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SECTION 7 Technical aspects ofcoronary artery bypass graft surgery378

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age, whichever is greater. is simplistic rule has a logical rationale and has earned many adherents. Low blood pressure during bypass has been related to cerebral ischaemia and infarcts. is may be exacerbated by reduced clearance of cerebral microemboli.,

might be explained by dosing and timing of enteric- coated aspirin administration.

No conclusive improvement in outcome has been shown for

pharmacological neuroprotection during bypass.

Acute rises in the central venous pressure that can be caused by malpositioning or kinking of the venous cannula should be avoided as it may reduce cerebral perfusion pressure gradients.

The postoperativeperiod

In the postoperative period, it is important to keep the patient hydrated and normotensive, avoiding periods of deep or prolonged hypotension. Blood products and clotting factors should also be used cautiously. e patient should be extubated early and their neurological status assessed as soon as possible in order to detect early cerebral ischaemia, leaving a possibility to intervene within the therapeutic window if stroke has occurred.

Salvage strategies for stroke following CABG (i.e. in a context where systemic brinolysis is contraindicated due to the high risk of haemorrhage) include intra- arterial brinolysis and mechanical thrombectomy; of note, the latter has been shown to accomplish higher recanalization rates (63.2% vs 83.6% for intra- arterial brinolysis vs mechanical thrombectomy, respectively; P <0.01). Importantly, mechanical thrombectomy should be performed in the rst 6 hours aer the onset of symptoms. is new reality should heighten awareness of the importance of early diagnosis with cerebral CT angiography and immediate intervention in the CABG patient who suers a neurological adverse event.

Dual antiplatelet therapy aer CABG does not seem to reduce the risk of subsequent stroke. In the Future Revascularization Evaluation in Patients with Diabetes Mellitus:Optimal Management of Multivessel Disease (FREEDOM) trial, the rate of stroke for CABG patients was similar at 5years in those discharged on dual antiplatelet therapy versus aspirin alone (hazard ratio 0.85, 95% CI 0.36– 1.99), as also conrmed in a 2018 meta- analysis on this

New technologies inthe ﬁeld ofcerebral embolicprotection

Cerebral protection devices fall into two main categories:embolic capture and embolic deection. e Montage® Cerebral Protection System (Claret Medical, Santa Rosa, CA, USA) has been shown by diusion- weighted magnetic resonance imaging to decrease embolic load to the brain by 60% and to decrease the incidence of clinical ataxia from 24% to 9% in patients undergoing transcatheter aortic valve replacement. ere are currently two available devices to decrease cerebral emboli aer surgical aortic valve replacement:the Embol- X® device (Edwards Lifesciences, Irvine, CA, USA), a lter designed to capture emboli, is positioned in the ascending aorta during placement and removal of the aortic cross- clamp. e CardioGard® Cannula (CardioGard Medical Ltd., Or Yehuda, Israel) has a suction side port as part of the aortic cannula that captures both solid and gaseous emboli and has demonstrated ecacy in a small randomized trial. In a 2017 multicentre randomized controlled trial (383 patients undergoing surgical aortic valve replacement), the potential neuroprotective role of the Embol- X® device vs CardioGard® Cannula) was tested. e authors found that the rate of freedom from cerebral infarction at 7days was 32.0% versus

33.3% for suction- based extraction versus control (i.e. standard aortic cannula), respectively (between- group dierence, −1.3%, 95% CI −13.8% to 11.2%) and 25.6% versus 32.4% for intra- aortic ltration versus control, respectively (between- group dierence,

−6.9%, 95% CI −17.9% to 4.2%); no signicant inter- group dierences in mortality or clinical stroke were shown.

topic.

Expert consensus recommends anticoagulation with unfractionated heparin or low- molecular- weight heparin for those patients experiencing postoperative atrial brillation persisting for 12– 48 hours, and anticoagulation therapy for at least 4 weeks if atrial brillation persists at discharge.

Pharmacological treatments toreduce neurological complications ofCABG

As per guideline recommendations, CABG patients should receive statins perioperatively. However, the role of statins in reducing the risk of neurological adverse outcomes is yet to be established. Bouchard etal. suggested that a combination of statins and beta blockers may reduce the risk of postoperative stroke.

