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J Thorac Cardiovasc Surg 1999;117:1227-1228
© 1999 Mosby, Inc.

LETTERS TO THE EDITOR

The use of the calcium antagonist nicardipine in arterial coronarybypass surgery

Department of Cardiovascular Surgery^a
Department of Anesthesiology^b
CHU du Sart-Tilman
4000 Liege, Belgium

To the Editor:

In the December 1998 issue of the Journal, Acar, ¹ Possati, ² and their associates independently provided important data on the5-year patency rate of the radial artery graft.

Both groups acknowledge the impressive spastic characteristics of thisarterial conduit and advocate perioperative release of spasm and routine administrationof the calcium antagonist diltiazem to the patients for 1 year or more. Interruptionof this treatment after 1 year or later during follow-up did not seem to adverselyinfluence either clinical outcome or 5-year patency. This observation is relatedto the apparent loss of reactivity of the radial graft over time.

The use of antispasmodic drugs for patients receiving arterial graftsis a common practice, although so far no study has demonstrated its valueon the surgical outcome, keeping in mind that "spasm" may be confoundedby other factors such as surgical technique, familiarity with arterial grafts,and perioperative conduit preparation. Since 1994, we have been using nicardipinehydrochloride, the first intravenously administered dihydropyridine calciumchannel antagonist, for sequential or bilateral internal thoracic artery grafting.The patients are started perioperatively on intravenous nicardipine hydrochloride(0.25 µg/kg per minute) after a 1 mg intravenous bolus. The drug is titratedaccording to the systemic vascular resistance and discontinued on the secondpostoperative day. For patients receiving a radial artery graft, we addedto this protocol gentle hydrostatic dilatation of the conduit with 1% papaverineand oral administration of nicardipine 20 to 30 mg three times a day afterdiscontinuation of intravenous perfusion on day 2. The first 50 patients undergoingmyocardial revascularization with a radial graft using that protocol wereobserved. A total of 150 anastomoses were performed with a mean of 3.0 anastomosesper patient, and 108 arterial grafts were used for the completion of 111 coronarydistal anastomoses. Fifty radial arteries were used for 52 distal anastomoses,and 36 venous grafts were used for 39 distal anastomoses. The radial arterywas placed on the obtuse marginal branch in 58% of cases, diagonal branchesin 13%, and the right coronary artery in 29%. Proximal anastomoses were donedirectly on the aorta in 80% of cases.

The operative mortality was 4% because of 2 cases of fulminant pulmonarysepsis. There was no evidence of perioperative myocardial infarction or arterialgraft hypoperfusion syndrome. Mean creatine kinase MB level at 18 hours was36 µg/L. Neither ischemic anomalies of the electrocardiogram nor wall motionabnormalities on discharge transthoracic echocardiography were detected. Angiographyperformed in the last 20 patients showed a 98% (51/52) permeability rate forall grafts. Nineteen of 20 radial grafts were patent. A moderate spasm (40%)developed in the middle part of the conduit in one radial artery.

Our experience with the radial artery is part of a larger experiencewith the perioperative use of nicardipine in more than 550 cases of bilateralor sequential internal thoracic artery grafting. This protocol has virtuallyeliminated internal thoracic artery spasm or hypoperfusion in our practice.Nicardipine has several potential advantages over diltiazem. Nicardipine isa more potent and selective arteriolar vasodilatory agent, which also hasthe capability to inhibit endothelin-induced vasoconstriction. ³ This drug has neither chronotropic, dromotropic, norinotropic negative effects. Its short action duration makes it convenientfor perioperative management, and it is well tolerated in association with b blockers in the routine management of patients withcoronary artery disease. Nicardipine also has a documented cardioprotectiveeffect on ischemic myocardium, and some data suggest cardioprotective effectsduring cardioplegic cardiac arrest. ⁴ We therefore suggest that the time has come to assess the real needfor antispasmodic drugs in arterial coronary bypass grafting and to determinethe most adequate pharmacologic management for patients receiving arterialgrafts such as the radial artery.

12/8/97598

References

1. Acar C, Ramsheyi A, Pagny JY, Jebara V,Barrier P, Fabiani JN, et al. The radial artery for coronary artery bypassgrafting: clinical and angiographic results at five years. J Thorac CardiovascSurg 1998;116:981-9.[Abstract/Free Full Text]
   
2. Possati G, Gaudino M, Alessandrini F, LucianiN, Glieca F, Trani C, et al. Midterm clinical and angiographic results ofradial artery grafts used for myocardial revascularization. J Thorac CardiovascSurg 1998;116:1015-21.[Abstract/Free Full Text]
   
3. Goto K, Kasuya Y, Matsuki N, Takuwa Y,Kurihara H, Ishikawa T, et al. Endothelin activates the dihydropyridine-sensitive,voltage-dependent Ca²⁺ channel in vascular smooth muscle. ProcNatl Acad Sci U S A 1989,86:3915-8.
   
4. Turlapaty P, Vary R, Kaplan JA. Nicardipine,a new intravenous calcium antagonist: a review of its pharmacology, pharmacokinetics,and perioperative applications. J Cardiovasc Vasc Anesth 1989;2:344-55.
   

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