Sproule 1

Off-Pump Coronary Artery Bypass BE 2352 Sec 2 Carly Sproule 6 December 2011

Sproule 2

ABSTRACT
Traditional heart surgery is performed on patients who have something affecting the heart. This type of surgery has been around for many years, and it is performed for many reasons that can range from congenital heart defects and coronary artery bypass. Advancements have been made to make this type of surgery not necessary for many procedures including coronary artery bypass. A new procedure called off-pump coronary artery bypass does not use a heart-lung machine, but a heart positioner and stabilizer instead. It has shown to be a safe and inexpensive alternative to traditional heart surgery; however, there are some issues with this surgery method that need to be dealt with in the future.

Sproule 3

Table of Contents
I. Reasons to Have Heart Surgery ...........................................................................4-5 a. Patent Ductus Arteriosus Ligation .................................................................4 b. Coarctation of the Aorta Repair .....................................................................4 c. Atrial Septal Defect Repair ............................................................................4 d. Ventricular Septal Defect Repair ...................................................................4 e. Coronary Artery Bypass Surgery ...................................................................4-5 II. III. Traditional Heart Surgery ....................................................................................5-6 Advancements in Heart Surgery ..........................................................................6-7 a. Thoracotomy Incision ....................................................................................6 b. Sternotomy Incision .......................................................................................6 c. Off-Pump Coronary Artery Bypass ...............................................................6-7 IV. V. Beating Heart Bypass Surgery .............................................................................7 Benefits ................................................................................................................7-9 a. Cockcroft-Gault Foumula ..............................................................................8-9 VI. VII. VIII. IX. Disadvantages ......................................................................................................9 Conclusions ..........................................................................................................9 Works Cited .........................................................................................................10-11 Appendix ..............................................................................................................11-13

Sproule 4 I. Reasons to Have Heart Surgery a. Patent Ductus Arteriosus Ligation (PDA)

A PDA occurs when the ductus arteriosus, which is a natural opening between the aorta and the pulmonary artery during fetus development, does not close after birth. A doctor would have to go in and tie the ductus arteriosus off. This method is called a ligation (University of Maryland Medical Center). b. Coarctation of the Aorta Repair

A coarctation of the aorta occurs when part of the aorta has a really narrow section in it. There are many ways to repair this defect, but one way is to cut the narrow section, then stich the remaining sections together (University of Maryland Medical Center). c. Atrial Septal Defect (ASD) Repair

A defect in the atrial septum, which is the wall between the left and right atria, occurs when there is a hole present after a child is born. This naturally occurring hole usually closes on its own after birth. To repair this defect, open-heart surgery would need to be performed to either stich or patch the hole shut (University of Maryland Medical Center). d. Ventricular Septal Defect (VSD) Repair

A defect in the ventricular septum occurs when a hole is present in the wall separating the left and right ventricles. This defect is not as life threatening; since this hole usually closes by age one. If it does not close, open-heart surgery would need to be performed to patch the hole (University of Maryland Medical Center). e. Coronary Artery Bypass

A coronary artery bypass would need to be performed if there is severe blockage in one of the arteries that supplies blood to the heart. Traditional open-heart surgery would need to be

Sproule 5 performed to fix this blockage. An artery from another part of your body, such as the leg, would be attached to the heart so blood could flow around the blockage, and supply the heart with oxygenated blood (Heart Bypass Surgery). Most people who need this type of operation are in their sixties and seventies, but some are about fifty years old. The people who have to have this surgery when they are fifty are usually male and are overweight. In these cases, the artery in question is usually the widow maker. The widow maker is an affectionate name given to the left coronary or left anterior descending artery. Usually when someone has a heart-attack from this blocked artery, they almost always die. This is due to the fact that the widow maker is the artery that supplies blood to the larger part of your heart, which is the left side (O'Daniel). II. Traditional Heart Surgery Traditional heart surgery is another name for open-heart surgery. This type of heart surgery is performed for many reasons, one of them being coronary artery bypass. During this procedure, an incision is made down the center of the chest to gain access to the sternum, which is the bone covering the heart, so it can be removed. This allows the doctor to see and operate on the heart after cutting the pericardium, which is the sac that surrounds the heart. Before the bypass is performed, the heart needs to be hooked up to a heart-lung machine (Heart Bypass Surgery). This immobilizes the heart making it easier to operate on. During the three to six hour surgery, the heart is stopped for about thirty to ninety minutes (Medtronic). The heart-lung machine keeps the blood circulating through the body by having two devices that act as the atria and ventricles of the heart. As blood flows through the machine, it collects in a chamber and is then pumped through an oxygenator that removes the carbon dioxide and incorporates oxygen into the blood. Once oxygenated, the blood is slowly pumped back into the patient. After surgery, the patient is taken off of the machine slowly so everything can get back into rhythm

