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• W2048367186 abstract "We have previously reported the effects of hemostatic devices on the endothelial function of coronary arteries in a porcine model reproducing the conditions of beating heart coronary artery bypass surgery. These methods included clamping of the coronary artery with bulldog clamps, gas jet insufflation, extravascular balloon occlusion [1Perrault L.P Menasché P Wassef M et al.Endothelial effects of hemostatic devices during continuous cardioplegia or minimally invasive surgery.Ann Thorac Surg. 1996; 62: 1158-1163Abstract Full Text PDF PubMed Scopus (27) Google Scholar], and snaring of the vessel on silicone tubings [2Perrault L.P Menasché P Bidouard J.P et al.Snaring of the target vessel in less invasive bypass operations does not cause endothelial dysfunction.Ann Thorac Surg. 1997; 63: 751-755Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar]. These experiments have shown that clamping produces a significant coronary endothelial dysfunction and gas jet insufflation but to a lesser degree, as demonstrated by the impaired endothelium-dependent relaxations to the receptor-operated agonist serotonin while endothelium-independent relaxations were maintained. Extravascular balloon occlusion and snaring caused no significant endothelial dysfunction assessed in organ chamber experiments. Because of the recent development of shunt catheters for perfusion during the construction of the anastomosis on the beating heart, experiments were conducted to determine the effects of these devices on coronary endothelial function in the same model. In brief, under general anesthesia and after median sternotomy, 2-mm experimental silicone perfusion catheters (not available commercially) (n = 6) and a 2.5-mm Anastaflo device (Research Medical Inc, Midvale, UT) (n = 6) matched to the size of the target artery were inserted in vivo through a 3-mm arteriotomy in the left anterior descending artery (Fig 1). The devices were applied for 15 minutes after which they were removed and the hearts were explanted and the coronary arteries dissected out in the standard fashion [1Perrault L.P Menasché P Wassef M et al.Endothelial effects of hemostatic devices during continuous cardioplegia or minimally invasive surgery.Ann Thorac Surg. 1996; 62: 1158-1163Abstract Full Text PDF PubMed Scopus (27) Google Scholar, 2Perrault L.P Menasché P Bidouard J.P et al.Snaring of the target vessel in less invasive bypass operations does not cause endothelial dysfunction.Ann Thorac Surg. 1997; 63: 751-755Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar]. Rings in contact with the catheters proximal and distal to the arteriotomy were harvested for the experiments (Fig 2). Coronary rings remote from the arteriotomy sites served as controls.Fig 2Schematic depicting the sites of instrumented and control coronary rings selected for vascular reactivity studies. LCX = left circumflex coronary artery; LAD = left anterior descending artery.View Large Image Figure ViewerDownload (PPT) There were no significant differences between the perfusion catheter, Anastaflo, or control groups in the amplitude of contraction to potassium chloride and prostaglandin F2α(Table 1). There was a significant decrease in endothelium-dependent relaxations to serotonin (10−10 to 10−5 M) in both the perfusion catheter and Anastaflo groups compared with control coronary arteries (Fig 3). There were no significant differences in endothelium-independent relaxations to the exogenous NO donor, Sin-1 (10−5 M, data not shown). These results show that intravascular catheters cause a significant endothelial dysfunction in normal porcine coronary arteries of the same magnitude as the intentional removal of the endothelium by endoluminal rubbing of the intimal surface often used in physiological studies [3Perrault L.P Menasché P Bidouard J.P et al.The endothelium in minimally invasive surgery.Can J Cardiol. 1997; 13 ([Abstract]): 116CGoogle Scholar]. The fact that contractile function and endothelium-independent relaxations were unaffected by the use of intravascular devices demonstrates the integrity of the underlying smooth muscle cells. Compared with intravascular devices, extravascular techniques create a lesser degree of endothelial functional damage. The effect of intravascular devices on the endothelium may not cause severe untoward consequences in severely atherosclerotic arteries, which are often dysfunctional. However, the unfavorable profile observed should raise caution in surgeons, because intravascular devices and insufflation of gas within the lumen of the coronary artery may favor coronary vasospasm in the acute period after surgery at the site of insertion because of the loss of endothelial coverage. Moreover, the endothelial denudation associated with insertion and removal of the catheters is followed by the regeneration of endothelial cells, which present a selective dysfunction of Gi-protein-mediated relaxations that can lead to a reduced bioavailibility of endothelial nitric oxide and loss of the protective effects of nitric oxide on smooth muscle proliferation and platelet aggregation. With exposure of the basement membrane and collagen fibers, the injured surface becomes a preferential site for platelet aggregation and activation of the coagulation pathway, possibly favoring the development of intimal hyperplasia at the site of endothelial injury, which can lead to premature graft failure [4Shimokawa H Flavahan N.A Vanhoutte P.M Loss of the endothelial pertussis toxinsensitive G-protein function in atherosclerotic porcine coronary arteries.Circulation. 1991; 83: 652-660Crossref PubMed Scopus (173) Google Scholar]. Finally, because most patients who undergo coronary artery bypass surgery probably have a significant endothelial dysfunction of their coronary arteries associated with advanced atherosclerosis [5Perrault L.P Menasché P Vanhoutte P.M High-flow gas insufflation to facilitate MIDCAB effects on the coronary endothelium [Letter to the editor].Ann Thorac Surg. 1999; 67: 892-896Google Scholar], additional injury to the endothelium from devices may not contribute to the progression of disease within the vessel wall unless the smooth muscle cell layer is injured. This would explain the satisfactory clinical results in most patients whose coronary arteries are probed during surgery, a procedure we do not recommend using routinely because intimal injury may have severe consequences. Indeed, iatrogenic left main stenosis has been reported after angioplasty or the use of rigid catheters inserted in the coronary ostia during aortic valve replacement secondary to intimal trauma [6Prachar H Muhlbauer J Pollak H Enenkel W Iatrogenic left main coronary artery stenosis following aortic valve replacement.Eur Heart J. 1988; 9: 1151-1154PubMed Google Scholar]. Nevertheless, further studies are needed to assess the effect of hemostatic devices used in minimally invasive coronary artery bypass surgery or continuous cardioplegia on atherosclerotic arteries with endothelial dysfunction to render this type of physiological evaluation more relevant to the current practice of cardiac surgery.Table 1Amplitude of Contraction to KCl (60 mM) and PGF2α Between GroupslegendPGF2α = prostaglandin F2α.Perfusion CatheterVisuflo CatheterControlsKCl 60 mM contraction (g)8.4 ± 2.88 ± 3.58.1 ± 2.4PGF2α contraction (g)4 ± 1.42.9 ± 1.52.9 ± 0.7PGF2α contraction (% of KCl contraction)35 ± 7.036 ± 1338 ± 3.0legend PGF2α = prostaglandin F2α. Open table in a new tab" @default.
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