Beating-Heart Valve Surgery: A Systematic Review

Abstract

Beating-heart continuous coronary perfusion (BHCCP) has been promoted as an alternative to the technique of cardioplegic arrest in valve surgery. Its potential advantage is the elimination of cardioplegia and the corollary risk of ischemic reperfusion injury. The use of CCP has been recommended especially when performing more complex operations, such as mitral valve repair, and particularly as surgeons become more familiar with beating-heart coronary surgery. We conducted a systematic review to assess the strength of the evidence supporting the efficacy of BHCCP compared to cardioplegia in valve surgery. Thirty nine reports were identified. Of these, only two were randomized control trials. Overall the studies were generally of poor quality and had a low evidence level. In those studies, mortality and major morbidity from BHCCP were within acceptable levels, nevertheless, there was no advantage over cardioplegic arrest. On the other hand there is weak evidence that it may reduce functional and biochemical markers of myocardial injury. In conclusion, BHCCP is an operative strategy in valve surgery with some potential benefits. There is, however a need for a high quality, prospective, randomized control trial to establish the exact role for BHCCP in complex valve surgery.

On-pump Beating Heart Surgery

“…However, Qiang et al believe that this method is not suitable for mitral valve surgery, because an exposed mitral valve presents difficulties and the accuracy of surgery is low [74]. Salhiyyah and Taggart conducted a systematic review to assess the efficacy of on-pump beating heart surgery compared to cardioplegia in valve surgery, and concluded that the former is a strategy in valve surgery with some potential benefits [75]. However, there is a need for a prospective, randomised, controlled trial.…”

Clinical and ultramicroscopic myocardial randomized study of beating versus arrested heart for mitral surgery

“…This knowledge has been extrapolated, but not proven by most these studies that beating heart protects against mitochondrial and cellular damage [6,10,23]. Even though our study had the limitation of small number of patients included into the study, the analysis of 2400 microphotographies from 102 biopsies performed among those 34 patients studied patients, do not support the idea of more injury occur in one technique than the other.…”

“…However, fewer are the studies that analyzed the ultrastructural aspects of human cardiomyocites during the surgical procedure. In a systematic review of beating-heart valve surgery, published by Salhiyyah & Taggart [10], 39 reports were reviewed, however only two were randomized control trials. Indeed, the report of Matsumoto et al [9] that studied 50 patients (25 each group ) concluded that the perfusion technique of either retrograde warm blood or blood perfusion on beating had similar outcome including mortality and complications even though ultra microscopy study were not performed, the biochemical markers of myocardial injury were significantly lower in the retrograde technique.…”

“…Since 1971 [21] when a warm blood cardioplegia surgery was introduced and routinely used most studies that compared with hypothermic cardioplegia, despite of the majority were observational studies, all of them agree that the major advantage of this technique is that heart beating protects against ischemia reperfusion injury in addition to reduced workload and cardiopulmonary bypass time, special for mitral valve replacement that the repair are done close to physiological conditions in the state of left ventricular beating tonus [10,21,22]. This knowledge has been extrapolated, but not proven by most these studies that beating heart protects against mitochondrial and cellular damage [6,10,23].…”

“…Although beating heart valve replacement with continuous coronary sinus perfusion is a good method for myocardial protection because eliminate the use of cardioplegia corollary risk of ischemic reperfusion injury [7,8]. In addition, beating heart surgery produces less cardiac arrhythmia events and no major differences in cerebrovascular events [9,10]. Beating heart technique is being demonstrated to produces less alterations on the biochemistry markers so, have better myocardium protection [11].…”