Effects of intraoperative diltiazem infusion on flow changes in arterial and venous grafts in coronary artery bypass graft surgery

Erdem, Ozan; Memetoğlu, Mehmet Erdem; Tekın, Ali; Arslan, Ümit; Akkaya, Özgür; Kutlu, Rasim; Golbasi, Ilhan

doi:10.5935/1678-9741.20150045

Cited by 4 publications

(6 citation statements)

References 17 publications

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“…Four trials reported arterial graft flow measurements, but the data were insufficient for synthesis. One study revealed that, compared to placebo, continuous perioperative IV infusion of DILT significantly increased IMA blood flow[ 41 ]. Results from two other studies showed that patients receiving NTG had significantly higher blood flow in IMA or radial grafts[ 50 , 51 ], while a study comparing DILT to NTG showed that patients in the DILT group had significantly higher IMA blood flow[ 34 ].…”

Section: Resultsmentioning

confidence: 99%

“…Studies in vitro and in vivo have consistently demonstrated that CCBs, topically applied or directly injected into the grafts, can significantly increase blood flow in human IMA and the radial artery (RA) grafts. Data from studies by Erdem[ 41 ] and Tabel[ 34 ] showed that continuous IV infusion of DILT is superior to both placebo and NTG in improving blood flow in dissected left IMA and RA segments before graft anastomosis. Although there were no data of direct flow measurement postoperatively, the lower incidence of cardiac ischemia and cardiac arrhythmia from the current meta-analysis indicated that coronary blood flow was likely better maintained early postoperatively in patients who received perioperative DILT infusion.…”

Section: Discussionmentioning

confidence: 99%

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Perioperative diltiazem or nitroglycerin in on-pump coronary artery bypass: A systematic review and network meta-analysis

Yang

Zhang

et al. 2018

PLoS ONE

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BackgroundArterial graft spasm is a severe complication after coronary artery bypass graft (CABG). Among numerous potential antispasmodic agents, systemic application of diltiazem and nitroglycerin had been investigated most frequently over the past three decades. However, it remains inconclusive if either or both agents could improve patient outcomes by preventing graft spasm when applied perioperatively, and, if so, which one would be a better choice. The current systematic review and network meta-analysis aims to summarize the data from all available randomized clinical trials of perioperative continuous intravenous infusion of diltiazem and/or nitroglycerin in patients undergoing on-pump CABG in order to define and compare their roles in graft spasm prevention and their impacts on perioperative outcomes.MethodsWe searched Ovid Medline, PubMed, CINAHL, Google Scholar and Cochrane Center for randomized controlled trials that reported outcome effects of perioperative continuous intravenous infusion of diltiazem and/or nitroglycerin in patients undergoing elective on-pump CABG. Conventional meta-analyses were conducted to evaluate the pairwise comparisons (diltiazem vs. placebo; nitroglycerin vs. placebo; diltiazem vs. nitroglycerin) on perioperative outcomes. Network meta-analyses were implemented to compare the three regimens through direct and indirect comparison.ResultsTwenty-seven studies involving 1,660 patients were included. Pairwise and network meta-analyses found no significant difference in mortality among the groups. There are four studies that reported blood flow measurements of internal mammary artery grafts intraoperatively after dissecting or immediately after distal anastomosis while patients were on continuous intravenous infusion of diltiazem and nitroglycerin. Although insufficient for data synthesis, the measured results from all four studies suggest that both diltiazem and nitroglycerin significantly increased blood flow of arterial grafts compared to placebo. For other perioperative outcomes, compared to diltiazem, patients that received nitroglycerin had higher odds of postoperative atrial fibrillation (OR = 2.67, 95% CI: 1.15 to 6.24) and higher peak serum cardiac enzymes. Patients that received placebo had higher odds of atrial fibrillation (OR = 3.00, 95% CI: 1.18 to 7.63) and lower odds of requiring inotrope support (OR = 0.19, 95% CI: 0.04 to 0.73) compared to diltiazem. Data from the network meta-analysis indicated that diltiazem had significantly lower odds of postoperative atrial fibrillation compared to nitroglycerin (OR = 0.39, 95% CI: 0.18 to 0.85). In fact, the rank from highest to lowest rates of postoperative atrial fibrillation was placebo>nitroglycerin>diltiazem. The rank from highest to lowest odds of requiring inotropic support is nitroglycerin> diltiazem>placebo. However, placebo had significantly higher odds of postoperative myocardial infarction than diltiazem (OR = 4.51, 95% CI: 1.34 to 15.25). The rank from highest to lowest odds of postoperative myocardial infarctio...

