Cardiac Surgery Was Performed Under Beating Heart

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Review REVIEW

On-pump Beating Heart Surgery Ansheng Mo, MD a,∗ and Hui Lin, MD a,b

a Department of Cardiothoracic Surgery, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, China b The People’s Hospital of Wuhan University, Wuhan, China

On-pump beating heart surgery has been proposed as a superior technique for cardiac surgery, and is receiving renewed interest from cardiac surgeons. Here, we review the technique, focusing on the basic principles of myocardial protection, operative methodology, category, intraoperative concerns, current status, organ protection, advantages, disadvantages, indications, contraindications, unanswered questions, and future research. (Heart, Lung and Circulation 2011;20:295–304) © 2011 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. On-pump; Beating heart; Ischaemia–reperfusion

Introduction Feasibility of Surgery on the Empty Beating Heart ardiac surgery was performed under beating heart Myocardial Protection C or ventricular fibrillation conditions prior to the During on-pump beating heart surgery, the oxygen advent of cardioplegia, which made surgery easier. How- consumption of the empty beating heart decreases to ever, inadequate preservation of myocardial function was about 50% at normothermia [7]. The application of mild ◦ largely responsible for mortality and morbidity after car- hypothermia (32–35 C) can reduce oxygen consumption diac surgery. Avoidance of the adverse consequences of by an additional 5–20% [8]. Oxygen supply to the empty cardioplegia has been the driving force behind the devel- beating heart is adequate at a perfusion pressure of opment of on-pump beating heart surgery. 40–70 mm Hg and a flow of 0.8–1 mL/g heart muscle per Lillehei and colleagues successfully performed intrac- minute [9]. ardiac surgery on empty beating hearts, using cross- circulation in 1952, and reported a clinical case of aortic Operability valve surgery using the on-pump beating heart tech- After tightening caval snares and maintaining the left nique in 1956 [1,2]. In 1960, Starr et al. performed aortic ventricle vented to the atmosphere, cardiac pre-load and valve replacement for the beating heart under cardiopul- post-load can be considered equal to zero; according to the monary bypass [3]; in 1965, McGoon et al. reported a Frank–Starling mechanism, reduction in heart inotropy series of 100 consecutive aortic valve replacements, using can be achieved. In addition, mild hypothermia fur- the beating heart technique [4]; and in 1976, Eyster et al. ther diminishes contractile function [10] and decreases inserted a mitral valve prosthesis for the correction of the heart rate by 50% [11]. Injection of esmolol further mitral regurgitation in a dog using the on-pump beating decreases heart rate and inotropy [12,13]. An empty beat- heart technique [5]. Although these early procedures were ing heart coupled with the use of esmolol is sufficient to performed on beating hearts, the advent of the favoured decrease heart rate and inotropy safely, and to perform arrested heart surgery changed the way these surgeries cardiac surgery conveniently. were performed. In 1991, Lichtenstein et al. suggested that warm-heart surgery could enhance perioperative myocardial metabolic function [6], renewing the interest of cardiac Anaesthesia surgeons in on-pump beating heart surgery. Here, we review this technique. Anaesthetic considerations for cardiac surgery on an empty beating heart are focused on the maintenance of the beating state of the heart, including strict control of elec- trolyte balance and maintenance of adequate perfusion Received 1 September 2010; received in revised form 16 January pressure. 2011; accepted 24 January 2011; available online 16 February 2011 ∗ Corresponding author at: No. 6 Taoyuan Road, Nanning City, Cardiopulmonary Bypass Guangxi Zhuang Autonomous Region, China. Tel.: +86 0771 2186312; fax: +86 0771 2802018. After accomplishing adequate anticoagulation, cardiopul- E-mail address: [email protected] (A. Mo). monary bypass is instituted. During the period of

© 2011 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of 1443-9506/04/$36.00 Australia and New Zealand. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.hlc.2011.01.021 Author's personal copy