Aspirin is used routinely in all CABG patients. e role of aspirin in lowering the risk of stroke is controversial, although it has been shown to be associated with lower in- hospital mortality. In the 2016 Aspirin and Tranexamic Acid for Coronary Artery Surgery (ATACAS) trial, Myles etal. report that among patients undergoing CABG the administration of preoperative aspirin did not result in either a lower risk of death or thrombotic complications nor a higher risk of bleeding than placebo. However, the absence of dier-

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Anaortic coronary artery bypassgraing

W. Brent Keeling, Michael E. Halkos, and John D. Puskas

Introduction

Since the advent of multivessel o- pump coronary artery bypass graing (OPCAB) in the late 1990s, anaortic CABG has come to

Coronary artery bypass graing (CABG) has evolved to become an incredibly safe and eective therapy for ischaemic heart disease. Despite advances in revascularization both with and without cardiopulmonary bypass (CPB), cerebrovascular events continue to occur following CABG. Many of these events have been directly related to aortic manipulation (cannulation, aortic clamping, proximal anastomotic devices), and this fact has led a number of surgeons to consider and implement a surgical revascularization strategy whereby the aorta is not manipulated at all. is ‘no- touch’ technique util-

be synonymous with an OPCAB without aorto- conduit anastomoses. Modern suction stabilizers and positioners as well as robotic and thoracoscopic harvest techniques have allowed for complete myocardial revascularization without the use of CPB and without any form of aortic manipulation. Recently, European guidelines regarding myocardial revascularization were issued, and as a result of increasing evidence favouring anaortic methods of surgical revascularization, several anaortic procedural recommendations were incorporated into the guidelines (Table 55.1).

izes a number of conduits and orientations in order to achieve complete myocardial revascularization while eliminating aortic manipulation and signicantly decreasing the risk of perioperative

Connectordevices

stroke. Outcomes of patients who suer a permanent stroke aer CABG are dismal. In- hospital mortality rates for patients suering a permanent stroke aer CABG have been reported to be as high as 13.5%. Following discharge from the hospital, patients who suffered a perioperative stroke have a signicantly higher risk of mortality within the rst year following surgery.

In one of the largest recent trials comparing CABG to percutaneous coronary intervention (PCI) for multivessel coronary artery disease, the reported stroke rates for CABG were 2.2% and 0.6% for PCI. e higher rate of stroke for the surgical arm of this study was oset by a higher rate of target vessel revascularization for patients who underwent PCI. Nevertheless, patients and other physicians

Early data on anaortic CABG included some studies where clampless facilitating devices were utilized. Many of these devices still involve some degree of aortic manipulation and are not ‘anaortic’ in the truest sense of the word. Nevertheless, early no- touch aortic CABG techniques included use of devices such as the Heartstring® device (Maquet Cardiovascular, Wayne, NJ, USA) that allowed for aortocoronary anastomoses in a relatively bloodless eld and avoided partial aortic clamping. Early data showed a decrease in postoperative stroke rates using clampless facilitating devices when compared to partial aortic clamping for the construction of proximal aortocoronary anastomoses. Modern reports of anaortic CABG

alike oen cite a higher risk of stroke as a rationale to pursue alternatives to surgical revascularization in the treatment of multivessel coronary disease. Surgeons, as a result, have further rened surgical techniques as a way to continue to provide the long- term benets associated with surgical coronary revascularization while avoiding the morbidity and mortality associated with permanent postoperative stroke.

Prior to the advent of o- pump techniques, anaortic CABG initially began using a variety of methods involving CPB with cannulation of peripheral vessels as a way to avoid manipulation of a completely calcied aorta. ese approaches allowed for decompression of the heart and haemodynamic stability without touching the aorta while graing occurred; however, they were limited by the embolic risks associated with retrograde femoral perfusion.

