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J Thorac Cardiovasc Surg 2002;124:732-738
© 2002 The American Association for Thoracic Surgery

Cardiopulmonary Support and Physiology (CSP)

Intrapulmonary shunt after cardiopulmonary bypass: The use of vital capacity maneuvers versus off-pump coronary artery bypass grafting

From the Departments of Cardiothoracic Anesthesia and CCM^a and Clinical Pharmacology and the Department of Cardiothoracic Surgery,^b University of Vienna, General Hospital, Vienna, Austria.

Received for publication Oct 19, 2001. Revisions requested Dec 11, 2001; revisions received Jan 10, 2002. Accepted for publication March 11, 2002. Address for reprints: Edda M. Tschernko, MD, Associate Professor of Cardiothoracic Anesthesia and CCM, Department of Cardiothoracic Anesthesia and CCM, University of Vienna, Vienna General Hospital, Waehringer Guertel 18-20, A-1090 Vienna, Austria (E-mail: edda.tschernko{at}univie.ac.at).

Objectives: It has been proved in human subjects and animals that atelectasis is a major cause of intrapulmonary shunting and hypoxemia after cardiopulmonary bypass. Animal studies suggest that shunting can be prevented entirely by a total vital capacity maneuver performed before termination of bypass. This study aimed to test this theory in human subjects and to evaluate possible advantages of off-pump coronary artery bypass grafting.
Methods: Twenty-four patients scheduled for coronary artery bypass grafting were randomly assigned to receive no total vital capacity maneuver (control group, n = 12) or standard total vital capacity maneuvers (TVCM group, n = 12). Additionally, 12 consecutive patients undergoing off-pump coronary artery bypass grafting (off-pump group) were studied. Systemic and central hemodynamics, the pattern of breathing, and ventilatory mechanics were evaluated after induction of anesthesia, after sternotomy, after cardiopulmonary bypass and skin closure, and 4 hours after extubation.
Results: The use of total vital capacity maneuvers reduced (P < .05) intrapulmonary shunting after termination of cardiopulmonary bypass. However, shunting increased (P < .05) in all groups (control group, 8.2% ± 3.3% vs 25.6% ± 8.1%; TVCM group, 8.7% ± 3.4% vs 24.4% ± 8.5%; and off-pump group, 7.8% ± 2.8% vs 14.0% ± 5.3%) after extubation, but the increase was significantly (P < .05) less pronounced in the off-pump group. Furthermore, pulmonary compliance decreased (P < .05) in all groups except the off-pump group after extubation. Duration of hospital and intensive care unit stay was significantly shorter (P < .05) in the off-pump group than in the other groups.
Conclusion: The development of intrapulmonary shunting and hypoxemia after coronary artery bypass grafting can be substantially reduced by performance of total vital capacity maneuvers while patients are mechanically ventilated. However, off-pump coronary artery bypass surgery is superior in preventing shunting and hypoxemia after bypass grafting in the immediate and early postoperative periods, probably leading to substantially shorter intensive care unit and hospital stays.

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