Haemodynamic changes during beating heart coronary surgery with the ‘Bristol Technique’

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Abstract
Objectives: Optimal exposure and stabilization of the target coronary vessel is essential to allow the construction of a precise coronary anastomosis during off pump coronary surgery. However, this might be achieved at the expense of significant haemodynamic deterioration, particularly while grafting the circumflex and the posterior descending coronary arteries. The present study was designed to assess the haemodynamic changes with the beating heart positioned for grafting the three main coronaries. Methods: Twenty-nine consecutive patients (21 male, mean age 62.6±7.1 years) undergoing off pump coronary surgery were enrolled in the study. Three different surgical settings of exposure and stabilization were used according to the site of anastomosis: left anterior descending (LAD – set-up 1; n=29), posterior descending (PDA – set-up 2; n=15), and circumflex (Cx – set-up 3; n=21) coronary arteries. Haemodynamic measurements were recorded before any cardiac manipulation (baseline) in set-ups 1, 2 and 3, and immediately after the completion of each distal anastomosis with the heart returned to its anatomical position. Results: There were no marked changes in heart rate (HR) and systemic mean arterial pressure during the construction of the anastomoses for any of the three surgical settings. Set-up 1 (LAD) showed a decrease of 15.5% in stroke volume (SV) and an increase of 9% in pulmonary capillary wedge pressure (PCWP) compared to baseline (both P≪0.05), with all the other haemodynamic parameters remaining unchanged. Set-up 2 (PDA) showed a marked decrease in SV and cardiac index (CI), and an increase in central venous pressure (CVP) when compared to baseline (all P≪0.05). The most extensive changes were observed in set-up 3 (Cx) with a considerable reduction in SV and CI, and an increase in CVP, PCWP, pulmonary arterial pressure, and systemic vascular resistance index (all P≪0.05). These haemodynamic changes were transient and totally recovered after the heart was returned to its anatomical position. Conclusions: Exposure and stabilization of the three main coronary arteries during beating heart surgery does not produce any appreciable change in systemic blood pressure and HR. The haemodynamic deterioration observed during the construction of the circumflex and posterior descending coronary arteries distal anastomoses is transient and well tolerated with no adverse clinical events.

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