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cardiopulmonary bypass, the mean arterial blood pres- Simultaneous Aortic and Coronary Sinus Perfusion sure is maintained within the range of 50–80 mm Hg at a With Aortic Cross-clamping (Fig. 3A) flow rate of 2.2–3.4 L/m2/min [14,15]; the perfusate temper- ◦ Systemic perfusion and heart perfusion employ different ature is adjusted to maintain temperature at 32–37 C; the perfusion systems. In heart perfusion, a cannula is placed haematocrit is maintained at 18–24% in mild hypothermia into the aorta and another cannula is inserted into the [14] and >20% in normothermia [16]. coronary sinus. Both cannulas are connected to a Y-tube attached to the cardiopulmonary bypass circuit [23,24]. Heart Perfusion Simultaneous Aortic and Coronary Sinus Perfusion Antegrade Perfusion via Aortic Root Without Aortic Without Aortic Cross-clamping (Fig. 3B) Cross-clamping (Fig. 1A) Continuous coronary perfusion is provided via retrograde This method of antegrade delivery [14,17–19] is suitable coronary sinus perfusion in an unclamped aorta. There- for any type of intracardiac or extracardiac repair except fore, the coronary ostia are perfused with blood from aortic root and/or aortic valve procedures, or cases of an ascending aortic cannula, and the coronary sinus is aortic insufficiency. In order to reduce the incidence of aor- perfused from a pump connected to the oxygenator. The tic insufficiency caused by mitral retraction, a transseptal advantage of this perfusion technique is that it allows for approach is recommended when performing mitral valve safer myocardial protection, should one system fail [25]. procedures. Simultaneous Coronary Ostia and Coronary Sinus Antegrade Perfusion via Aortic Root With Aortic Perfusion (Fig. 3C) Cross-clamping (Fig. 1B) Antegrade flow is maintained at approximately A cross-clamp is used between the two perfusion cannu- 100 mL/min with a line pressure of 200 mm Hg, but las, and the pressure of the proximal segment of the aortic the pressure in the coronary ostia system is the same root is maintained at 40–70 mm Hg [9,13]. This heart per- as the systemic blood pressure (usually 70 mm Hg mean fusion pattern may be an optimal method to reduce the pressure); simultaneous retrograde flow is 75–100 mL/min risk of air embolism, providing better myocardial protec- with a coronary sinus pressure of 50 mm Hg [26]. tion and facilitating surgery [9,12,13]. This method has a similar application as antegrade perfusion via the aortic Simultaneous Left Coronary Ostium and Coronary root without aortic cross-clamping. Sinus Perfusion (Fig. 3D) A cannula is introduced into the left coronary ostium after Antegrade Perfusion via Selective Cannulation of the aortotomy, and the coronary ostium is infused at a rate of Coronary Ostia (Fig. 1C) 300 mL/min. Meanwhile, the coronary sinus is perfused at Direct cannulation of the coronary ostia using a Jehler a rate of 200 mL/min to maintain the mean distal catheter coronary perfusion cannula allows continuous perfusion pressure at 55 mm Hg once the aorta is cross-clamped [27]. with oxygenated blood at a rate of 200–300 mL/min [20]. The disadvantages of direct antegrade perfusion include risk of ostial injury, postcannulation ostial stenosis, and Intraoperative Concerns interruption of surgical procedures. However, the devel- Maintaining Adequate Coronary Perfusion opment of coronary perfusion cannula may reduce the Maintaining adequate coronary perfusion is very impor- incidence of postcannulation ostial stenosis with direct tant for maintaining the heart beat. Consequently, cannulation of the coronary ostia using a soft and appro- the perfusion catheter must be in place throughout priately sized cannula. the procedure. In antegrade perfusion, a rate flow of 0.8–1.0 mL/g heart muscle/min assures heart perfusion Antegrade Perfusion via Coronary Bypass Grafts adequacy [9]. In retrograde perfusion, a perfusion pres- (Fig. 1D) sure of 45–60 mm Hg with a flow rate of 200–500 mL/min When coronary artery bypass grafts allow the heart to is enough to supply myocardial oxygen in an empty beat- be perfused adequately, the aorta is cross-clamped below ing state [28–31]. One study reported on the recovery of the level of proximal graft anastomoses. This technique sinus rhythm with a maximum flow rate of 650 mL/min, greatly depends on the quality of the aorta at the site of the and maintenance of sinus rhythm with a flow rate of proposed cross-clamping and the disposition of previous 650 mL/min and a coronary sinus mean pressure of less vein grafts on the ascending aorta [21]. than 120 mm Hg [32]. The optimal flow rate of retrograde perfusion of the beating heart under normal tempera- Retrograde Perfusion via the Coronary Sinus (Fig. 2) ture has been suggested to be 7.0 mL/kg/min [33]. For In retrograde perfusion, the heart is perfused via the coro- simultaneous perfusion, the antegrade perfusion pressure nary sinus, and the blood drains via the coronary ostia. and retrograde perfusion demands are 50–80 mm Hg and This method of delivery is usually applied in aortic root 45–60 mm Hg, respectively. The adequacy of myocardial and/or aortic valve surgery, except in small children, in perfusion is visually assessed by electrocardiography, by patients with persistent left superior vena cava or in cases measuring the blood returning from the coronary ostium, of failed cannulation [22]. and by determining myocardial colour [14]. Author's personal copy