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Perioperative diltiazem or nitroglycerin in on-pump coronary artery bypass: A systematic review and network meta-analysis

Yang

Zhang

et al. 2018

PLoS ONE

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“…However, there has been no de nitive anatomical evidence supporting that perioperative continuous iv application of diltiazem had a direct vasodilatory effect on coronary grafts after the sternum was closed. Diltiazem became the preferred antispasmodic agent because, compared to nitroglycerine, it had more favorable perioperative outcome pro les, including lower incidences of new onset A-b and cardiac ischemia 7,9,21,22 . Noticeably, data from these RCTs also suggest that patients on diltiazem may need prolonged hemodynamic support from inotropic and/or vasoactive support, indicating that the usage of diltiazem may have potential negative perioperative and long-term outcome impacts 22 .…”

Section: Discussionmentioning

confidence: 99%

“…Over the past three decades, numerous drugs have been investigated in RCTs for preventing graft spasm 6 , among which certain calcium channel blockers (CCBs), e.g., diltiazem and nitroglycerin, were the top choices because of their well-known coronary selectivity and their proven track records of reliable symptomatic relief of unstable angina. Data from these RCTs, mostly conducted between the 1980s and early 2000s with small sample sizes on LITA grafts, suggested that, by direct ow check intraoperatively, both diltiazem and nitroglycerin increased arterial graft blood ow when applied locally and/or systemically, while when applied through continuous intravenous (iv) infusion perioperatively, diltiazem was superior to nitroglycerin for lower incidences of perioperative cardiac ischemia and arrythmia [7][8][9][10][11][12][13][14][15] . Currently, perioperative continuous iv infusion of diltiazem is frequently chosen as the intervention for preventing arterial graft spasms, especially for patients who receive RA grafts; however, its perioperative and long-term outcome bene ts remain uncon rmed.…”

Section: Introductionmentioning

confidence: 99%

Perioperative Application of Diltiazem in Patients Undergoing On-Pump Coronary Artery Bypass Grafting

Zhang

Friscia

et al. 2022

Preprint

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Diltiazem is frequently applied during the perioperative period of coronary artery bypass grafting with cardiopulmonary bypass (on-pump CABG) to prevent arterial graft spasm; however, the short- and long-term outcome effects are unclear. In this retrospective cohort study, from October 2008 to October 2018, adult patients who underwent isolated CABG with cardiopulmonary bypass (CPB) were identified. Patients in the perioperative diltiazem (DILT) and non-intervention (non-DILT) cohorts were matched based on propensity scores. Logistic regression was fitted to evaluate the impact on short-term outcomes. Long-term outcome was investigated by survival analyses. Total of 1004 patients were included. There were no statistically significant differences between the cohorts in perioperative outcomes, although at 24 hours postoperatively, patients in DILT were more likely to be on hemodynamic support from inotropic and/or vasoactive agents. The overall long-term survival was similar between the cohorts; however, in the subgroup of patients who received more than one arterial graft, perioperative diltiazem may be associated with higher long-term all-cause mortality. Based on these data, the perioperative and long-term outcome benefits of continuous iv infusion of diltiazem in patients who underwent on-pump CABG.

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“…It is another commonly applied vasodilator agent to prevent vasospasm and increase flow of coronary artery bypass conduits during CABG. Intraoperative intravenous infusion of diltiazem in addition to topical application of papaverine to test LITA flow was assessed by Erdem O et al [ 27 ] , and the authors found that the maneuver significantly increased the arterial graft flows as well as provided lower incidence of atrial fibrillation during the intraoperative and postoperative periods [ 27 ] . Other than the flow alteration properties of diltiazem, apoptotic properties of this agent on tissues were also assessed in the literature.…”

Section: Discussionmentioning

confidence: 99%

Comparison of the Apoptotic Effects of Topically Applied Papaverine, Diltiazem, and Nitroprusside to Internal Thoracic Artery

Ünal¹,

Ulukan²,

Bakuy³

et al. 2020

Braz J Cardiovasc Surg

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Objective To detect and to compare the apoptotic effects of intraoperatively topically applied diltiazem, papaverine, and nitroprusside. Methods Internal thoracic artery segments of ten patients were obtained during coronary bypass grafting surgery. Each internal thoracic artery segment was divided into four pieces and immersed into four different solutions containing separately saline (Group S), diltiazem (Group D), papaverine (Group P), and nitroprusside (Group N). Each segment was examined with both hematoxylin-eosin and the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) method in order to determine and quantify apoptosis. Results Apoptotic cells were counted in 50 microscopic areas of each segment. No significant difference was observed among the four groups according to hematoxylin-eosin staining. However, the TUNEL method revealed a significant increase in mean apoptotic cells in the diltiazem group when compared with the other three groups (Group S=4.25±1.4; Group D=13.31±2.8; Group N=9.48±2.09; Group P =10.75±2.37). The differences between groups were significant ( P =0.0001). No difference was observed between the samples of the diabetic and non-diabetic patients in any of the study groups. Conclusion The benefit of topically applied vasodilator drugs must outweigh the potential adverse effects. In terms of apoptosis, diltiazem was found to have the most deleterious effects on internal thoracic artery graft segments. Of the analyzed medical agents, nitroprusside was found to have the least apoptotic activity, followed by papaverine. Diabetes did not have significant effect on the occurrence of apoptosis in left internal thoracic artery grafts.

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Effects of intraoperative diltiazem infusion on flow changes in arterial and venous grafts in coronary artery bypass graft surgery

Cited by 4 publications

References 17 publications

Perioperative diltiazem or nitroglycerin in on-pump coronary artery bypass: A systematic review and network meta-analysis

Perioperative diltiazem or nitroglycerin in on-pump coronary artery bypass: A systematic review and network meta-analysis

Perioperative Application of Diltiazem in Patients Undergoing On-Pump Coronary Artery Bypass Grafting

Comparison of the Apoptotic Effects of Topically Applied Papaverine, Diltiazem, and Nitroprusside to Internal Thoracic Artery

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