±.73); P < 0.05.

  21. Results Single-vessel grafting is significantly higher in the off-pump group, while three-vessel grafting is significantly higher in on-pump group.

  22. Results Targets On-pump group included more patients with ( OM, RCA and PDA) grafting.

  23. Results Incomplete revascularization Incomplete revascularization was higher in the off-pump group, but non-significant.

  24. Results • Patients on the On-pump group show a higher incidence(36.7%-46.7%0) respectively for blood and fresh frozen plasma transfusion intra-operatively (significant). • The On-pump group shows a higher incidence of pulmonary and neurological complication, but non-significant. • Non-significant difference was found between the two groups as regard to creatinine level post-operatively.

  25. Results • Non-significant difference was found between the two groups as regard to bilirubin level post-operatively. • More patients in the On-pump group were re-explored for bleeding. • Superficial and harvest site infection occurred less in the Off-pump group however, non-significant.

  26. Results • The on-pump group showed a higher duration of mechanical ventilation( statistically significant P < 0.05 ), otherwise patients in the off-pump group had less ICU and hospital stay but (non-significant).

  27. 1.8 1.6 1.4 1.2 1 Tn Level(ng/ml) 0.8 0.6 0.4 0.2 0 Tn after 4 hours Tn after 12 hours Tn after 24 hours Tn after 48 hours Off pump On pump Postoperative troponin • Cardiac TnT concentrations were significantly higher in the on pump group than in the off pump group at hours 4, 12, 24, and 48.

  28. Postoperative CK-MB level The release of CK-MB was significantly higher in the on pump group however, it does not indicate MI.

  29. Incidence of perioperative MI • There was no statistically significant difference between both groups as regard the occurrence of perioperative MI.

  30. Conclusion

  31. Conclusion • Perioperative effectiveness outcomes were similar for both OPCAB and on-pump with the exception of the number of grafts performed per patient, which was significantly lower during OPCAB • No technique was found to be superior over the other for less incidence of occurrence of perioperative myocardial infarction

  32. Conclusion • Surgeons must consider achieving complete revascularization on the beating heart with only minor alterations in hemodynamics. • OPCAB should be used appropriately in indicated patients to achieve effective and safe revascularization

  33. ThankYou

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