Five-Year Outcomes after Off-Pump or On-Pump Coronary-Artery Bypass Grafting

Cardiopulmonary bypass associated acute kidney injury: better understanding and better prevention

Cardiopulmonary bypass (CPB) is a common technique in cardiac surgery but is associated with acute kidney injury (AKI), which carries considerable morbidity and mortality. In this review, we explore the range and definition of CPB-associated AKI and discuss the possible impact of different disease recognition methods on research outcomes. Furthermore, we introduce the specialized equipment and procedural intricacies associated with CPB surgeries. Based on recent research, we discuss the potential pathogenesis of AKI that may result from CPB, including compromised perfusion and oxygenation, inflammatory activation, oxidative stress, coagulopathy, hemolysis, and endothelial damage. Finally, we explore current interventions aimed at preventing and attenuating renal impairment related to CPB, and presenting these measures from three perspectives: (1) avoiding CPB to eliminate the fundamental impact on renal function; (2) optimizing CPB by adjusting equipment parameters, optimizing surgical procedures, or using improved materials to mitigate kidney damage; (3) employing pharmacological or interventional measures targeting pathogenic factors.

Impact of High-Sensitivity Cardiac Troponin I Elevation after On- and Off-pump Coronary Artery Bypass Grafting on Long-term Prognosis

BACKGROUND

Postoperative myocardial injury is correlated with long-term prognosis after coronary artery bypass grafting (CABG) and is diagnosed with troponin levels, which vary substantially upon surgical strategies. We aimed to explore the troponin I cut-off values for prognostically significant myocardial injury separately in on-pump and off-pump procedures with a high-sensitivity assay (hs-cTnI).

METHODS

Patients who underwent isolated CABG from 2018 to 2020 with available perioperative hs-cTnI measurements were included in the current study and followed up. We explored the relationships between hs-cTnI levels and different outcomes. To identify hs-cTnI threshold levels indicative of higher risks, restrictive spline regressions were performed for on-pump and off-pump procedures.

RESULTS

A total of 7813 patients were included with a median follow-up of 2.7 years (interquartile range [IQR]: 1.7-3.3 years) years, 218 (2.8%) of whom experienced death. Upon adjusting for clinical variables, the study found a significant association between peak hs-cTnI levels within the first 48 hours after surgery and all endpoints. The spline regressions demonstrated that the hs-cTnI levels measured within 48 hours after surgery, which were associated with a hazard ratio of more than 1.00 for all-cause death, were 1,446ng/L (55.6×upper reference limit [URL], 95% CI: 45.0-106.5) for on-pump and 564ng/L (21.7×URL, 95% CI: 21.0-30.2) for off-pump.

CONCLUSIONS

Elevated hs-cTnI levels after CABG were associated with poorer longer-term outcomes. A prognosis relevant hs-cTnI cut-off value within 48 hours post-CABG for on-pump is significantly higher than that for off-pump.

Techniques and Results of Multiple Arterial Bypass Grafting: Towards More "Curative" Coronary Revascularizations

Surgical coronary bypass has evolved continually, and most analyses currently favor performing coronary grafts with autologous living arterial conduits to obtain better long-term patencies and clinical outcomes. With bilateral internal mammary artery grafts and both radial arteries, 4 excellent arterial conduits exist for creating "all-arterial" revascularization in the majority of multivessel disease patients, including those with valve disorders. Using contemporary surgical techniques, it is possible to obtain greater than 95% overall early graft patencies that translate into better late outcomes, including improved survival, freedom from myocardial infarction, fewer percutaneous coronary interventions, and redo coronary bypass procedures. The overall goal is to revascularize the 2 most important coronary systems with internal mammary artery grafts, and the rest with radial arteries, depending on the anatomy, experience, and choice of the surgeon. Using highly validated management strategies, early postoperative complications, including the incidence of sternal infections, are extremely uncommon, and in many practices, multi-arterial grafts currently are used in the majority of multivessel patients, including those with concomitant valve disease. Because patencies and outcomes are significantly better than with saphenous vein bypass or percutaneous coronary interventions, referring physicians frequently favor multi-arterial bypass procedures as the primary therapy for patients with prognostically serious multivessel disease. Thus, coronary bypass using predominantly autologous arterial conduits should play an increasingly important role in the future management of severe coronary atherosclerosis.

