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Combining Coronary Revascularization and Valvular Surgery on a Beating Heart: An Analysis.

Background: The term “beating heart surgery” (BHS) has been used to describe a range of surgical procedures but is most appropriately used for all types of cardiac surgery in which the heart is beating (but not fibrillating) in the same type of rhythm (sinus, atrial fibrillation, pacemaker rhythm) as before the operation. BHS should be considered an appropriate term to describe either on-pump or off-pump surgery in which retrograde coronary sinus perfusion is used. It is well known that at least two factors contribute to postoperative cardiac mortality and morbidity: the use (and duration) of cardiopulmonary bypass (CPB) and cardioplegic arrest. Reducing the need for and duration of CPB and minimizing the deleterious effects of cardioplegia are primary goals of BHS. Beating heart surgery accomplishes this in a number of ways. It provides perfusion of the myocardial muscle, avoidance of reperfusion injury, reduction of aortic crossclamp time, retrograde blood flow that delivers nutrients to the myocardium, and other advantages. Beating heart surgery is not synonymous with “off-pump” surgery. While the goal of the off-pump technique may also be to avoid the effects of cardiopulmonary bypass or cardioplegia, it may be better to view it as part of a flexible approach to match the operation to the patient rather than the patient to the operation. With this goal of flexibility in mind, we believe that on-pump BHS is also justifiable, especially in patients with impaired left ventricular function. Appropriate BHS procedures might include pure coronary artery bypass grafting (CABG) cases, pure valvular cases, and combined (valvular-CABG) cases. We have previously described the use of BHS with retrograde coronary sinus perfusion as a technique for patients with poor left ventricular function, but further experience with greater numbers of patients has convinced us that the technique can also be used for “normal” patients. The combined surgical techniques we have used are discussed, and the phenomenon of ischemiareperfusion injury, as well as the mechanism of ischemic preconditioning, are also examined.