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A Common Occurrence After Coronary Bypass Surgery

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A Common Occurrence After Coronary Bypass Surgery CORE Metadata, citation and similar papers at core.ac.uk Provided by Elsevier - Publisher Connector lACC Vol. 15, No.6 1261 May 1990:1261-9 Acute Myocardial Dysfunction and Recovery: A Common Occurrence After Coronary Bypass Surgery WARREN M. BREISBLATT, MD, FACC, KEITH L. STEIN, MD, CYNTHIA J. WOLFE, RN, WILLIAM P. FOLLANSBEE, MD, FACC, JOHN CAPOZZI, CNMT, JOHN M. ARMITAGE, MD, ROBERT L. HARDESTY, MD, FACC Pittsburgh, Pennsylvania To evaluate whether acute myocardial dysfunction was min after coronary bypass and showed complete recovery common in the early postoperative period, serial hemody• within 48 h. Left ventricular end-systolic and end-diastolic namic measurements and radionuclide evaluation of ven• volume index increased significantly postoperatively, but tricular function were performed before and after opera• recovery in left ventricular ejection fraction was mostly due tion in 24 patients undergoing elective coronary bypass to decreases in end-systolic volume index (50 ± 22 ml at surgery. All patients had uncomplicated surgery, and no trough and 32 ± 16 ml at recovery). Depressed myocardial patient sustained an intraoperative infarction. In 96% of function was independent of bypass time, number of grafts patients, significant depression in right and left ventricular placed, preoperative medications or core temperatures ejection fraction was seen postoperatively, reaching a nadir postoperatively. Postoperative therapy with pressors or at 262 ± 116 min after coronary bypass. Left ventricular inotropic agents delayed but did not prevent the occurrence ejection fraction was 58 ± 12% preoperatively and 37 ± of postoperative ventricular dysfunction. 10% at trough. Right ventricular function displayed a Despite improvements in operative techniques and similar pattern. These findings were also associated with methods of myocardial protection, postoperative left ven• depressed cardiac and left ventricular stroke work index tricular dysfunction continues to be common in patients despite maintenance of adequate ventricular filling pres• undergoing cardiopulmonary bypass surgery. Although the sures and mean arterial pressure. mechanism of myocardial depression in the early postoper• The depression in ventricular function was partially ative period is unclear, the results are suggestive of reper• reversible within 8 to 10 h after surgery. Left ventricular fusion injury. ejection fraction had increased to 55 ± 13% at 426 ± 77 (J Am Coil CardioI1990;15:1261-9) Acute myocardial dysfunction has been suggested to be a remains unclear, some studies (5,6) have suggested that common occurrence after cardiopulmonary bypass, but its inadequate myocardial protection or the effects of cold time course and frequency have not been well established cardioplegia may play a role. Recent studies (7-9) have 0-4). It appears to be a reversible event within 24 h of implicated reperfusion injury secondary to oxygen-derived surgery and ma.y have profound importance in the early free radicals after cardiopulmonary bypass. postoperative period, especially in patients with already To further evaluate this process, serial hemodynamic and compromised ventricular function. This may have an effect radionuclide monitoring was utilized to assess right and left on patient management and on the assessment of early ventricular function in the pre- and postoperative period in 24 postoperative morbidity and mortality. Although its origin patients undergoing elective uncomplicated coronary bypass surgery. This approach was used to determine how frequently biventricular dysfunction occurred, assess its reversibility From the Departments of Cardiology. Critical Care Medicine and Car· and define the role of routine postoperative therapy. diothoracic Surgery, University of Pittsburgh. School of Medicine. Pitts· burgh, Pennsylvania. This work has been partially supported by Chiron Corporation, Emeryville, California. Manuscript received August 7. 1989; revised manuscript received Novem· ber I. 1989, accepted December 8, 1989. Methods Address for reprints: Warren M. Breisblatt. MD, Division of Cardiology. Room 3496, Presbyterian· University Hospital. O'Hara & DeSoto Streets. Study patients. Twenty-four patients undergoing routine Pittsburgh, Pennsylvania 15213. elective coronary bypass surgery completed the study. Pa- © 1990 by the American College of Cardiology 0735·1097/90/$3.50 1262 BREISBLATT ET AL. lACC Vol. 15. No.6 MYOCARDIAL FUNCTION AFTER BYPASS SURGERY May 1990: 1261-9 Table 1. Clinical Data in 24 Patients ond derivative and threshold techniques. Ejection fraction Mean age (yr) 63 ± II determination also relied on the use of periventricular back• No. of grafts 3.2 ± 0.9 ground subtraction and a variable region of interest. Nuclear Ischemic time (min) 57 ± 18 probe studies were performed with the NIC II (Bios), which CPB time (min) 105 ± 26 is a high temporal resolution (10 ms) nonimaging device Preop medications (no. of patients) (11-13). All studies were performed for 60 s, and background Nitrates 13 (I. 2. 