Secondary Conduits in Coronary Artery Bypass Grafting Surgery

BACKGROUND

Recent evidence has suggested use of the right internal mammary artery (RIMA) is associated with worse clinical outcomes in patients undergoing coronary artery bypass grafting (CABG) surgery. Therefore, we compared the clinical consequences of secondary conduit selection (RIMA vs radial artery vs saphenous vein) after CABG.

METHODS

A post-hoc analysis of the CABG Off or On Pump Revascularization Study, involving 3913 patients from 79 centers in 19 countries who underwent CABG surgery and received arterial grafting with at least 2 grafts. Outcomes of interest were all-cause mortality, myocardial infarction, stroke, and revascularization.

RESULTS

A total of 3913 patients received veins (3210; 68%), radial arteries (549; 12%), or RIMAs (154; 3%) to supplement left internal mammary artery to left anterior descending artery grafts. The risk of all-cause mortality was reduced in patients who received secondary radial arteries compared with veins (weighted hazard ratio [HR], 0.79; 95% CI, 0.64-0.98) and increased in patients who received RIMA compared with veins (weighted HR, 1.37; 95% CI, 1.13-1.68) after 4.8 years of follow-up. Multiple and single arterial grafting had a similar mortality risk (weighted HR, 0.87; 95% CI, 0.73-1.03).

CONCLUSIONS

Supplementing left internal mammary artery to left anterior descending artery grafting using radial arteries led to better clinical outcomes than veins, and too few RIMA were available to draw definitive conclusions. A randomized trial is needed to clarify the role of the RIMA in multiple arterial grafting CABG surgery.

On-Pump or Off-Pump Impact of Diabetic Patient Undergoing Coronary Artery Bypass Grafting 5-Year Clinical Outcomes

Background

For diabetic patients undergoing coronary artery bypass grafting (CABG), there is still a debate about whether an off-pump or on-pump approach is advantageous.

Methods

A retrospective review of 1269 consecutive diabetic patients undergoing isolated, primary CABG surgery from January 1, 2013 to December 31, 2015 was conducted. Among them, 614 received non-cardiopulmonary bypass treatment during their operation (off-pump group), and 655 received cardiopulmonary bypass treatment (on-pump group). The hospitalization outcomes were compared by multiple logistic regression models with patient characteristics and operative variables as independent variables. Kaplan-Meier curves and Cox proportional-hazard regression models for mid-term (2-year) and long-term (5-year) clinical survival analyses were used to determine the effect on survival after CABG surgery. In order to further verify the reliability of the results, propensity-score matching (PSM) was also performed between the two groups.

Results

Five-year all-cause death rates were 4.23% off-pump vs. 5.95% on-pump (p = 0.044), and off-pump was associated with reduced postoperative stroke and atrial fibrillation.

Conclusions

These findings suggest that off-pump procedures may have benefits for diabetic patients in CABG.

Is minimally invasive multi-vessel off-pump coronary surgery as safe and effective as MIDCAB?

Introduction

The safety and efficacy of minimally invasive direct coronary artery bypass (MIDCAB) surgery has been confirmed in numerous reports. However, minimally invasive multi-vessel off-pump coronary artery bypass grafting (MICS CABG) has lower uptake and has not yet gained widespread adoption. The study aimed to investigate the non-inferiority of MICS CABG to MIDCAB in long-term follow-up for several clinical outcomes, including angina pectoris, major adverse cardiac and cerebrovascular events (MACCE) and overall survival.

