Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942011000400005
Brazilian Journal of Anesthesiology
Scientific Article

Alterações hemodinâmicas durante a revascularização do miocárdio sem utilização de circulação extracorpórea

Hemodynamic changes during myocardial revascularization without extracorporeal circulation

Silvia Minhye Kim; Luiz Marcelo Sá Malbouisson; José Otávio Costa Auler Jr; Maria José Carvalho Carmona

http://dx.doi.org/10.1590/S0034-70942011000400005 Braz J Anesthesiol, vol.61, n4, p.440-446, 2011
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Resumo

JUSTIFICATIVA E OBJETIVOS: O posicionamento e a estabilização cardíaca durante a revascularização miocárdica sem circulação extracorpórea (CEC) podem causar alterações hemodinâmicas de acordo com o local abordado. O objetivo deste estudo foi avaliar essas alterações durante a realização das anastomoses coronarianas distais. MÉTODOS: Vinte pacientes adultos submetidos à revascularização do miocárdio sem CEC receberam monitoração com cateter de artéria pulmonar e ecodoppler transesofágico. Os dados hemodinâmicos foram coletados: (1) após ajustes volêmicos, (2) no início das anastomoses distais e (3) após 5 minutos, antes da remoção do estabilizador de parede. As coronárias tratadas foram agrupadas segundo sua localização: na parede lateral, anterior ou posterior. Realizaram-se ANOVA de duplo fator com repetição e pós-teste de Newman-Keuls. Considerou-se significativo p inferior a 0,05. RESULTADOS: Durante a revascularização do miocárdio sem CEC, a pressão de oclusão de artéria pulmonar elevou-se de 17,7 ± 6,1 para 19,2 ± 6,5 (p < 0,001) e 19,4 ± 5,9 mmHg (p < 0,001), enquanto a pressão venosa central de 13,9 ± 5,4 subiu para 14,9 ± 5,9 (p = 0,007) e 15,1 ± 6,0 mmHg (p = 0,006). O débito cardíaco intermitente sofreu redução de 4,70 ± 1,43 para 4,23 ± 1,22 (p < 0,001) e 4,26 ± 1,27 L.min-1 (p < 0,001). Houve interação grupo-tempo significativa no débito cardíaco obtido por Doppler transesofágico, que sofreu redução no grupo lateral de 4,08 ± 1,99 para 2,84 ± 1,81 (p = 0,02) e 2,86 ± 1,73 L.min-1 (p = 0,02), e no fluxo sanguíneo aórtico, de 2,85 ± 1,39 para 1,99 ± 1,26 (p = 0,02) e 2,00 ± 1,21 L.min-1 (p = 0,02). Não se observaram outras alterações hemodinâmicas durante as anastomoses. CONCLUSÕES: Houve deterioração hemodinâmica significativa durante a revascularização do miocárdio sem CEC. Com o Doppler transesofágico detectou-se redução do débito cardíaco apenas no grupo lateral.

Palavras-chave

CIRURGIA, CIRURGIA, EQUIPAMENTOS, EQUIPAMENTOS, EXAMES DIAGNÓSTICOS, EXAMES DIAGNÓSTICOS, MONITORAÇÃO, TÉCNICAS DE MEDIÇÃO