5, 8-10. 12-14, 18.20.22,23) activity was determined in both a manual and automatic Beta-blockers 15 (I. 3. 5. 6. 8-12. 14, 18-21. 24) mode. All probe studies were performed by one operator Ca antagonists 19 (I, 3-5, 7-9, 11-20, 22. 23) who had great proficiency with this device. Core temperature (ec) Before surgery, a right ventricular ejection fraction cath• Immediately postop 36 ± 0.7 eter was placed in the pulmonary artery. This fast response Trough 36.7 ± 1.0 Recovery 37.2 ± 0.8 thermodilution catheter (REF I-Baxter Edwards) uses an onboard computer to exponentially fit the thermodilution Therapy received within 8 h of CPB (no. of patients) output curve so that right ventricular volumes and right None 7 (6. 7. 9. 16.21. 22. 24) ventricular ejection fraction can be determined (14,15). Dobutamine II (1-3. 5, 11-14, 17. 18.20) Thermodilution right ventricular ejection fraction with this Dopamine 9 (4, 5. 8, 10. 12, 14, 15, 18. 20) technique correlates well with contrast and radionuclide Nipride 9 (1.3,5. ll. 13, 14. 18, 19,23) ventriculography over a wide range of ejection fractions, Nitroglycerin 4 (13,17,20.23) however, in patients with significant tricuspid regurgitation, Neosynephrine 2 (2, 18) a wide range of error can be seen (16). Other hemodynamic Ca = calcium channel; CPB = cardiopulmonary bypass; postop = measurements recorded included heart rate, right atrial postoperatively; Preop = preoperative; numbers in parentheses indicate patient number; numbers to the right of ± signs indicate standard deviation. pressure, pulmonary artery pressure, pulmonary capillary wedge pressure and mean systemic arterial pressure. Car• diac output and right ventricular ejection fraction were determined with iced dextrose in water in triplicate at 15 min tients undergoing repeat coronary surgery as well as those intervals pre- and intraoperatively by an experienced user of with unstable angina or concurrent valve repair or aneurysm this catheter. The three measurements were averaged if they resection were excluded. Five patients who initially signed were within 10% of each other; curves judged to be "bad" informed consent were excluded; one had an extensive intraoperative myocardial infarction, three had a poor radio• by the computer were excluded. nuclide tag and one had inadequate positioning with the Postoperative evaluation. Within 131 ± 13 min after car• nuclear probe. There were 19 men and 5 women, with a diopulmonary bypass, patients arrived in the surgical inten• mean age of 63 ± 11 years. Preoperative medical therapy is sive care unit and were again labeled with 25 mCi of indicated in Table 1; all patients were on antianginal therapy. technetium pertechnetate. The nuclear probe was positioned The mean number of grafts placed was 3.2 ± 0.9, with a over the left ventricular region of interest, and serial deter• 57 ± 18 min ischemic time and a 105 ± 26 min cardiopulmo• minations of left ventricular ejection fraction and filling nary bypass time. All patients enrolled in the study gave variables were recorded. Nuclear probe and hemodynamic informed consent. The study was approved by the Institu• measurements were obtained serially at 15 min intervals for tional Review Board of Biomedical Research and Radiation up to 10 h (mean 8.8 ± 0.8) after operation. An automated Safety Committee. background approach was utilized with the nuclear probe Pre- and intraoperative evaluation. All patients had radio• (78% of end-diastolic counts), but background was re• nuclide angiography and nuclear probe studies performed checked manually and recorded at hourly intervals during preoperatively to determine baseline ejection fraction and the study. Repeat radionuclide angiograms were performed regional wall motion and to correlate the gamma camera and within 4 h of surgery and at 24 to 48 h postoperatively. Serial nuclear probe findings. The best left anterior oblique view hemodynamic assessment included systolic and diastolic for evaluating the left ventricular region of interest was also blood pressure, as well as all preoperative measurements assessed. Labeling was performed with 25 mCi of techne• recorded together with right ventricular ejection fraction and tium pertechnetate by the modified in vivo labeling tech• cardiac output. Other variables recorded included core tem• nique (10). Three view-gated blood pool studies were per• peratures, arterial oxygen saturation and concordant medi• formed with a mobile GE Starcam. Ejection fraction was cal therapy (including
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