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Figure 1. One way perfusion (antegrade perfusion). (A) Antegrade perfusion via the aortic root without aortic cross-clamping. The aorta is unclamped throughout the cardiopulmonary bypass; therefore, perfusion of the coronary ostia is derived from the ascending aortic cannula, which allows systemic perfusion the patient. (B) Antegrade perfusion via the aortic root with aortic cross-clamping. A coronary perfusion cannula is placed into the proximal segment of the ascending aorta and connected to a branch line of the main perfusion line of the cardiopulmonary bypass circuit. The ascending aorta is cross-clamped between the two perfusion cannulas. Simultaneously, esmolol and nitroglycerine infusions are continuously applied via the coronary perfusion line. (C) Antegrade perfusion via a selective cannulation of the coronary ostia. The coronary ostia are cannulated using a Jehler coronary perfusion cannula once the aorta is clamped. The coronaries are continuously perfused with oxygenated blood. (D) Antegrade perfusion via coronary bypass grafts. When functioning coronary bypass grafts with or without a functioning left internal mammary graft allows the heart to be perfused adequately, the aorta is cross-clamped below the level of proximal graft anastomoses and heart perfusion is obtained via coronary bypass grafts.

Temperature Management aortic root mean blood pressure greater than 60 mm Hg In the initiation of cardiopulmonary bypass, the temper- for adults and 50 mm Hg for children are necessary to ◦ ature of the priming solution must be greater than 32 C. avoid aortic valve opening [14]. In direct cannulation for ◦ Maintenance of the perfusate above 32 C for heart per- coronary ostia perfusion, heart perfusion via coronary fusion is essential to keep the heart beating and to avoid bypass grafts, or simultaneous antegrade and retro- ventricular fibrillation during the bypass. A gradual reduc- grade perfusion, air embolism can be avoided by aortic tion in temperature in cardiopulmonary bypass is another cross-clamping. important factor to prevent ventricular fibrillation. Dur- After intracardiac procedures, de-airing of the left ing surgery, the temperatures should be monitored closely ventricle is achieved using the Trendelenburg position, and adjusted according to the complexity of the proce- stopping left ventricular suction, keeping the mitral valve dures. or ventricular septal defect open, placing a suction vent in the ascending aorta, and inflating the lung briefly; the air will be expelled, filling the chambers with blood [14]. Air Embolism Prevention Salerno et al. [15] revealed that de-airing of the left ven- During intracardiac procedures, for antegrade perfusion tricle can be achieved by inducing ventricular fibrillation. via the aortic root, keeping the left ventricle vented De-airing of the left atrium is achieved using the Trende- to the atmosphere using left ventricular decompression lenburg position, stopping left atrial suction, keeping the suction and vena cava occlusion, and maintaining the atrial septal defect or incision open, placing a suction vent Author's personal copy

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Figure 2. One way perfusion (retrograde perfusion). (A) Retrograde perfusion via the coronary sinus. After a retrograde perfusion catheter is inserted into the coronary sinus, the perfusate is delivered via the catheter by a specialised pump with the aorta cross-clamped. (B) Retrograde perfusion via the coronary sinus. After a retrograde perfusion catheter is inserted into the coronary sinus and connected to a main perfusion line of the cardiopulmonary bypass, the perfusate from the cardiopulmonary bypass is delivered via the catheter with the aorta cross-clamped.