Methods

This is an observational, retrospective, single center study of 1,149 patients who underwent either MIDCAB (n = 626) or MICS CABG (n = 523) at our institution between 2007 and 2018. The left internal thoracic artery and portions of the radial artery and saphenous vein were used for the patients' single-, double-, or triple-vessel revascularization procedures. We used gradient boosted propensity-score estimation to account for possible interactions between variables. After propensity-score adjustment, the two groups were similar in terms of preoperative demographics and risk profile. Long-term follow-up (mean 5.87, median 5.6 years) was available for 1,089 patients (94.8%).

Results

A total of 626, 454 and 69 patients underwent single, double and triple coronary revascularization, respectively. The long-term outcomes of freedom from angina pectoris, acute myocardial infarction, and revascularization rate were similar between the two groups. During follow-up, there were 123 deaths in the MIDCAB group and 96 in the MICS CABG group. The 1-, 3-, 5-, and 10-year survival rates were 97%, 92%, 85%, and 69% for the MIDCAB group and 97%, 93%, 89%, and 74% for the MICS CABG group, respectively. The hazard ratio of overall survival for patients with two or more bypass grafts compared to those with one bypass graft was 1.190 (p-value = 0.234, 95% CI: 0.893-1.586). This indicates that there was no significant difference in survival between the two groups. Furthermore, if we consider a hazard ratio of 1.2 to be clinically non-relevant, surgery with two or more grafts was significantly non-inferior to surgery with just one graft (p-value = 0.0057).

Conclusion

In experienced hands, MICS CABG is a safe and effective procedure. Survival and durability are comparable with MIDCAB.

Clinical outcomes of on-pump versus off-pump coronary-artery bypass surgery: a meta-analysis

BACKGROUND

The ongoing debate regarding off-pump coronary artery bypass grafting (CABG) and on-pump CABG has endured for over three decades. Although numerous randomized controlled trials (RCTs) and meta-analyses have been reported, new evidence has emerged. Therefore, an updated and comprehensive meta-analysis to guide clinical practice is essential.

MATERIALS AND METHODS

A comprehensive search for eligible articles published after 2000, reporting RCTs involving at least 100 patients and comparing off-pump CABG with on-pump CABG, was performed throughout the databases including Embase, Ovid Medline, and Web of Science. The primary interested outcomes included the short-term incidence of stroke and long-term mortality. The primary analysis utilized fixed-effect model with the inverse variance method. The Grade of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the certainty of evidence.

RESULTS

After thorough screening, 39 articles were included, consisting of 28 RCTs and involving a total of 16 090 patients. Off-pump CABG significantly reduced the incidence of short-term stroke (1.27 vs. 1.78%, OR: 0.74, P =0.03, high certainty). However, it was observed to be associated with increased mid-term coronary reintervention (2.77 vs. 1.85%, RR: 1.49, P <0.01, high certainty) and long-term mortality (21.8 vs. 21.0%, RR: 1.09, P =0.02, moderate certainty).

CONCLUSIONS

Off-pump CABG significantly reduces the short-term incidence of stroke, but it also increases the incidence of mid-term coronary reintervention. Moreover, it may increase long-term mortality.

Clinical impact of coronary revascularization over medical treatment in chronic coronary syndromes: A systematic review and meta-analysis

OBJECTIVE

To provide a quantitative comparison between myocardial revascularization (REVASC) and optimal medical treatment (OMT) alone in patients with chronic coronary syndrome (CCS).

METHODS

Pertinent studies were searched for in PubMed/Medline until 12/03/2023. Randomized controlled trials that compare REVASC to OMT reporting clinical outcomes were selected according to PRISMA guidelines. The primary outcome was cardiovascular death. Two investigators independently assessed the study quality and extracted data.

