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(Circulation. 2006;114:I-477 – I-485.)
© 2006 American Heart Association, Inc.

Surgery for Coronary Artery Disease

Emergency Coronary Artery Bypass Graft Surgery for Acute Coronary Syndrome

Beating Heart Versus Conventional Cardioplegic Cardiac Arrest Strategies

Ardawan Julian Rastan, MD; Judith Isabell Eckenstein, MD; Bettina Hentschel, PhD; Anne Kathrin Funkat, PhD; Jan Fritz Gummert, MD, PhD; Nicolas Doll, MD, PhD; Thomas Walther, MD, PhD; Volkmar Falk, MD, PhD; Friedrich Wilhelm Mohr, MD, PhD

From Department of Cardiac Surgery (A.J.R., J.I.E., A.K.F., J.F.G., N.D., T.W., V.F., F.W.M.), Heart Center, University of Leipzig, Germany; Institute of Medical Informatics (B.H.), Statistics and Epidemiology (IMISE), University Leipzig, Germany.

Correspondence to Ardawan Julian Rastan, University of Leipzig, Department of Cardiac Surgery, Heart Center Leipzig, Struempellstr. 39, 04289 Leipzig, Germany. E-mail rastan{at}rz.uni-leipzig.de

Background— Aim of this study was to compare the outcome of beating heart versus conventional coronary artery bypass graft (CABG) strategies in acute coronary syndromes for emergency indications.

Methods and Results— 638 consecutive patients with acute coronary syndrome (ACS) receiving emergency CABG surgery via midline sternotomy from January 2000 to September 2005 were evaluated. Propensity score analysis was used to predict the probability of undergoing beating heart (BH) (n=240) versus cardioplegic cardiac arrest (CA) (n=398) strategies. Patients presented with stable hemodynamics (n=531) or in cardiogenic shock (CS) (n=107). Hospital and follow-up outcome was compared by propensity score adjusted multiregression analysis. BH included 116 on-pump and 124 off-pump (OPCAB) procedures. There was a propensity to operate CS patients on the beating heart (multivariate odds ratio [OR], 3.8; P=0.001). Under stable hemodynamics significant predictors for BH selection were logEuroSCORE >20% (OR, 2.05), creatinine >1.8 mg/dL (OR, 4.12), complicated percutaneous coronary intervention (OR, 1.88), ejection fraction <30% (OR, 2.64), whereas left main disease (OR, 0.68), circumflex artery (OR, 0.32), and 3-vessel disease (OR, 0.67) indicated preference for cardioplegic arrest. Time from skin incision to culprit lesion revascularization was significantly reduced in BH patients. BH surgery led to a significant benefit in terms of less drainage loss, less transfusion requirement, less inotropic support, shorter ventilation time, lower stroke rate, and shorter intensive care unit stay. In CS, BH was associated with lower incidence of stroke, inotropic support, acute renal failure, new atrial fibrillation and sternal wound healing complications. In CS patients, hospital mortality rate was reduced when using beating heart strategies (P=0.048). Overall survival, major adverse cerebral and cardiovascular event rate, and repeated revascularization was comparable during a 5-year follow-up.

Conclusions— Beating heart strategies are associated with an improved hospital outcome and comparable long-term results for high-risk patients presenting acute coronary syndrome with or without CS.

Key Words: acute coronary syndrome • beating heart surgery • cardioplegia • cardiopulmonary bypass • myocardial infarction