Xpose: a new device that provides reproducible and easy access for multivessel beating heart bypass grafting

BACKGROUND

Off-pump coronary artery bypass (OPCAB) is gaining acceptance and is now more widely used for coronary revascularization. Accessing the vessels, particularly on the lateral and inferior walls of the heart, can sometimes be challenging while the heart is beating.

CASE REPORTS

The Xpose Access Device (Xpose; Guidant Corporation, Cupertino, Ca.) was used in 5 patients undergoing beating heart surgery to position the heart for coronary grafting. Hemodynamic and mixed venous oxygen saturation (MVO2) monitoring was performed with the device in place. In all cases, Xpose was successfully used to easily access and graft all of the target vessels including lateral and inferior wall vessels with the patients maintaining stable hemodynamic performance.

CONCLUSION

Xpose was used to successfully perform multivessel coronary bypass on all walls of the beating heart. These case reports suggest that use of the Xpose will facilitate and expand the ability to easily and consistently perform coronary artery bypass grafting on the beating heart.

Complete myocardial revascularization on the beating heart with epicardial stabilization: anesthetic considerations

OBJECTIVE

To describe an anesthetic management protocol for patients undergoing cardiac surgery with multiple coronary artery bypass grafts without cardiopulmonary bypass (off-pump CABG surgery) by median sternotomy with mechanical stabilization.

DESIGN

Retrospective nonrandomized analysis.

SETTING

Tertiary care hospital.

PARTICIPANTS

Sixty-six consecutive patients on whom off-pump CABG surgery by median sternotomy was attempted.

INTERVENTIONS

Anesthesia was induced with a combination of etomidate and fentanyl; pancuronium bromide was given for muscle relaxation; and anesthesia was maintained with isoflurane, desflurane, or sevoflurane in 100% oxygen. Maintenance of normothermia was attempted by keeping the room temperature at 70 degrees F, warming all fluids to 41 degrees C, and using 2.5 L/min of fresh gas flows and a heat and humidity exchanger. When available, a convective forced-air blanket was used to cover patients' head and shoulders. Patients who were not slated for revascularization of the circumflex vessels and who had good ventricular function received central venous pressure monitoring (26%); all other patients received a pulmonary artery catheter.

MEASUREMENTS AND MAIN RESULTS

Of the 66 patients, 36% required an epinephrine infusion at a mean rate of 1.45+/-2.05 microg/min intraoperatively to maintain hemodynamic stability; 25% required inotropic support for < 12 hours in the intensive care unit.

CONCLUSION

Institution of systematic hemodynamic management was associated with the successful completion of the surgical procedure in 61 patients (92%). Only 5 patients required conversion to regular CABG surgery with cardiopulmonary bypass.

Thromboembolic complications in a peripartum cardiomyopathy patient supported with the Abiomed BVS-5000 ventricular assist device

A case of systemic embolization arising from an akinetic left ventricle in a peripartum cardiomyopathy patient supported with the Abiomed BVS-5000 ventricular assist device is reported. In an akinetic ventricle, prevention of blood stasis by positioning the atrial cannula tip across the mitral valve to decompress the ventricle may prevent this complication.

Sinusoidal fetal heart rate pattern during cardiopulmonary bypass

A gravida 3, para 2 woman underwent an emergency mitral valve replacement at 24 weeks' gestation. A sinusoidal fetal heart pattern was recorded throughout cardiopulmonary bypass. This pattern persisted despite a pump flow maintained at 31 ml/m2 min and an intravenous infusion of phenylephrine to maintain the mean systemic arterial pressure at 50 mm Hg.