Transcript Percutaneous Aortic valve replacement

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.
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
• 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.
Type of the study
This is a prospective descriptive study including
60 patients undergoing coronary artery bypass
grafting either on-pump or off-pump.
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.
Inclusion criteria:
Patients with coronary artery disease indicated
for coronary artery bypass grafting operation
for the first time either on-pump or off-pump
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
Group A
30 patients underwent
coronary artery bypass
grafting on beating heart.
Group B
30 patients underwent
coronary artery bypass
grafting using CPB
Preoperative assessment
 Clinical assessment
 ECG
 Echocardiography
 Coronary angiography
 Carotid duplex for all patients over 60
 Complete blood picture, liver function, kidney
function tests.
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
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





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





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.
Most of the cases were in the age group between 51-60 yrs old.

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.
Single-vessel grafting is significantly higher in the
off-pump group, while three-vessel grafting is
significantly higher in on-pump group.
On-pump group included more patients with ( OM, RCA and PDA)
grafting.
Incomplete revascularization was higher in the off-pump group, but nonsignificant.

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.

Non-significant difference was found between
the two groups as regard to bilirubin level
post-operatively.

More patients in the On-pump group were reexplored for bleeding.

Superficial and harvest site infection occurred
less in the Off-pump group however, nonsignificant.

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 (nonsignificant).

Cardiac TnT concentrations were significantly higher in
the on pump group than in the off pump group at
hours 4, 12, 24, and 48.
50
45
40
CK-MB levels
35
30
25
20
15
10
5
0
CK-MB after 4 hours
CK-MB after 12 hours
Off pump
CK-MB after 24 hours
CK-MB after 48 hours
On pump
The release of CK-MB was significantly higher in the on pump group however, it does not indicate MI.
Incidence of peri-operative MI
6.7%
10%
Off pump
On pump
• There was no statistically significant difference between both
groups as regard the occurrence of perioperative MI.

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

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
Thank You