in the ascending aorta, and briefly inflating the lung [14]. by no ischaemia and energy imbalance. A priming solu- ◦ De-airing of the right atrium and ventricle is achieved by tion temperature lower than 32 C, a quick reduction in unsnarling both the cavae before completion of the closure temperature during cardiopulmonary bypass, a temper- ◦ of the right heart incision. Generally, the air is expelled by ature below 30 C, and hypotension in the initiation of filling the chambers with blood from the coronary sinus. partial cardiopulmonary bypass are the causes of ventric- Additionally, massaging is also used to remove air from ular fibrillation and heart arrest. Usually, the heart beat is the right heart [14]. recovered after these issues are resolved. If not, defibril- lation is used immediately or after the completion of the Optimal Surgical Field of View critical procedures. An optimal field of view during the operation is essential to ensure that the surgery is carried out smoothly. Conversion to Cardioplegia Arrest To obtain a bloodless operative field, suction catheters Cardioplegia is a back-up technique that must routinely are required. Yingbin et al. suggested that simultaneous be kept in preparation. Conversion to cardioplegic arrest is suction of the left ventricle and atrium could provide an necessary when there is inadequate visualisation or tech- excellent view in paediatric patients with two catheters nical accuracy is compromised during the intraoperative through the atrial septal defect or incision [17]. Borowski period. and coworkers [9,13] introduced continuous drainage of the coronary sinus to facilitate operative viewing. Mo Preventing the Side-effects of Esmolol et al. [14] described another option, suggesting that an Esmolol is an ultra short-acting beta-adrenergic receptor inflated Foley’s catheter can be used to block the blood blocking agent. Although it acts rapidly and has a short life shunt temporarily. Briefly lowering perfusion flow rates (about 15 min), esmolol may have side effects. One study also allows better occasional visualisation during cardiac reported a case where use of esmolol alone resulted in surgical procedures by decreasing the coronary and medi- postoperative ischaemia [9]. In order to prevent its side astinal non-coronary blood return. Esmolol induction of effects, we propose that routine use of esmolol in on- bradycardia and minimal myocardial contraction is a com- pump beating heart surgery is unnecessary; if necessary, mon method for reducing movement of the surgical target. intracoronary application together with nitroglycerine is Continuous esmolol infusions via the coronary perfusion recommended. line or vein maintain the heart rate at 30–50 beats/min [9,12,13]. Categories for On-pump Beating Heart Surgery Ventricular Fibrillation and Heart Arrest Normothermia and Mild Hypothermia On-pump Ventricular fibrillation and heart arrest occur occasionally Beating Heart Surgery during on-pump beating heart surgery. In this situation, According to the temperatures in cardiopulmonary ventricular fibrillation and heart arrest are characterised bypass, on-pump beating heart surgery can be divided Author's personal copy

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Figure 3. Simultaneous antegrade and retrograde perfusion. (A) Simultaneous aortic and coronary sinus perfusion with aortic cross-clamping. A cannula is placed into the aorta and another cannula with a self-inflating balloon is inserted into the coronary sinus via the right atrium. Both cannulas are connected to a Y-tube attached to the cardiopulmonary bypass. (B) Simultaneous aortic and coronary sinus perfusion without aortic cross-clamping. The coronary ostia are perfused with blood from the ascending aortic cannula and the coronary sinus is perfused with blood from a calibrated centrifugal pump. (C) Simultaneous coronary ostia and coronary sinus perfusion. Antegrade perfusion is via two soft, self-inflating cannulas in the coronary ostia, and retrograde perfusion is performed with a catheter placed in the coronary sinus. (D) Simultaneous left coronary ostium and coronary sinus perfusion. Antegrade perfusion is via a soft, self-inflating cannula in the left coronary ostium and retrograde perfusion is performed with a catheter placed in the coronary sinus.