Abstract

BACKGROUND AND OBJECTIVE: Cardiac positioning and stabilization during myocardial revascularization without extracorporeal circulation (ECC) may cause hemodynamic changes dependent to the surgical site. The objective of this study was to evaluate these changes during distal coronary anastomosis. METHODS: Twenty adult patients undergoing myocardial revascularization without ECC were monitored by pulmonary artery catheter and transesophageal Echo Doppler. Hemodynamic data were collected at the following times before removing the stabilizer wall: (1) after volume adjustments, (2) at the beginning of distal anastomosis, and (3) after 5 minutes. Treated coronary arteries were grouped according to their location in the lateral, anterior, or posterior wall. Two-way ANOVA with repetition and Newman-Keuls post-test were used in the analysis. A p value < 0.05 was considered statically significant. RESULTS: During myocardial revascularization without ECC, pulmonary artery wedge pressure showed elevation from 17.7 ± 6.1 to 19.2 ± 6.5 (p < 0.001) and 19.4 ± 5.9 mmHg (p < 0.001), while the central venous pressure went from 13.9 ± 5.4 to 14.9 ± 5.9 mmHg (p = 0.007) and 15.1 ± 6.0 mmHg (p = 0.006). Intermittent cardiac output was reduced from 4.70 ± 1.43 to 4.23 ± 1.22 (p < 0.001) and 4.26 ± 1.25 L.min-1 (p < 0.001). According to transesophageal Doppler, a significant group-time interaction was observed in cardiac output, which was reduced in the lateral group from 4.08 ± 1.99 to 2.84 ± 1.82 (p = 0.02) and 2.86 ± 1.73 L.min-1 (p = 0.02), and aortic blood flow, which went from 2.85 ± 1.39 to 1.99 ± 1.26 (p = 0.02) and 2.00 ± 1.21 L.min-1 (p = 0.02). Other hemodynamic changes were not observed during anastomoses. CONCLUSIONS: A significant hemodynamic deterioration was observed during myocardial revascularization without ECC. Transesophageal Doppler detected a decrease in cardiac output only in the lateral group.

Keywords

Hemodynamics, Echocardiography, Transesophageal, Coronary Artery Bypass, Extracorporeal Circulation

References

Chassot PG, van der Linden P, Zaugg M. Off-pump coronary artery bypass surgery: physiology and anaesthetic management. Br J Anaesth. 2004;92:400-413.

Jansen EW, Lahpor JR, Borst C. Off-pump coronary bypass grafting: how to use the Octopus Tissue Stabilizer. Ann Thorac Surg. 1998;66:576-579.

Grundeman PF, Borst C, van Herwaarden JA. Vertical displacement of the beating heart by the octopus tissue stabilizer: influence on coronary flow. Ann Thorac Surg. 1998;65:1348-1352.

Singer M. Esophageal Doppler monitoring of aortic blood flow: beat-by-beat cardiac output monitoring. Int Anesthesiol Clin. 1993;31:99-125.

Poli de Figueiredo LF, Malbouisson LM, Varicoda EY. Thermal filament continuous thermodilution cardiac output delayed response limits its value during acute hemodynamic instability. J Trauma. 1999;47:288-293.

Higgins TL, Estafanous FG, Loop FD. Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients: A clinical severity score. JAMA. 1992;267:2344-2348.

Couture P, Denault A, Limoges P. Mechanisms of hemodynamic changes during off-pump coronary artery bypass surgery. Can J Anaesth. 2002;49:835-849.

D'Ancona G, Karamanoukian H, Lima R. Hemodynamic effects of elevation and stabilization of the heart during off-pump coronary surgery. J Card Surg. 2000;15:385-391.

Grundeman PF, Borst C, Verlaan CW. Exposure of circumflex branches in the tilted, beating porcine heart: echocardiographic evidence of right ventricular deformation and the effect of right or left heart bypass. J Thorac Cardiovasc Surg. 1999;118:316-323.

Jansen EW, Borst C, Lahpor JR. Coronary artery bypass grafting without cardiopulmonary bypass using the octopus method: results in the first one hundred patients. J Thorac Cardiovasc Surg. 1998;116:60-67.

Mathison M, Edgerton JR, Horswell JL. Analysis of hemodynamic changes during beating heart surgical procedures. Ann Thorac Surg. 2000;70:1355-1361.

Mishra M, Shrivastava S, Dhar A. A prospective evaluation of hemodynamic instability during off-pump coronary artery bypass surgery. J Cardiothorac Vasc Anesth. 2003;17:452-458.

Nierich AP, Diephuis J, Jansen EW. Heart displacement during off-pump CABG: how well is it tolerated?. Ann Thorac Surg. 2000;70:466-472.

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