Smith Nathan J, Ramamurthi Adhitya, Joyce Lyle D, Durham Lucian A, Kohmoto Takushi, Joyce David L
Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
J Card Surg. 2021 Mar;36(3):864-871. doi: 10.1111/jocs.15309. Epub 2021 Jan 11.
Coronary artery bypass grafting (CABG) is a durable treatment for coronary artery disease. Left ventricular dysfunction (LVD) (a division of cardiothoracic surgery) (ejection fraction < 35%) significantly elevates perioperative risk for patients pursuing surgical revascularization. Periprocedural support with temporary mechanical circulatory support (tMCS) has shown benefit in this patient population.
Four patients with ischemic cardiomyopathy and LVD underwent CABG at our institution between 2017 and 2018. Each patient received perioperative ventricular support using a microaxial tMCS device (Impella 5.0®). The occurrence of a postoperative low-output state (LOS) was assessed for as well as postoperative morbidity and mortality, device-specific complications, and tMCS support duration.
All patients survived to device explant without device-related complications. Two patients required reoperation for nondevice-related bleeding. All patients were without an LOS at 24 h postoperatively with cardiac indices of 2.9-3.6 L/min/m , normalized serum lactate, and vasoactive-inotrope scores of 0-12.0. There was a notably high incidence of acute renal failure (50%), which was observed in patients with preoperative cardiogenic shock. One patient died 10 days after the device explant. Of the three patients that survived to discharge, two were alive at the most recent follow-up. Postoperative device support varied widely (0-500 h).
Perioperative tMCS may be a viable strategy for preventing postoperative LOS in high-risk CABG patients with a low complication rate and acceptable morbidity. The application of microaxial tMCS devices in CABG is an area that warrants further investigation to delineate its impact on perioperative outcomes and potentially expand the indications for such devices.
冠状动脉旁路移植术（CABG）是治疗冠状动脉疾病的一种持久有效的方法。左心室功能障碍（LVD）（心胸外科的一个分支）（射血分数＜35%）会显著增加接受手术血运重建患者的围手术期风险。围手术期使用临时机械循环支持（tMCS）已显示对该患者群体有益。
2017年至2018年期间，4例患有缺血性心肌病和LVD的患者在我们机构接受了CABG。每位患者在围手术期使用微轴tMCS设备（Impella 5.0®）接受心室支持。评估术后低心排血量状态（LOS）的发生情况以及术后发病率、死亡率、设备特异性并发症和tMCS支持持续时间。
所有患者均存活至设备取出，无设备相关并发症。2例患者因非设备相关出血需要再次手术。所有患者术后24小时均无LOS，心脏指数为2.9 - 3.6L/min/m²，血清乳酸正常，血管活性药物-正性肌力药物评分0 - 12.0。急性肾衰竭发生率显著较高（50%），在术前发生心源性休克的患者中观察到。1例患者在设备取出后10天死亡。在存活至出院的3例患者中，2例在最近一次随访时仍存活。术后设备支持时间差异很大（0 - 500小时）。
围手术期tMCS可能是预防高风险CABG患者术后LOS的一种可行策略，并发症发生率低且发病率可接受。微轴tMCS设备在CABG中的应用是一个值得进一步研究的领域，以明确其对围手术期结局的影响，并可能扩大此类设备的适应证。