Sproule 6 (University of Southern California). Afterward, the patient may experience some side effects of the heart-lung machine such as kidney failure; however, advancements in coronary artery bypass have been made so hopefully this will not be an issue in the future (Everyday Health, Inc. ). III. Advancements in Heart Surgery In recent years, advancements have been made to reduce the time, stress, and cost of open-heart surgery. Some advancements for this procedure include thoracotomy and sternoactomy incisions and off-pump coronary artery bypass. a. Thoracotomy Incision A thoracotomy incision is an incision made on the side of the body so a doctor can access the heart between the ribs. However, there are many nerves along the side of your body, so this type of procedure can cause severe pain. Most people who need this type of surgery are infants that need corrective surgery for a congenital heart disease. If they do have this type of operation; however, they need only ibuprofen and Tylenol for the pain (Cincinnati Children's Hospital Medical Center). b. Sternotomy Incision A sternotomy incision is made on the front of the body. This procedure is typically less painful than a thoracotomy incision because there are fewer nerves, so fewer nerves are irritated. The majority of people who require this type of surgery are infants who have a congenital heart disease and need corrective surgery (Cincinnati Children's Hospital Medical Center). c. Off-Pump Coronary Artery Bypass Off-pump coronary artery bypass (OPCAB) ironically gets its name from the heartlung machine, which is commonly referred to as a pump. This type of surgery is used for

Sproule 7 people who have blockage in the arteries that supply blood to their heart. As its name implies, the procedure does not use a heart-lung machine to perform a bypass (Everyday Health, Inc. ). IV. Beating Heart Bypass Surgery Beating heart bypass surgery has been introduced in the last decade. It is an alternative to traditional bypass surgery. This procedure is the same as traditional heart surgery except for the fact that the patient does not need the heart-lung machine because a heart stabilizer and positioner are used. These devices keep the heart beating except for the section of the heart the doctor needs to operate on. The Medtronic Starfish2 and Urchin Heart Positioners are used to position the heart if the artery that needs to be operated is located on the back of the heart. The surgeon attaches them to the heart so he can have easy access to the blocked artery. The Medtronic Octopus Tissue Stabilizer stretches the tissue around the artery to immobilize that section of the heart (Medtronic). The drugs Adenosine and Esmolol are administered to slow the heart, also. When operating, sponges are used to soak up any excess blood and to help with the positioning of the heart. An (OPCAB) usually takes a shorter time to complete because the patient does not have to be slowly taken of the heart-lung machine (Brown University). V. Benefits There are many benefits of having a beating heart surgery bypass versus a traditional heart bypass. They include fewer blood clots, less weight gain, less risk for strokes, and many more. One big benefit of having this surgery is that it is twenty-five percent cheaper than a traditional heart bypass. There is less kidney stress involved in this type of surgery. A study was done to compare the tissue damage done during off-pump coronary artery bypass and traditional heart bypass surgery. They observed oxygen-deprived free radicals that can cause this tissue damage to see which surgery is better. They came to the conclusion that the beating heart bypass

Sproule 8 surgery had lower oxygen-deprived free radicals than the traditional surgery (Gonenc, Hacevki and Griffiths). Another study was done to see the effects of mini extracorporeal circulation on high risk patients during on-pump beating heart surgery. The mini extracorporeal circulation system is used in beating heart surgery sometimes used during the surgery. They found that this procedure is a good alternative for high-risk patients, and the methods are safe, secure and effective (Munos, Calderon and Pillois). a. Cockcroft-Gault Formula Male: GFR = (140-age)*bodyweight 72*serum creatinine Female: GFR = 0.85*(140-age)*bodyweight 72*serum creatinine Age: years Bodyweight: kg Glomerular Filtrate Rate (GFR): mgL/min Serum Creatinine: mg/dL (Computer Aided Therapy for Oncology) The Cockcroft-Gault formula is used to measure the glomerular filtrate rate of the kidneys. The higher the number the equation yields mean the better your kidneys are functioning. During traditional heart bypass surgery, the heart-lung machine puts great stress on the kidneys and muscles. This means that more creatinine is released from the muscles, which makes it harder for the kidneys to function. Mild acute kidney failure is associated with a glomerular filtrate rate less than sixty milliliter per minute (Kolli, Rajagopalam and Patel). During off-pump coronary bypass surgery, there has been speculation that intra-aortic balloon pumps, which are used sometimes during this procedure, were not safe because they decrease kidney function. A