RESULTS

Twenty-eight randomized controlled studies (RCTs) including 20692 patients were included in this meta-analysis. The rate of cardiovascular mortality was significantly lower among patients treated with myocardial revascularization [risk ratio (RR) 0.79, 95% CI 0.69-0.90]. Age (p = 0.03), multivessel disease (p < 0.001), and follow-up duration (p = 0.001) were significant moderators of CV mortality. Subgroup analyses showed a larger benefit in patients treated with drug-eluting stents and those without chronic total occlusion. Among secondary outcomes, myocardial infarction was less frequent in the REVASC group (RR = 0.74; p < 0.001), while no significant difference was found for all-cause mortality (p = 0.09) nor stroke (p = 0.26).

CONCLUSIONS

The present analysis showed lower rates of CV mortality and myocardial infarction in CCS patients treated with myocardial revascularization compared to OMT. This benefit was larger with increasing follow-up duration. Personalized treatment based on patient characteristics and lesion complexity may optimize clinical outcomes in patients with CCS.

Effects of different surgical strategies and left ventricular remodelling on the outcomes of coronary artery bypass grafting in heart failure patients with reduced ejection fraction

Background

Ischaemic heart failure with reduced ejection fraction (HFrEF) caused by coronary artery disease accounts for the largest proportion of heart failure cases with the worst prognosis. Coronary artery bypass grafting (CABG) is the most effective treatment for ischaemic HFrEF. On-pump and off-pump are the two surgical methods used for CABG. Whether patients with HFrEF should undergo on- or off-pump CABG is controversial in coronary heart disease surgery. The left ventricular end-systolic volume index (LVSEVI) is the gold standard for evaluating the severity of left ventricular remodelling; however, its effect on the perioperative risk and long-term survival rate of patients with HFrEF undergoing CABG remains unclear.

Methods

This single centre prospective cohort analysis included 118 coronary heart disease patients with symptoms and signs of heart failure and a left ventricular ejection fraction (LVEF) of <40% who were enrolled consecutively from January 2019 to December 2023. Operative mortality, perioperative complications, and long-term survival were compared among patients treated with various LVESVIs and surgical methods. The primary outcomes were cardiac death, myocardial infarction, heart failure, stroke, and revascularization, (percutaneous coronary intervention or redo CABG) with a median follow-up of 38 ± 10 months.

Results

The 30-day postoperative mortality of 118 patients was 6.8%. Patients in the off-pump group had significantly higher perioperative mortality than those in the on-pump group (12.5% vs. 3.8%, p = 0.03). In the off-pump group, a higher proportion of patients required perioperative mechanical assistance, such as intra-aortic artery balloon pump (IABP) or extracorporeal membrane oxygenation (ECMO), compared to those in the on-pump group (IABP: 75% vs. 47.4%, p = 0.004; ECMO: 22.5% vs. 1.3%, p = 0.000). Patients in the off-pump group were more likely to have postoperative atrial fibrillation (AF) (35% vs. 14.1%, p = 0.01). In the on-pump group, the incidence of postoperative AF (25% vs. 6.5%, p = 0.02) and IABP use (62.5% vs. 36.9%, p = 0.03) were significantly higher in patients with more severe left ventricular remodelling than in those with less severe left ventricular remodelling. In the off-pump group, patients with more severe left ventricular remodelling had higher ECMO usage (38.9% vs. 9.1%, p = 0.04), incidence of postoperative AF (61.1% vs. 13.6%, p = 0.02), and perioperative mortality (22.2%). Major adverse cardiac event (MACE)-free survival rate was significantly higher in the on-pump group than in the off-pump group, and there was no significant difference in MACE free survival rates between the two groups of patients with different degrees of left ventricular remodelling.

Conclusion

On-pump bypass is a better surgical procedure for patients with ischaemic HFrEF, especially those with severe left ventricular remodelling. Left ventricular remodelling increases perioperative mortality but has no effect on long-term survival.

