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CARDIOVASCULAR ANESTHESIA

Segmental Wall Motion Abnormalities During Telerobotic Totally Endoscopic Coronary Artery Bypass Grafting

Stephan Mierdl, MD^*, Christian Byhahn, MD^*, Selami Dogan, MD, Tayfun Aybek, MD, Gerhard Wimmer-Greinecker, MD, PhD, Paul Kessler, MD, PhD^*, Dirk Meininger, MD^*, and Klaus Westphal, MD, PhD^*

Departments of *Anesthesiology, Intensive Care Medicine and Pain Control and Thoracic and Cardiovascular Surgery, J. W. Goethe-University Hospital Center, Frankfurt, Germany

Address correspondence and reprint requests to Klaus Westphal, MD, PhD, Head of the Department of Anesthesiology, Katharina-Kasper Kliniken, Richard-Wagner Str. 14, D-60318 Frankfurt, Germany. Address e-mail to klaus.westphal{at}em.uni-frankfurt.de

In addition to single-lung ventilation (SLV), intrathoracic CO₂ insufflation is mandatory for adequate exposure during totally endoscopic coronary artery bypass grafting. With transesophageal echocardiography, we investigated biventricular myocardial wall motion in 25 patients with isolated disease of the left anterior descending coronary artery who underwent totally endoscopic coronary artery bypass grafting with the "Da Vinci" robotic surgical system. At distinct time points during the operation, a cine loop of both ventricles was registered from a transgastric mid-short-axis view. Myocardial wall motion analysis was performed according to an established segmentation model of the left ventricle and to an established five-point scale for wall motion (1, normal; 5, dyskinesia). Significant alterations from preoperative baseline wall motion were visible in the septal, inferior, and anterior segments of the left ventricle at some time during the prebypass period, combined with a markedly decreased PaO₂ under SLV and increased intrathoracic pressure. The same findings applied to the right ventricle; however, wall motion abnormalities were more pronounced here. After myocardial revascularization, weaning from cardiopulmonary bypass, CO₂ deflation, and return to double-lung ventilation, myocardial wall motion recovered to baseline values. Clinically significant hemodynamic instability did not occur. The data suggest that robot-assisted coronary artery bypass grafting leads to significant prebypass alterations of biventricular segmental wall motion. On the basis of our data, it cannot be definitively stated whether the observed results were due to reduced oxygenation during SLV and thus "real" myocardial ischemia, intrathoracic CO₂ insufflation with positive pressure leading to mechanical compromise of the heart, absolute or relative hypovolemia, or a combination of these factors. However, in this cohort, which consisted of patients with single-vessel disease and good ventricular function, these changes were of limited clinical relevance.

IMPLICATIONS: Segmental myocardial wall motion was evaluated with transesophageal echocardiography during robot-assisted totally endoscopic coronary artery bypass grafting. Significant biventricular segmental wall motion abnormalities occurred before cardiopulmonary bypass under single-lung ventilation and carbon dioxide insufflation. The changes in myocardial wall motion were of limited clinical relevance.

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999