◦ into normothermia (35–37 C) and mild hypothermia One Way Perfusion and Simultaneous Antegrade and ◦ (32–35 C). The optimal temperature of on-pump beat- Retrograde Perfusion ◦ ing heart surgery is probably 32–33 C, because there In one way perfusion, blood perfuses from one direction of is increasing evidence that mild hypothermia provides the coronary system and drains via the coronary sinus or myocardial and brain protection and permits immediate coronary ostia. In simultaneous antegrade and retrograde recovery of cardiac function [34–37]. perfusion, the arterial inflow for perfusion of the heart is via the coronary sinus and coronary ostia and the blood drains via the thebesian veins, and arterio-sinusoidal and Aortic Clamping and Aortic Unclamping On-pump arterio-luminal vessels to the heart chambers. Simulta- Beating Heart Surgery neous perfusion aims to relieve the inadequate blood In on-pump beating heart surgery, aortic clamping is not distribution beyond a stenotic coronary artery in one way equivalent to interrupting the coronary blood flow. Aortic perfusion, flush air out of the coronary system and pro- cross-clamping can provide the following benefits: coro- vide a more homogeneous distribution of blood [20,23–25]. nary perfusion can be pressure- and volume-controlled; Wang et al. [38,39] found that retrograde perfusion could different perfusate temperatures can be applied; the not provide adequate protection to the hypertrophied dosage together with adverse effects of esmolol can be pig heart in beating heart surgery, and compared with reduced; and the risk of air embolisation is reduced [9,13]. the antegrade perfusion, simultaneous perfusion led to In on-pump beating heart surgery without aortic clamp- slightly impaired myocardial oxygenation and energy ing, air embolism is a cause of concern. metabolism. So far, there is no general agreement as to Author's personal copy

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the single best method of heart perfusion during cardiac Table 1. The List of Procedures Performed (Congenital surgery. Valve procedures have been routinely performed Cardiovascular Diseases). on an empty beating heart, using simultaneous antegrade Operation and retrograde perfusion. However, there is no infor- Atrial septal defect repair mation about the clinical data regarding simultaneous Ventricular septal defect repair retrograde/antegrade perfusion in infants and paediatric Radical operation for tetralogy of Fallot cardiac surgery. Patent ductus arteriosus closure Atrioventricular canal corrective surgery Watt’s sinus aneurysm rupture repair Organ Protection Coronary artery fistula repair Ebstein’s malformation corrective surgery Inflammatory Response Surgery for single atrium On-pump beating heart surgery is associated with a Surgery for partial anomalous pulmonary venous drainage Radical operation for trilogy of Fallot smaller systemic inflammatory response by reducing Double-chambered right ventricle the release of interleukin-6, interleukin-8, interleukin- Radical resection of pulmonary valve stenosis 10, and tumour necrosis factor-␣. It has been reported Modification of the children’s II operation for hypoplastic left that continuous heart perfusion can reduce the systemic heart syndrome Total anomalous pulmonary venous drainage inflammatory response [40–42]. Coronary arterio fistula Fontan Myocardial Protection Trilogy of Fallot Evidence indicates that there is less myocardial damage with on-pump beating heart surgery compared to conventional cardiac surgery [29,39,43–45]. grafts and avoiding injury to major vascular structures in repeat cardiac surgery. Neurological Function We observed no neurologic deficits in relation to air Disadvantages embolism in 701 consecutive patients with on-pump beating heart surgery [14]. Karadeniz et al. found that there Although beating heart procedures have many clear ben- was no significant difference between on-pump beating efits, heart motion and a less than optimal surgical heart and hypothermic arrested heart valve replacement field of view can make the safe manipulation of tissues surgery regarding the major neurological outcome [16]. extremely challenging in some cases. In addition, the on-pump beating heart technique increases the risk of Other Organs and Systems systemic emboli and haemolysis for excess suction during bypass. It is reported that on-pump beating heart surgery is of benefit to the lungs [46], liver [47], hormonal system [48,49] and immune system [50]. There are no comparisons of Current Status of On-pump Beating Heart Surgery renal function between on-pump beating heart surgery and conventional cardiac surgery. Masroor et al. reported On-pump beating heart surgery has been applied to most that beating-heart valve surgery in nine patients with congenital and acquired cardiovascular diseases. The pro- renal failure requiring haemodialysis had a low rate of cedures performed thus far are summarised in Table 1 complications and short intensive care unit and hospital [9,12–14,17,22,52–55] and Table 2 [9,12–14,26–33,56–73]. It stays [51]. Comparisons between on-pump beating heart is estimated that most cardiac units in China perform on- cardiac surgery and conventional cardiac surgery in peri- pump beating heart surgery to varying degrees. Recently, operative bleeding and the consequent requirement for blood products are limited. Table 2. The List of Procedures Performed (Acquired Cardiovascular Diseases). Advantages Operation The advantages of on-pump empty beating heart are Mitral valve replacement Aortic valve replacement as follows: myocardial ischaemic–reperfusion injury and Mitral and aortic valve replacement hyperkalemic cold cardioplegia are avoided; in cases of Aortic root procedures mitral valve repair, small ventricular septal defect, resid- Combined valve and coronary artery bypass graft ual leakage, ablation for chronic atrial fibrillation, and Paravalvular leakage Removal of a left atrial thrombus conduction block in beating-heart surgery, diagnosis and Ablate atrial fibrillation treatment are more feasible; the option of conversion to Aortic root replacement the conventional technique is always immediately avail- Total aortic arch replacement able, if the surgeon is not satisfied with the beating heart Maze procedure variants technique; and a shorter cardiopulmonary bypass time Ventricular reconstruction Proximal descending aorta replacement is noted [19]. In addition, the technique allows reduced Modified Norwood operation adhesion dissection, avoiding damage of coronary bypass Author's personal copy

