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J Thorac Cardiovasc Surg 2008;135:1110-1119
© 2008 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Myocardial injury in coronary artery bypass grafting: On-pump versus off-pump comparison by measuring high-sensitivity C-reactive protein, cardiac troponin I, heart-type fatty acid–binding protein, creatine kinase-MB, and myoglobin release

Ujjwal K. Chowdhury, MCh, Diplomate NBa,*, Vishwas Malik, DMb, Rakesh Yadav, DMc, Sandeep Seth, DMc, Lakshmy Ramakrishnan, PhDd, Mani Kalaivani, MSc (Biostatistics)e, Srikrishna M. Reddy, MSa, Ganapathy K. Subramaniam, MCha, Raghu Govindappa, MSa, Madhava Kakani, MDb

a Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
b Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
c Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
d Department of Cardiac Biochemistry, All India Institute of Medical Sciences, New Delhi, India
e Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India

Received for publication July 20, 2007; revisions received December 17, 2007; accepted for publication December 27, 2007.

* Address for reprints: Ujjwal K. Chowdhury, MCh, Diplomate NB, Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi-110029, India. (Email: ujjwalchow{at}rediffmail.com; ujjwalchowdhury{at}gmail.com).

Objectives: We sought to investigate the release pattern of different cardiac biomarkers (high-sensitivity C-reactive protein, cardiac troponin I, heart-type fatty acid–binding protein, creatine kinase-MB, and myoglobin) and to establish the diagnostic discrimination limits of each marker protein to evaluate perioperative myocardial injury in patients undergoing coronary artery bypass grafting with or without cardiopulmonary bypass.

Methods: Fifty patients were randomly assigned to on-pump or off-pump coronary artery bypass grafting. All cardiac biomarkers were measured in serial venous blood samples drawn before heparinization in both groups and after aortic unclamping at 1, 2, 4, 8, 24, 48, and 72 hours in the on-pump group. In the off-pump group samples were taken after the last distal anastomosis and at same time intervals as in the on-pump group.

Results: The total amount of heart-type fatty acid–binding protein, cardiac troponin I, and high-sensitivity C-reactive protein released was significantly higher in the on-pump group than in the off-pump group. Receiver operating characteristic curve analysis of cardiac biomarkers indicated cardiac troponin I and heart-type fatty acid–binding protein as the superior diagnostic discriminators of myocardial injury, with an optimal cutoff value of greater than 0.92 ng/mL (area under the curve, 0.95 [95% CI, 0.88–1.00]; sensitivity, 92%; specificity, 92%; likelihood ratio [+], 11.50) and greater than 6.8 ng/mL (area under the curve, 0.94 [95% CI, 0.88–1.00]; sensitivity, 88%; specificity, 88%; likelihood ratio [+], 7.33), respectively. Logistic regression analysis revealed that patients with increased cardiac troponin I levels of greater than 0.92 ng/mL and heart-type fatty acid–binding protein levels of greater than 6.8 ng/mL were at 132.25 (95% confidence interval, 17.14–1020.49) times and 53.77 (95% confidence interval, 9.76–296.12) times higher risk of myocardial injury after on-pump coronary artery bypass grafting.

Conclusions: Off-pump coronary artery bypass grafting provides better myocardial protection than on-pump coronary artery bypass grafting. Cardiac troponin I and heart-type fatty acid–binding protein, but not high-sensitivity C-reactive protein, served as superior diagnostic discriminators of perioperative myocardial damage after on-pump coronary artery bypass grafting.

Abbreviations and Acronyms ACT = activated clotting time; AUC = area under the curve; CABG = coronary artery bypass grafting; CI = confidence interval; CK-MB = creatine kinase-MB; CPB = cardiopulmonary bypass; cTn-I = cardiac troponin I; hFABP = heart-type fatty acid–binding protein; hs-CRP = high-sensitivity C-reactive protein; ICU = intensive care unit; MRI = magnetic resonance imaging; ROC = receiver operating characteristic




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L. G. Chandrasena, H. Peiris, and H. D. Waikar
Biochemical Changes Associated with Reperfusion After Off-Pump and On-Pump Coronary Artery Bypass Graft Surgery
Ann. Clin. Lab. Sci., January 1, 2009; 39(4): 372 - 377.
[Abstract] [Full Text] [PDF]


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