Table55.1 Recent European Society ofCardiology/ European

Association forCardio- Thoracic Surgery procedural recommendations foranaortic methods duringOPCAB

Recommendation Class Level of

Minimize aortic manipulation I B

Routine use of epiaortic ultrasound IIa C

Anaortic techniques recommended in patients with signiﬁcant atherosclerotic disease of the aorta

Source data from Neumann FJ, Sousa- Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, etal. 2018 ESC/ EACTS Guidelines on myocardial revascularization. European Heart Journal. 2019;40(2):87– 165.

I B

evidence

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exclude the use of these devices as they still require aortic manipulation, but subsequent data have conrmed a decrease in postoperative neurological events with clampless facilitating device utilization.

Conduits

True anaortic CABG involves no manipulation of the aorta at all. In order to accomplish a no- touch CABG, a thoughtful surgeon must rst consider conduit options and various congurations to achieve complete revascularization with consideration of appropriate geometry. Conduit choices include both the right and le internal thoracic arteries (ITAs), the radial artery, the gastroepiploic artery, and greater saphenous veins. ITAs may be harvested with either a skeletonized or pedicled technique, and both ITAs may be used either in situ with inow from the respective subclavian artery or as free gras with inow from other sources. Likewise, the gastroepiploic artery may be used either in situ or as a free gra. Harvest of the gastroepiploic artery can usually be accomplished through the diaphragm, and this gra can be very useful for lesions on the inferior wall of the heart. Radial arteries and greater saphenous veins are increasingly harvested using endoscopic techniques and are most frequently utilized as free gras in anaortic CABG.

Conﬁguration

Inow for free gras can come from a variety of anatomic locations. For both ITAs and gastroepiploic arteries, the in situ route is preferred when technically feasible. In the event that free gras are utilized, inow options include in situ gras or utilizing the in situ gras for sequential graing. One of the rst reports regarding anaortic CABG showed excellent patency of saphenous vein gras where the proximal anastomoses were sewn to the right axillary artery. Further reports have documented inow from all of the great vessels and the descending thoracic aorta for lateral wall distal targets.

Fig.55.1 Bilateral internal thoracic Y- graft.

with a long I- gra extended along the lateral wall to the inferior wall of the heart. Standard OPCAB techniques are employed in order to avoid direct aortic manipulation and cannulation including modern suction positioners and stabilizers, coronary artery shunting using appropriately sized silastic shunts when necessary, and proper positioning of the heart to avoid inow occlusion and haemodynamic instability. Coupled with a proper anaesthetic plan, these techniques allow o- pump anaortic CABG to be safely applied to a large

number of patients. While occasionally useful, these congurations and utilization of CPB likely represent the minority of anaortic CABGs performed in modern cardiac surgical practices.

Results

More oen, surgeons have chosen to congure gras using both in situ ITAs applying hand- sewn anastomoses to facilitate further revascularization and conduit utilization without the use of CPB. Gras oen take on the conguration of a Y, I, or T but can be oriented in any way according to the anatomy of the patient (Fig. 55.1). ese composite Y, I, or T gras are usually composed of both ITAs with one as a free gra supplying the lateral wall, a single ITA with a radial artery supplying the lateral wall, or a single ITA with a saphenous vein(s) as a gra to the lateral wall. While the Y and T

Early angiographic results following composite Y- graing demonstrate excellent gra patency of greater than 99%. Mid- term patency rates for composite congurations have been demonstrated to be greater than 90%. When gra occlusions occur, the ITA gra to the anterior wall almost always remains patent when the composite T or Y portion to the lateral wall loses ow. Composite gras, however, are more susceptible to competitive ow and are not recom-

mended for targets with mild stenoses due to higher rates of gra congurations necessitate an end- to- side anastomosis that is usually performed with 8- 0 monolament suture, the I- gra employs an end- to- end anastomosis with multiple sequential side- to- side anastomoses from a single, long conduit. Using the Y, T, and even

Minimally invasivetechniques

Icongurations, it is oen necessary to tack the conduits to the epicardium to preserve the appropriate geometry and avoid kinking. With a combination of bilateral ITAs and radial arteries, total arterial revascularization using a no- touch technique is entirely feasible. Right- sided revascularization is usually accomplished with an in situ right ITA or with a gastroepiploic artery but can also occur

Anaortic surgical revascularization can also take the form of ITA

harvest and direct o- pump anastomosis to the anterior wall of the

heart. is procedure usually utilizes either thoracoscopic or robotic

harvest of the le ITA followed by a small anterior thoracotomy

to facilitate a hand- sewn anastomosis to an anterior wall target.