Surgical Coronary Revascularization in Patients With Underlying Atrial Fibrillation: State-of-the-Art Review

The number of individuals referred for coronary artery bypass grafting (CABG) with preoperative atrial fibrillation (AF) is reported to be 8% to 20%. Atrial fibrillation is a known marker of high-risk patients as it was repeatedly found to negatively influence survival. Therefore, when performing surgical revascularization, consideration should be given to the concomitant treatment of the arrhythmia, the clinical consequences of the arrhythmia itself, and the selection of adequate surgical techniques. This state-of-the-art review aimed to provide a comprehensive analysis of the current understanding of, advancements in, and optimal strategies for CABG in patients with underlying AF. The following topics are considered: stroke prevention, prophylaxis and occurrence of postoperative AF, the role of surgical ablation and left atrial appendage occlusion, and an on-pump vs off-pump strategy. Multiple acute complications can occur in patients with preexisting AF undergoing CABG, each of which can have a significant effect on patient outcomes. Long-term results in these patients and the future perspectives of this scientific area were also addressed. Preoperative arrhythmia should always be considered for surgical ablation because such an approach improves prognosis without increasing perioperative risk. While planning a revascularization strategy, it should be noted that although off-pump coronary artery bypass provides better short-term outcomes, conventional on-pump approach may be beneficial at long-term follow-up. By collecting the current evidence, addressing knowledge gaps, and offering practical recommendations, this state-of-the-art review serves as a valuable resource for clinicians involved in the management of patients with AF undergoing CABG, ultimately contributing to improved outcomes and enhanced patient care.

Off-Pump Reduces Risk of Coronary Bypass Grafting in Patients with High MELD-XI Score

BACKGROUND

 This study aimed to assess the influence of the model of end-stage liver disease without International Normalized Ratio (INR) (MELD-XI) score on outcomes after elective coronary artery bypass surgery (CABG) without (Off-Pump) or with (On-Pump) cardiopulmonary bypass.

METHODS

 We calculated MELD-XI (5.11 × ln serum bilirubin + 11.76 × ln serum creatinine in + 9.44) for 3,535 consecutive patients having undergone elective CABG between 2009 and 2020. A MELD-XI threshold was determined using the Youden Index based on receiver operating characteristics. Propensity score matching and logistic regression was performed to identify risk factors for inhospital mortality and Major Adverse Cardiac and Cerebrovascular Event (MACCE).

RESULTS

 Patients were 68 ± 10 years old (76% male). Average MELD-XI was 10.9 ± 3.25. The MELD-XI threshold was 11. Patients below this threshold had somewhat lower EuroSCORE II than those above (3.5 ± 4 vs. 4.1 ± 4.7, p < 0.01), but mortality was almost four times higher above the threshold (below 1.5% vs. above 6.2%, p < 0.001). Two-thirds of patients received Off-Pump CABG. There was a trend towards higher risk in Off-Pump patients. Mortality was numerically but not statistically different to On-Pump below the MELD XI threshold (1.3 vs. 2.2%, p = 0.34) and was significantly lower above the threshold (4.9 vs. 8.9%, p < 0.02). Off-Pump above the threshold was also associated with less low-output syndrome and fewer strokes. Equalizing baseline differences by propensity matching verified the significant mortality difference above the threshold. Multivariable regression analysis revealed MELD-XI, On-Pump, atrial fibrillation, and the De Ritis quotient (Aspartate aminotransferase (ASAT)/Alanine Aminotransferase (ALAT)) as independent predictors of mortality.

CONCLUSION

 Elective CABG patients with elevated MELD-XI scores are at increased risk for perioperative mortality and morbidity. This risk can be significantly mitigated by performing CABG Off-Pump.

