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Randomized Controlled Trial
. 2017 Aug 1;52(2):288-296.
doi: 10.1093/ejcts/ezx087.

Shortening cardioplegic arrest time in patients undergoing combined coronary and valve surgery: results from a multicentre randomized controlled trial: the SCAT trial

Chris A Rogers  1 , Radek Capoun  2 , Lauren J Scott  1 , Jodi Taylor  1 , Anil Jain  3 , Gianni D Angelini  2 , Pradeep Narayan  4 , M-Saadeh Suleiman  2 , Kunal Sarkar  4 , Raimondo Ascione  2
Affiliations
Randomized Controlled Trial

Shortening cardioplegic arrest time in patients undergoing combined coronary and valve surgery: results from a multicentre randomized controlled trial: the SCAT trial

Chris A Rogers et al. Eur J Cardiothorac Surg. .

Abstract

Objectives: Combined coronary artery bypass grafting and valve surgery requires a prolonged period of cardioplegic arrest (CA) predisposing to myocardial injury and postoperative cardiac-specific complications. The aim of this trial was to reduce the CA time in patients undergoing combined coronary artery bypass grafting and valve surgery and assess if this was associated with less myocardial injury and related complications.

Methods: Participants were randomized to (i) coronary artery bypass grafting performed on the beating heart with cardiopulmonary bypass support followed by CA for the valve procedure (hybrid) or (ii) both procedures under CA (conventional). To assess complications related to myocardial injury, we used the composite of death, myocardial infarction, arrhythmia, need for pacing or inotropes for >12 h. To assess myocardial injury, we used serial plasma troponin T and markers of metabolic stress in myocardial biopsies.

Results: Hundred and sixty patients (80 hybrid and 80 conventional) were randomized. Mean age was 66.5 years and 74% were male. Valve procedures included aortic (61.8%) and mitral (33.1%) alone or in combination (5.1%). CA time was 16% lower in the hybrid group [median 98 vs 89 min, geometric mean ratio (GMR) 0.84, 95% confidence interval (CI) 0.77-0.93, P = 0.0004]. Complications related to myocardial injury occurred in 131/160 patients (64/80 conventional, 67/80 hybrid), odds ratio 1.24, 95% CI 0.54-2.86, P = 0.61. Release of troponin T was similar between groups (GMR 1.04, 95% CI 0.87-1.24, P = 0.68). Adenosine monophosphate was 28% lower in the hybrid group (GMR 0.72, 95% CI 0.51-1.02, P = 0.056).

Conclusions: The hybrid procedure reduced the CA time but myocardial injury outcomes were not superior to conventional approach.

Trial registration: ISRCTN65770930.

Keywords: Beating heart coronary surgery; Cardioplegic arrest; Myocardial protection; Valve surgery.

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Figures

Figure 1
Figure 1
Flow of participants through the trial. Notes: 1Reasons for exclusion are only available for the Bristol site. 2Some patients were ineligible for more than one reason.
Figure 2
Figure 2
Primary and secondary clinical outcomes. OR and 95% CI for the effect of hybrid versus conventional surgery on the primary and secondary outcomes. CICU: cardiac intensive care unit.
Figure 3
Figure 3
(A) Overall troponin concentrations over time by treatment group. Geometric mean (ng/l) and 95% CI at all time points by group, and geometric mean ratio and 95% CI for the effect of hybrid versus conventional surgery on troponin concentration. (B) Troponin concentrations over time by treatment group and centre. Geometric mean and 95% CI at all time points by group and centre. Test for treatment by centre interaction, P = 0.48. Pre-op: preoperative; Post-op: postoperative.
Figure 4
Figure 4
Myocardial metabolic stress outcomes. (A) Mean differences (MD) and 95% CI for the effect of hybrid versus conventional surgery on ATP, ATP/ADP and ATP/AMP (nmole/mg wet weight). (B) GMR and 95% CI for the effect of hybrid versus conventional surgery on ADP, AMP and Lactate (nmole/mg wet weight). ATP: adenosine triphosphate; ADP: adenosine diphosphate; AMP: adenosine monophosphate.
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