55 Anaortic coronary artery bypassgrafting 383

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Despite the lower risk of stroke reported with most techniques, the future of anaortic CABG is uncertain. Recent studies have cast doubt on the durability of o- pump techniques, so enthusiasm for true anaortic, multivessel OPCAB has notably waned. Conversely, multiple studies have demonstrated the feasibility and excellent short- term outcomes of minimally invasive and hybrid coronary revascularization techniques. In order to match the low stroke rate of PCI, surgeons must continue to attempt to mitigate the risk of permanent neurological decit. As the majority of strokes following CABG are related to aortic manipulation, anaortic CABG will continue to have a role in surgical coronary revascularization. As there are multiple iterations of anaortic CABG, surgeons will be able to better match the appropriate procedure to the patient.

Fig.55.2 Minimally invasive left ITA– left anterior descending artery

anastomosis with a silastic shunt in place.

Alternatively, minimally invasive direct CABG procedures utilize the same small le anterior thoracotomy for both harvest and anastomosis. For both procedures, the aorta is never manipulated, and the reported stroke rates are resultantly low. ese procedures have the disadvantage of usually only being utilized for the treatment of lesions on the anterior wall of the heart and are seldom utilized for multivessel graing.

Yet another form of surgical coronary revascularization that avoids direct aortic manipulation for patients with multivessel coronary artery disease is hybrid coronary revascularization. Most frequently, this takes the form of either a thoracoscopic or robotic harvest of the le ITA followed by o- pump revascularization of the anterior wall through a small anterior thoracotomy (Fig. 55.2). e remainder of the diseased coronary territories are then treated via PCI. As such, there is no direct aortic manipulation during hybrid revascularization, and multivessel revascularization is possible. As such, low rates of stroke and other postoperative major morbidities have been detailed following hybrid revascularization.

Advantages anddisadvantages

e advantages of anaortic multivessel CABG are potentially many, and most surgeons cite a decreased rate of postoperative stroke to justify routine use of the technique. Stroke rates of less than 1% have been routinely documented across multiple centres aer no- touch CABG., A meta- analysis published in 2017 with over 37,000 patients showed that anaortic CABG eectively reduced the risk of stroke by 78% and 66% over traditional CABG and traditional OPCAB, respectively. It has been well documented that any degree of aortic manipulation leads to an increased risk of postoperative stroke. As a result, the no- touch technique has the lowest reported stroke rates for any surgical revascularization strategy. Anaortic CABG, when performed by experienced surgeons, also confers an equivalent completeness of revascularization when compared to either PCI or on- pump CABG. In a report from a high- volume centre detailing a 3- year follow- up, researchers documented a stroke rate of 1.3%, which was statistically superior to the CABG arm (3.4%; P=0.032) and equivalent to the PCI arm (2.0%; P=0.347) of the Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) trial.

REFERENCES

1. Halkos ME, Puskas JD, Lattouf OM, Kilgo P, Guyton RA, ourani VH. Impact of preoperative urologic events on outcomes aer coronary artery bypass graing. Ann orac Surg. 2008;86(2):504– 10.

2. Dacey LJ, Likosky DS, Leavitt BJ, Lahey SJ, Quinn RD, Hernandez F Jr, etal. Perioperative stroke and long- term survival aer coronary bypass gra surgery. Ann orac Surg. 2005;79(2):532– 6.

3. Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, etal. Percutaneous coronary intervention versus coronary- artery bypass graing for severe coronary artery disease. N Engl J Med. 2009;360(10):961– 72.

4. Neumann FJ, Sousa- Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, etal. 2018 ESC/ EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87– 165.