Comparison of outcomes between off-pump and on-pump coronary artery bypass graft surgery using collaborative targeted maximum likelihood estimation

There are some discrepancies about the superiority of the off-pump coronary artery bypass grafting (CABG) surgery over the conventional cardiopulmonary bypass (on-pump). The aim of this study was estimating risk ratio of mortality in the off-pump coronary bypass compared with the on-pump using a causal model known as collaborative targeted maximum likelihood estimation (C-TMLE). The data of the Tehran Heart Cohort study from 2007 to 2020 was used. A collaborative targeted maximum likelihood estimation and targeted maximum likelihood estimation, and propensity score (PS) adjustment methods were used to estimate causal risk ratio adjusting for the minimum sufficient set of confounders, and the results were compared. Among 24,883 participants (73.6% male), 5566 patients died during an average of 8.2 years of follow-up. The risk ratio estimates (95% confidence intervals) by unadjusted log-binomial regression model, PS adjustment, TMLE, and C-TMLE methods were 0.86 (0.78-0.95), 0.88 (0.80-0.97), 0.88 (0.80-0.97), and 0.87(0.85-0.89), respectively. This study provides evidence for a protective effect of off-pump surgery on mortality risk for up to 8 years in diabetic and non-diabetic patients.

10-Year Mortality of Off-Pump Versus On-Pump Coronary Artery Bypass Grafting: An Updated Systematic Review, Meta-Analysis, and Meta-Regression

The longstanding debate on off-pump coronary artery bypass grafting (OPCAB) versus on-pump coronary artery bypass grafting (ONCAB) has primarily focused on short-term and mid-term outcomes, with limited attention to long-term survival. This study aims to address this gap by providing an updated analysis of 10-year mortality rates after OPCAB versus ONCAB. We have conducted a systematic review and meta-analysis, incorporating 22 studies comprising 69,449 patients. The primary end point was all-cause mortality at 10 years. Meta-regression analysis explored sources of heterogeneity. The meta-analysis revealed no significant difference in long-term all-cause mortality between OPCAB and ONCAB (hazard ratio 1.000, 95% confidence interval 0.92 to 1.08, p = 0.95). Although substantial heterogeneity existed across studies, meta-regression identified older age as a significant factor favoring OPCAB. However, patient characteristics like gender, co-morbidities, and graft numbers did not significantly influence the choice of surgical technique. In conclusion, this study challenges historical concerns regarding OPCAB's quality of revascularization and long-term survival demonstrating comparable outcomes to ONCAB in well-selected patients when performed by experienced surgeons. The results emphasize the importance of surgeon proficiency and advocate for recognizing surgical revascularization as a subspecialty.

Assessing the benefits of anaortic off-pump coronary artery bypass grafting

Introduction

The procedure called the "aorta no-touch" (NT) or anaortic technique in off-pump coronary artery bypass grafting (OPCAB) is designed to reduce the perioperative risk of stroke. We have observed an increased frequency of anaortic OPCAB procedures at our institution. The main purpose of the present study is to investigate the effectiveness of anaortic OPCAB in reducing the perioperative risk of stroke.

Methods

From April 2011 to July 2023, a total of 2,236 patients underwent isolated OPCAB at our single center. The patients were divided into the anaortic group (NT, n = 762) and the aortic group (A, n = 1,474). The NT group was propensity score-matched (PSM) with the A group at a 1:1 ratio (NT n = 640; A n = 640), and matching was performed based on 26 covariates with preoperative clinical characteristics.

Results

In both the unmatched and matched cohorts of the NT and A groups, there were no significant differences observed in new stroke rates (NT vs. A; unmatched, 1.0% vs. 1.2%, p = 0.624; matched, 0.9% vs. 1.3%, p = 0.789). The univariable logistic analysis did not identify the anaortic technique as an independent factor negatively associated with new stroke events (OR = 0.81, 95% CI = 0.35-1.86, p = 0.624).

Conclusion

The present study did not find the anaortic technique to reduce the perioperative risk of stroke in OPCAB. Hence, further large studies are needed to identify patient cohorts in which anaortic OPCAB is significantly beneficial.