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increasing numbers of surgeons have become interested posing unnecessary ischaemic intervals during ventricular in on-pump beating heart surgery worldwide. rebuilding [80–83]. REVIEW

Congenital Cardiovascular Diseases AORTIC SURGERY. There are cases reports of a modified On-pump beating heart surgery is almost universally Bentall operation for aortic root replacement under on- practiced in individuals of any age and body weight. Many pump beating heart conditions [72]. Chang et al. [73] first studies reported that on-pump beating heart surgery is reported a total aortic arch replacement with the on-pump a safer and more reliable option for congenital heart beating heart technique. disease. Furthermore, some studies have concluded that on-pump beating-heart surgery is superior to the conventional technique in paediatric cardiac surgery. However, Comment one study suggested that on-pump beating heart surgery has a major impact on plasma calcium and blood gas in The on-pump beating heart has been proposed as a children weighing less than 10 kg [54]. Another study indi- superior technique in cardiac surgery. However, the avail- cated that transatrial repair of intraventricular defects is able evidence largely consists of retrospective series possibly accompanied by an increased incidence of resid- and case reports, and very few randomised trials with ual or recurring intraventricular shunts in children less high methodological quality comparing on-pump beat- than three months of age [13]. ing heart surgery with conventional cardiac surgery have been conducted. Therefore, most of these studies, unfortu- nately, lack sufficient scientific rigour to allow meaningful Acquired Cardiovascular Diseases conclusions to be drawn. VALVULAR SURGERY. Studies have shown that on-pump beat- Indications and contraindications are inconsistent. It is ing heart valvular surgery is efficient and safe and has reported that beating heart surgery could be applied to advantages because conditions for the heart are more most cardiovascular diseases, especially for hypertrophied physiologic with beating tonus than with cardioplegia. hearts, high-risk patients with low ejection fractions, com- However, Qiang et al. believe that this method is not suit- plex intracardiac lesions, repeat cardiac surgery, mitral able for mitral valve surgery, because an exposed mitral valve replacement patients with a porcelain aorta, car- valve presents difficulties and the accuracy of surgery is diac surgery in pregnant patients [27], cardiac surgery low [74]. Salhiyyah and Taggart conducted a systematic in a sickle cell patient undergoing cardiac surgery [84], review to assess the efficacy of on-pump beating heart and time-consuming cardiac procedures. Some authors surgery compared to cardioplegia in valve surgery, and consider that the on-pump beating heart technique is concluded that the former is a strategy in valve surgery inappropriate for surgical field exposure in patients with with some potential benefits [75]. However, there is a need reduced blood return to the heart [14], or a large ventricu- for a prospective, randomised, controlled trial. lar septal defect [14], or in mitral valve surgery in patients with a small left atrium [14], mild aortic insufficiency [14] or CORONARY ARTERY BYPASS GRAFTING. A number of studies found that on-pump beating heart coronary artery bypass extensive mitral valve vegetation [70]. However, in the set- grafting offered the possibility of eliminating intraop- ting of mild aortic insufficiency, Salerno et al. [85] believed erative global myocardial ischaemia and improving the that pressure on the root of the aorta from the outside usu- hospital outcome for high-risk patients [76–78]. However, ally eliminated aortic insufficiency, and another choice is in a study by Pegg et al. [79], the incidence of new irre- a procedure using retrograde perfusion. versible myocardial injury was significantly higher with In the absence of available objective parameters to the on-pump beating heart using antegrade perfusion determine the indication, the application of the on-pump than in conventional coronary artery bypass grafting. beating heart procedure currently depends on the attitude The most likely mechanism for this scenario was inad- and experience of the surgeon performing the operation. equate coronary perfusion to distal myocardial tissue in That on-pump beating heart surgery could rather eas- patients with severe proximal coronary disease. Thus, they ily lead to cardioplegic arrest might be the reason why suggested that on-pump beating heart surgery using ante- the indications and contraindications are seldom men- grade heart perfusion is not suitable for use in patients tioned. This surgery should be performed only when it suffering from ischaemic heart disease with impaired ven- is in the patient’s best interests, not simply because of a tricular function. A comparison between on-pump beating desire for innovation. Customising the operation accord- heart surgery using retrograde perfusion or simultaneous ing to the patient is fundamental to surgical care, as in perfusion and conventional coronary artery bypass graft- some patients, for example, avoiding cardioplegia may be ing in patients with ischaemic heart disease remains to be very important, whilst for others, the impact of cardiople- reported. gia may be relatively trivial compared with possibility of technical accuracy. Thus we must insist on a subjective VENTRICULAR RECONSTRUCTION. The safety of the beating principle that impaired vision and compromised techni- method is shown in studies of ventricular reconstruction cal accuracy are indications to convert the beating heart in chronically dilated hearts with heart failure, left ven- to cardioplegic arrest. Attention must be paid to prevent tricular aneurysm, left ventricular pseudo-aneurysm and widespread inappropriate clinical application of the tech- simulated left ventricular restoration, to avoid superim- nique. Author's personal copy