5. Emmert MY, Seifert B, Wilhelm M, Grunenfelder J, Falk V, Salzberg SP. Aortic no- touch technique makes the dierence in o- pump coronary artery bypass graing. J orac Cardiovasc Surg. 2011;142(6):1499– 506.

6. ourani VH, Razavi SA, Nguyen TC, Kilgo PD, Puskas JD, Guyton RA, etal. Incidence of postoperative stroke using the Heartstring device in 1,380 coronary artery bypass gra patients with mild to severe atherosclerosis of the ascending aorta. Ann orac Surg. 2014;97(6):2066– 72.

7. Bonatti J, Hangler H, Oturanlar D, Posch L, Muller LC, Voelckel W, etal. Beating heart axillocoronary bypass for management of the untouchable ascending aorta in coronary artery bypass graing. Eur J Cardiothorac Surg. 1999;16(Suppl

2):S18– 23.

8. Duvan I, Ates S, Onuk BE, Sungar UP, Kurtoglu M, Karagoz YH. Redo o- pump coronary artery bypass graing via a le thoracotomy. Cardiovasc J Afr. 2015;26(1):25– 8.

9. Kim KB, Kang CH, Chang WI, Lim C, Kim JH, Ham BM, etal. O- pump coronary artery bypass with complete avoidance of aortic manipulation. Ann orac Surg. 2002;74(4):S1377– 82.

10. Hwang HY, Kim JS, Cho KR, Kim KB. Bilateral internal thoracic artery in situ versus y- composite graings:ve- year angiographic patency and long- term clinical outcomes. Ann orac Surg. 2011;92(2):579– 85.

11. Nakajima H, Kobayashi J, Funatsu T, Shimahara Y, Kawamura M, Kawamura A, etal. Predictive factors for the intermediateterm patency of arterial gras in aorta no- touch o- pump coronary revascularization. Eur J Cardiothorac Surg. 2007;32(5):711– 7.

SECTION 7 Technical aspects ofcoronary artery bypass graft surgery384

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12. Manabe S, Fukui T, Shimokawa T, Tabata M, Katayama Y, Morita S, etal. Increased gra occlusion or string sign in composite arterial graing for mildly stenosed target vessels. Ann orac Surg. 2010;89(3):683– 7.

13. Halkos ME, Rab ST, Vassiliades TA, Morris DC, Douglas JS, Kilgo PD, etal. Hybrid coronary revascularization versus o- pump coronary artery bypass for the treatment of le main coronary stenosis. Ann orac Surg. 2011;92(6):2155– 60.

14. Halbersma WB, Arrigoni SC, Mecozzi G, Grandjean JG, Kappetein AP, van der Palen J, etal. Four- year outcome of OPCAB no- touch with total arterial Y- gra:making the best treatment a daily practice. Ann orac Surg. 2009;88(3):796– 801.

15. Arrigoni SC, Mecozzi G, Grandjean JG, Hillege JL, Kappetein AP, Mariani MA. O- pump no- touch technique:3- year results compared with the SYNTAX trial. Interact Cardiovasc orac Surg. 2015;20(5):601– 4.

16. Zhao DF, Edelman JJ, Seco M, Bannon PG, Wilson MK, Byrom MJ, etal. Coronary artery bypass graing with and without manipulation of the ascending aorta:a network meta- analysis. J Am Coll Cardiol. 2017;69(8):924– 36.

17. Moss E, Puskas JD, ourani VH, Kilgo P, Chen EP, Leshnower BG, etal. Avoiding aortic clamping during coronary artery bypass graing reduces postoperative stroke. J orac Cardiovasc Surg. 2015;149(1):175– 80.

