Arif GÜCÜ, İris KAN, İlkin ÇAVUŞOĞLU, Serdar ENER, İmer OKAR, Selçuk ATASOY, Emine ÖZÇINAR, Bilal PERÇİN, Fatma Nur KAYA

Koroner anastomoz alanına hava üflenmesi ve endotel hasarı

Amaç: Çalışan kalpte koroner cerrahisinde cerrahi alandaki kanı uzaklaştırmak ve görüşü iyileştirmek amacıyla anastomoz alanına yüksek akımlı gaz üflenmesi kullanışlı bir yöntemdir. Bu yöntemin koroner endotelde oluşturabileceği histopatolojik değişiklikleri araştırmak amacıyla bu deneysel çalışma planlandı. Materyal ve Metod: Sekiz Mongrel köpek deneğe genel anesteziyle sol torakotomi uygulandı. Sol ön inen koroner arter orta segment "Octopus2" ile stabilize ve buldog klemple oklude edildi. Koroner arteriyotomi sonrası 10 dak süresince filtre edilmiş yüksek akımlı oda havası ile aralıklı üfleme yapıldı. Grup I (n = 8) için işlem bölgesinden, Grup II (n = 8) için oklüzyon yapılan bölgenin proksimalinden doku örnekleri alındı. Arter örnekleri gerekli işlemlerden geçirilerek taramalı elektron mikroskop incelemesine hazırlandı. İnceleme kör yöntemle yapıldı, skorlandı ve sonuçlar istatistik değerlendirmeyle birlikte yorumlandı. Bulgular: Doku örneklerinin incelemesinde, Grup I'de sadece 1 örnekte endotel hasarı saptanmadı. Altı örnekte Tip I, bir örnekte Tip II hasar oluştuğu belirlendi. Grup II'de 1 örnekte Tip I hasarın oluştuğu, 7 örnekte hasar oluşmadığı görüldü. Grup I ile Grup II arasında endotel hasarı oluşması açısından istatistiksel anlamlı fark olduğu belirlendi. Sonuç: Filtre edilmiş yüksek akımlı oda havasının 10 dakika süreyle aralıklı üflenmesi sıklıkla Tip I, seyrek olarak Tip II hasara neden olabilmektedir. Endotel hasarı riski nedeniyle koroner cerrahisinde hava üfleme tekniği dikkatle uygulanmalı ve hasarlama olasılığını azaltacak şekilde önlem alınmalıdır.

Air blowing to coronary anastomotic area and endothelial injury

Background: High flow gas insuflation is a useful method in order to remove blood out of the surgical field and improve the sight during off-pump coronary surgery. An experimental study was planned to investigate the potentially harmful histopathologic changes on coronary endothelium of this technique. Methods: Under general anaesthesia left thoracotomy was carried out on eight Mongrel dogs. The left anterior descending coronary artery was stabilized using Octopus2 and occluded with a bulldog clamp. Coronary arteriotomy was carried out and filtrated high flow room air was insufflated for ten minutes. Tissue samples were taken from the procedure area as Group I (n = 8), and from the proximal part of the occlusion as control Group II (n = 8). Tissue samples were processed for scanning electron microscopic examination. Examination and scoring of endothelial injury were performed in blind fashion, and results were analyzed statistically. Results: There was no endothelial damage in one sample while Type I injury in six samples and Type II injury in one other were observed in Group I. In Group II, Type I injury was observed in only one sample, whereas no damage was observed in the other seven samples. There was statistically significant difference between the groups in the meaning of frequency of endothelial injury. Conclusion: This study reveals that intermittent insufflation of the filtrated high flow room air to the coronary anastomotic area for ten minutes may frequently cause Type I and rare Type II endothelial injury. Because of the risk of endothelial injury, air blower should be used cautiously and be modified so as to decrease the risk of endothelial injury.

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1. Calafiore AM, Di Giammarco G, Teodori G, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-65.
2. Hangler HB, Pfaller K, Antretter H, Dapunt OE, Bonatti JO. Coronary endothelial injury after local occlusion on the human beating heart. Ann Thorac Surg 2001;71:122-7.
3. Teoh KH, Panos AL, Harmantas AA, Lichtenstein SV, Salerno TA. Optimal visualization of coronary artery anastomoses by gas jet. Ann Thorac Surg 1991;52:564.
4. Burfeind WR, Duhaylongsod FG, Annex BH, Samuelson D. High-flow gas insufflation to facilitate MIDCABG: Effects on coronary endothelium. Ann Thorac Surg 1998;66:1246-9.
5. Herbert BH, Kristian P, Herwig A, Otto ED, Johannes OB. Coronary endothelial injury after local occlusion on the human beating heart. Ann Thorac Surg 2001;71:122-7.
6. Poulton TJ. Visualization of coronary artery anastomoses by gas jet [letter]. Ann Thorac Surg 1992;54:598-9.
7. Okazaki Y, Takarabe K, Murayama J, et al. Coronary endothelial damage during off-pump CABG related to coronary-clamping and gas insufflation. Eur J Cardiothorac Surg 2001;19:834-9.
8. Bjorling DE, Saban R, Tengowski MW, Gruel SM, Rao V K . Removal of venous endothelium with air. J Pharmacol Toxicol Methods 1992;28:149-57.
9. Perrault LP, Menasche PM, Wassef MD, Bidourad JP. Endothelial effects of hemostatic devices for continuous cardioplegia or minimally invasive operations. Ann Thorac Surg 1996;62:1158-63.
10. Furchgott RF, Vanhoutte PM. Endothelium-derived relaxing and contracting factors. FASEB J 1989;3:2007-18.
11. Vanhoutte PM. The endothelium-modulator of vascular smooth-muscle tone. N Engl J Med 1988;319:412-3.
12. Billiar TR. Nitric oxide: Novel biology with clinical relevance. Ann Surg 1995;221:339-49.
13. Luscher TF, Tanner FC, Tschudi MR, Noll G. Endothelial dysfunction in coronary artery disease. Annu Rev Med 1993;44:395-418.
14. Wilentz JR, Sanborn TA, Haudenschild CC, Valeri CR, Ryan TJ, Faxon TP. Platelet accumulation in experimental angioplasty: Time course and relation to vascular injury. Circulation 1987;75:636-42.
15. Fingerle J, Johnson R, Clowes AW, Majesky MW, Reidy MA. Role of platelets in smooth muscle cell proliferation and migration after vascular injury in rat carotid artery. Proc Natl Acad Sci USA1989;75:8412-6.
16. Davies MG, Hagen PO. Pathobiology of intimal hyperplasia. Br J Surg 1994;81:1254-69.
17. Ip JH, Fuster V, Badimon L, Badimon J, Taubman MB, Chesebro JH. Syndromes of accelerated atherosclerosis: Role of vascular injury and smooth muscle cell proliferation. J Am Coll Cardiol 1990;15:1667-87.
18. Mariani MA, Gu YJ, Boonstra PW, Grandjean JG, van Oeveren W, Ebels T. Procoagulant activity after off-pump coronary operation: Is the current anticoagulation adequate. Ann Thorac Surg 1996;67:1370-5.
19. Chavanon O, Perrault LP, Menasche P, Carrier M. Endothelial effects of hemostatic devices for continuous cardioplegia or minimally invasive operations. Update. Ann Thorac Surg 1999;68:1118-20.
20. Fingerle J, Tina Au YP, Clowes AW, Reidy MA. Intimal lesion formation in rat carotid arteries after endothelial denudation in absence of medial injury. Arteriosclerosis 1990;10:1082-7.