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On-pump beating heart surgery, as a complement to [14] Mo A, Lin H, Wen Z, Lu W, Long X, Zhou Y. Efficacy and cardioprotective strategies, cannot abolish the use of a safety of on-pump beating heart surgery. Ann Thorac Surg cardioplegic solution. A large, multicentre, randomised 2008;86(6):1914–8. prospective study comparing the on-pump beating heart [15] Salerno TA, Panos AL, Tian G, Deslauriers R, Calcaterra technique and conventional heart surgery in all aspects D, Ricci M. Surgery for cardiac valves and aortic root is needed to determinate the indications and contraindi- without cardioplegic arrest (“beating heart”): experience with a new method of myocardial perfusion. J Card Surg cations. In order to overcome the shortcomings of com- 2007;22(6):459–64. promised technical accuracy and widespread appropriate [16] Karadeniz U, Erdemli O, Yamak B, Genel N, Tutun U, application of the techniques, exploiting intra-operative Aksoyek A, et al. On-pump beating heart versus hypother- devices, such as a valved stent and Amplatzer septal mic arrested heart valve replacement surgery. J Card Surg occluder to reduce intercardiac sutures is necessary to 2008;23(2):107–13. simplify surgical procedures. Alternatively, open heart [17] Yingbin X, Lin C, Xuefeng W, Qianjin Z, Jingjin C, Bocheng surgery, air removal and incision closure are done in the C. On-pump beating-heart intracardiac procedures in 2100 beating state, and key procedures are done under the cases. Chin J Extracorporeal Circ 2006;4(4):210–2. arrested state, which combines the advantages of two car- [18] Gersak B. Mitral valve repair or replacement on the beating dioprotective strategies to compensate for their individual heart. Heart Surg Forum 2000;3(3):232–7. [19] Gersak B, Sutlic Z. Aortic and mitral valve surgery on the shortcomings. beating heart is lowering cardiopulmonary bypass and aortic cross-clamp time. Heart Surg Forum 2002;5(2):182–6. 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