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Management and impact ofpreoperative, intraoperative, and postoperative cardiogenic shock/ cardiac arrest incoronary artery bypass grapatients

The role of circulatory support

Roberto Lorusso, Hadi Toeg, Simon Maltais, Scott DeRoo, and Koji Takeda

Preamble

Cardiogenic shock (CS) and cardiac arrest (CA) due to acute coronary syndromes (ACS) are almost exclusively approached, as rstline treatment, with percutaneous coronary intervention (PCI). In a few instances, however, coronary artery bypass graing (CABG) may be the procedure of choice or necessary in life- threatening scenarios based on the failure of PCI due to unfavourable/ unsuitable anatomical features or for complications arising from PCI. CABG in CS or CA is frequently characterized by challenging and disadvantageous clinical and haemodynamic conditions. Furthermore, these conditions may also either persist or occur aer surgical revascularization in the operating room or a few hours later in the intensive care unit. Standard supportive and pharmacological therapies are employed to counteract ongoing CS or CA, but refractoriness to rst- line treatments may lead to further myocardial compromise. In such circumstances, more aggressive approaches are mandatory and include temporary mechanical assist devices. Such scenarios have profound dierences in mechanisms and treatment, particularly with regard to the management, indications, and timing of mechanical circulatory support (MCS), but also in terms of patient prognosis. In such critical circumstances, a smooth post- CABG period is strictly dependent on the decision- making and strategy applied prior to, during, or aer the surgical revascularization. Mandatory supportive strategies can be established prior to surgery, but also implemented in the operating room or the intensive care unit. us, besides any particular surgical revascularization strategy, a comprehensive evaluation of ongoing and/ or expected cardiovascular dysfunction is essential to optimize therapeutic choices. MCS may represent a bridge to recovery or indicate the need for more

advanced treatment, if myocardial and haemodynamic dysfunction persist. Overall, and with increased availability and expertise, the use of such mechanical devices is increasing, particularly those that permit a percutaneous approach. However, the increased complexity and associated comorbidities in such CABG patients play an additional critical role in decision- making. Supportive evidence for such strategies is growing, but additional well- dened and structured research is still needed to determine the ecacy of mechanical support in high- risk CABG patients.

Introduction

CS is the leading cause of death in ACS, with a range between 5% and 10% of the overall patient population, and with a mortality rate reaching 40%.–  is condition occurs in up to 1.5% of patients undergoing cardiac surgery. e presence of CS at the time of CABG is associated with a marked increase of in- hospital mortality (25.4% in CS patients, vs 1.8% without it), as shown by several clinical series., CS may also occur following CABG for several reasons, and is associated with increased in- hospital mortality and with specic patient- related predictors, including older age, impaired le ventricular (LV) function prior to surgery, on- pump CABG, emergent cardiopulmonary bypass (CPB), and incomplete revascularization.,,

Patient management strategies in these circumstances appear dependent not only on the extent of myocardial damage or the modality of revascularization, but also the management of existing or developing unstable haemodynamic conditions, especially if MCS is ultimately indicated.

SECTION 7 Technical aspects ofcoronary artery bypass graft surgery386

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Recent trials have demonstrated that MCS represents an invaluable support resource, especially when pharmacological strategies are ineective.–  For MCS, deciding on its timing, nature, and conguration by appropriately trained personnel is critical both to patient management and prognosis. Finally, if transition to more durable cardiocirculatory assistance is required, it should be performed in well- structured organizations or networks.

Results ofemergency and salvageCABG

e impact of early CABG on in- hospital outcome aer acute myocardial infarction (AMI) was demonstrated in more than 4600 patients by Weiss and colleagues who reported an in- hospital mortality of 8.6% in patients undergoing CABG on day 0 compared to

3.0% in patients with delayed surgery (day 3 or later). In the presence of CS at the time of surgery, early mortality was 25% (16% in the presence of an intra- aortic balloon pump (IABP)). Alexsson etal. reported the results of emergency or salvage CABG in 614 patients in a multicentre study from Northern European centres. Of the total patient population, cardiopulmonary resuscitation prior to CABG was performed in 49 patients (8%) and nine patients (1%) had cardiac massage at the time of sternotomy. Hospital survival for patients submitted to emergency operation was 13%, and 41% for salvage operations. e overall post- discharge survival was 79% for emergency surgery and 46% for salvage procedures, with only one patient receiving cardiac massage during sternotomy surviving at 5years. Sergeant and colleagues reported that shock or CA was present in 2.1% of the total CABG population. However, this group of patients accounted for 20% of the total hospital mortality, with a respective 30- day mortality of 28.1% + 8% in the shock group and

44.7% + 13% in the CA group and with a 10- year survival of 53% for shock patients, versus 37% of the patients operated during CA.