Sproule 9 study was done to show that it does not decrease kidney function and that serum creatinine remained about the same (Muniraju, Pandey and Chakravarthy). VI. Disadvantages There have been arguments that the off-pump coronary artery bypass is not as effective as we thought it was going to be. There are reports about how not all the grafts that need to be done are completed during surgery, that the grafts themselves are not very secure, and that more patients had died, had a heart attack, or need another procedure to fix a blocked artery. The Veterans Affairs medical clinics did a study that had these results; however, surgeons only needed to complete twenty beating heart surgeries to participate in the study (Harvard University). VII. Conclusion We can conclude that off-pump coronary bypass surgery is a new alternative to traditional bypass surgery that has shown great promise. So far; however, this type of surgery has shown that it is a safe and cost effective procedure. It has also shown that it is a much better option for at-risk patients such as people who are over seventy years old since it does not involve a machine that puts a greater amount of stress on the body. There are issues that need to be addressed by more studies with higher requirements to participate in. When presenting this information, I feel that I got my main point across to the audience, which was that off-pump coronary artery bypass surgery is a new procedure that could potentially be better than traditional heart surgery. For my next presentation, I would practice more, so I will not have so much nervous energy, and I would slow my speech down so the audience would be able to follow better.

Sproule 10 VIII. Works Cited

Brown University. OFF PUMP CORONARY ARTERY BYPASS, OPCAB. 2011. 25 November 2011<http://biomed.brown.edu/Courses/BI108/BI108_2000_Groups/Heart_Surgery/OPC AB.htm>. Cincinnati Children's Hospital Medical Center. Closed Heart Surgery. July 2009. 25 November 2011 <http://www.cincinnatichildrens.org/health/c/closed/>. Computer Aided Therapy for Oncology. Dosage Calculator for GFR by Cockcroft-Gault. 2007. 25 November 2011 <http://www.cato.eu/gfr-cockcroft-gault.html>. Everyday Health, Inc. . Off-Pump Coronary Artery Bypass Surgery. 2011. 20 November 2011 <http://www.everydayhealth.com/heart-disease/off-pump-coronary-artery-bypasssurgery.aspx>. Gonenc, A., et al. "Free radical reaction products and antioxidant capacity in beating heart coronary artery surgery compared to conventional bypass." Biochemistry 76.6 (2011): 677. Harvard University. Off-pump bypass surgery: Promise unfulfilled. 2011. 23 November 2011 <http://www.health.harvard.edu/newsletters/off-pump-bypass-surgery-promiseunfulfilled>. Heart Bypass Surgery. 7 November 2011. 25 November 2011 <http://www.nlm.nih.gov/medlineplus/ency/article/002946.htm>. Kolli, Hari, et al. "Mild acute kidney injury is associated with increased mortality after cardiac surgery in patients with eGFR < 60 mL/min/1.73 m²." Renal Failure 32.9 (2010): 1066-1072. Medtronic. What Is Beating Heart Bypass Surgery? 22 September 2010. 27 November 2011 <http://www.medtronic.com/patients/coronary-artery-disease/therapy/beating-heartbypass-surgery/what-is-beating-heart-bypass-surgery/>. Muniraju, Geetha, et al. "Intra-aortic balloon pump use does not affect the renal function in patients undergoing off pump coronary artery bypass surgery." Annals of Cardiac Anaesthesia 14.3 (2011): 188-191. Munos, Emmanuel, et al. "Beating-heart coronary artery bypass surgery with the help of mini extracorporeal circulation for very high-risk patients." Perfusion 26.2 (2011): 123-131. O'Daniel, Gillian. Heartsick and Headstrong. 3 April 2010. 27 November 2011 <http://heartsickandheadstrong.blogspot.com/2010/04/widowmaker.html>.

Sproule 11 University of Maryland Medical Center. Congenital Heart Defect Corrective Surgeries. 2011. 20 November 2011 <http://www.umm.edu/ency/article/002948.htm>. University of Southern California. Cardiothoracic Surgery. 2011. 20 November 2011 <http://www.cts.usc.edu/zglossary-heartlungmachine.html>. IX. Appendix See Attached