Interestingly in a registry of 470 CABG patients with ST- elevation myocardial infarction (STEMI) or non- STEMI complicated by CS, in- hospital mortality and rates of major adverse cardiac and cerebrovascular events were 24% and 49% in STEMI patients, compared to 15% and 34% (P <0.001) in non- STEMI subjects. e presence of reduced ejection fraction and a European System for Cardiac Operative Risk Evaluation score predicted unfavourable in- hospital outcome.

Table 56.1 shows a summary of the most important studies re-

porting data from CABG in CS or CA, with in- hospital outcome and rate of temporary circulatory support.– ,– 

and, crucially, the type and extent of ventricular dysfunction (isolated LV, right ventricular, or biventricular dysfunction).

Potential algorithms to manage such conditions, in case of CS or CA prior to CABG, are shown in Fig. 56.1. Severely impaired haemodynamic states may predict diculty of weaning from CPB or further impaired myocardial contractility during the rst hours aer revascularization. e timely application of cardiocirculatory support, even if partial, may reduce cardiac workload and promote myocyte recovery. Prophylactic placement of MCS, depending on the extent of preoperative haemodynamic and tissue compromise, may enhance intraoperative management including smoother and more controlled weaning from CPB, and provide optimal assistance in the potentially unstable rst ICU hours, thereby reducing the need for inotropic pharmacological support, a well- known factor for perioperative adverse events.

e use of extracorporeal membrane oxygenation (ECMO)- based peripheral cannulation for CPB, particularly in CA at sternotomy, can be utilized to transfer from CPB to controlled short- term postoperative circulatory assistance, avoiding several attempts to wean from CPB invariably requiring high doses of inotropes to avoid low perfusion (Fig. 56.1). e ‘prophylactic’ application of such MCS (also depending on the team status, expertise, and device availability) may therefore reduce the oen observed highly haemodynamic instability that invariably promotes peripheral hypoperfusion, refractory acidosis, lung and liver stasis, renal impairment, and other adverse events. In extreme cases, particularly if CS or CA occur aer initially successful PCI, temporary MCS prior to surgery to induce recovery of severely impaired metabolic and haemodynamic conditions might represent an additional strategy, to improve the outcome of high- risk procedures.,

Post- CABG cardiogenic shock or cardiacarrest

In this condition, the onset of isolated or biventricular failure might be a de novo event, a persistence of prior compromised cardiocirculatory and respiratory function, or a recurrence of preoperative impaired cardiocirculatory conditions, likely linked to the intraoperative events and/ or management. Beside the investigation of potential reversible causes (technical/ surgical, metabolic, embolization, and others), a rapid assessment of the potential need for MCS should be contemplated prior to further haemodynamic deterioration, onset of severe acidosis, and possible CA. Indeed, Fux and associates have reported that the extent of lactate levels is directly associated with in- hospital outcomes, showing a 91% in- hospital mor-

Cardiogenic shock and cardiac arrest inCABG patients: the role and timing ofmechanical circulatory support indifferentsettings

Preoperative low cardiac output syndrome or cardiac arrest inCABGpatients

e presence of low cardiac output syndrome or CA in patients prior to isolated CABG requires a careful evaluation of patient and myocardial status (acute or chronic ischaemic cardiomyopathy). e latter includes the extent of previous or ongoing myocardial damage and dysfunction and the presence of stunned (potentially reversible) or scarred myocardium (irreversible). Intraoperatively important considerations include the appropriateness of myocardial protection, completeness of revascularization, extent of reperfusion injury, persistence of ischaemia due to technical or anatomical reasons,

tality in patients with lactate levels greater than 10mmol/ L, and a 100% death rate in patients with veno- arterial (VA) ECMO implants with lactate levels above 15mmol/ L. e impact of lactate levels as a predictor of in- hospital outcome was even more important in patients with ischaemic heart disease.

e critical timing of MCS implant has been repetitively underlined by several investigators.,, Potential algorithms regarding MCS decision- making and timing, in case of CS or CA occurring intraoperatively or aer CABG, are shown in Fig. 56.1.

Type oftemporary mechanical circulatory support inCABGpatients

e type of MCS in CABG patients may vary according to the surgical/ treatment strategy, the team expertise, and device availability. e benets and shortcomings of various devices currently available

Table56.1 Overview ofpublished series ofpatients operated forcoronary artery bypass grafting incardiogenic shock

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First author (Reference)

Sergeant

White

Rastan

Dar

Weiss

Mehta

Chiu

Parikh

Madershahian

Algarni

Caceres

Khaladj

Ding

Santarpino

Axelsson

Yea r Patients

(nr.)

2003 259 104 (40.1%) IABP 92 (35.5%) n.a. n.a. n.a. IABP,

Preop mechanical support (%)

Type of preop temporary support

Cardiac arrest at sternotomy or prior to surgery

LITA use (%) Postop

cardiogenic shock or cardiac arrest

Postop mechanical support

Type of postop temporary support

HTx (%) Long-

lasting VAD (%)

In- hospital survival (%)

3 (1.1%) n.a. 91 (35%) 59.4% at 1year univentricular assist device, biventricular assist device

2005 47 97.9% 15.2% 52.6%

30- d 57.7%

2006 107 39 (36.6%) IABP n.a. 106 (99%) n.a. 86 (80.4%) IABP

3 (2.8%) ECMO/

IABP; ECMO/ VAD

n.a. n.a. 79 (74%) 87.7% at 1year

VAD

2006 13 CS

23% (total) IABP n.a. n.a. n.a. n.a. n.a. n.a. n.a. 10/ 13 (77%) n.a. (overall CABG 412)

2008 9476 881 (9.3%) IABP n.a. n.a. n.a. n.a. n.a. n.a. n.a. 9032 (95.3%) n.a.

2008 14,956 70.3% IABP n.a. 58.1% n.a. 2.5% VAD n.a. 2.5% 22.1%

(33% CABG + valve)

2009 44 n.a. n.a. n.a. n.a. n.a. 6 (13.6%) ECMO n.a. n.a. 35 (79.5%)

30- day

2010 2647 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 2548 (96.3%) n.a.

2011 8 0% n.a. n.a. 8 8 (100%) IABP + ECMO n.a. n.a. n.a. n.a.

2011 25,175 840 (3.4%) IABP n.a. 22,190 (88.2%) 1431 (5.7%) 1130 (4.5%) IABP n.a. n.a. 24764 (98.4%)

Survival? Not speciﬁed

2013 44,141

22,070 (50%) IABP 3443 (7.8%) 34871 (79%) n.a. n.a. n.a. n.a. n.a. n.a. n.a. CS 9270 (21%)

2013 127 t tot

14 (11%) CS

27/ 127

(21%) IABP

IABP ECLS

9 (7%) 74 (58%) n.a. 84 (66%) IABP

2 (2%) ECLS

IABP ECLS

n.a. n.a. 120 (94%) n.a.

2/ 127 (1.6%)

ECLS

2014 1524 n.a. n.a. n.a. 1420 (93.2%) 205 (13.5%) n.a. n.a. n.a. n.a. 154 (74.6%)

Surgical mortality 52 (25.4%)

2015 85 58 (68%) IABP 100% 47 (55%) n.a. IABP

ECMO

2016 614 13% IABP Cardiac

n.a. n.a. 13% ECMO 18% massage 9 (1%) Resuscitation

IABP 82%; ECMO

23.5%

(6 of the 34 salvage)

n.a. n.a. 35.3%

(60% in ECMO pts)

0% 0% 15% (13% for

emergency and 41% for salvage)

49 (8%)

Long- term survival

47.5% at 10years

40.6% at 15years

53.2% at 1year

46.8%

73.1% at 4years

n.a.

58.6% at 1year

49.8% at 3years

40.9% at 5years (29.2% at 1year in ECMO pts)

79% at 5years (emergency) 46% (for salvage)

(continued)

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