Low-Cost Innovations in Global Cardiac Surgery

Cardiovascular diseases are the leading cause of morbidity and mortality worldwide, costing the lives of 18 million people annually, with up to one-third being attributable to cardiac surgical conditions. Approximately 6 billion people do not have access to safe, timely, and affordable cardiac surgery, predominantly affecting populations living in low-middle income countries. Cardiac surgical care is costly, resulting in few centers in variable-resource contexts operating continuously or with the resources observed in higher-resource environments. As a result, innovations may be formally developed or informally adopted to bypass resource constraints and ensure care delivery. Innovations have been observed across the cardiac surgical care continuum and across settings, potentially benefiting both high-income countries, where growing health care costs are becoming unsustainable, and low- and middle-income countries, where competing health agendas may limit investments into cardiac surgery. This narrative review attempts to address the costs associated with cardiac surgery, placing an emphasis on frugal innovations in the perioperative and postoperative care spectrum.

Outcomes following coronary artery bypass grafting with multiple arterial grafting by pump status in men and women

BACKGROUND

Multiple arterial grafting (MAG) and off-pump surgery are strategies proposed to improve outcomes with coronary artery bypass grafting (CABG). This study was conducted to determine the impact of off-pump surgery on outcomes after CABG with MAG in men and women.

METHODS

This cohort study used population-based data to identify all Ontarians undergoing isolated CABG with MAG between October 2008 and September 2019. The primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiac and cerebrovascular events (MACCE; hospitalization for stroke, myocardial infarction hospitalization or heart failure, or repeat revascularization). Analysis used propensity-score overlap-weighted cause-specific Cox proportional hazard regression.

RESULTS

A total of 2989 women (1188 off-pump, 1801 on-pump) and 16,209 men (6065 off-pump, 10,144 on-pump) underwent MAG with a median follow-up of 5.0 years (interquartile range, 2.7-8.0) years. Compared to the on-pump approach, all-cause mortality was not changed with off-pump status (hazard ratio [HR] in women: 1.25 [95% CI, 0.83-1.88]; in men: 1.08 [95% CI, 0.85-1.37]). In women, the risk of MACCE was significantly higher off-pump (HR, 1.45; 95% CI, 1.04-2.03), with nonsignificantly increased risk observed for all component outcomes.

CONCLUSIONS

In patients undergoing CABG with MAG, this population-based analysis found no association between pump status and survival in either men or women. However, it did suggest that off-pump MAG in women may be associated with an increased risk of MACCE.

Off-pump coronary artery bypass grafting with clampless aortic anastomosis devices: Aortic sealing devices versus automated anastomosis punching

Objectives

Clampless aortic anastomosis devices aim to lower stroke risk in off-pump coronary artery bypass grafting. Two main strategies for clampless anastomosis devices emerged with automated anastomosis punching and aortic sealing devices, prompting the question of perioperative outcome differences.

Methods

All consecutive patients undergoing elective off-pump coronary artery bypass grafting with a clampless aortic anastomosis device between September 2014 and December 2021 in 2 centers were retrospectively included. Cohorts were divided by the use of an automated anastomosis punching device or an aortic sealing device to achieve proximal anastomosis on the ascending aorta. To reach group comparability propensity score matching was performed. The primary end point was defined as a composite of all-cause mortality, stroke and rethoracotomy. Secondary end points were perioperative outcome parameters.

Results

A total of 3703 patients were enrolled of whom 575 and 3128 were included in the automated anastomosis punching and the aortic sealing device group, respectively. By propensity score matching a total of 1150 patients were included with 575 in each group. The primary composite endpoint showed no significant difference with 6.3% versus 5.9% events (odds ratio, 0.9; 95% confidence interval, 0.58-1.53, P = .81). All-cause mortality (P = .36), stroke (P = .81), and rethoracotomy (P = .89) also exhibit no disparity. Operation time was significantly longer in the aortic sealing device cohort with 220.0 ± 50.8 minutes and 204.6 ± 53.8 minutes (P < .01).

Conclusions

Clampless aortic anastomosis strategies aortic sealing device and automated anastomosis punching did not differ in perioperative outcome parameters, whereas the implementation of aortic sealing devices were associated with a prolonged operation time without inducing any inferior clinical outcome.

Intraoperative Anemia Mediates Sex Disparity in Operative Mortality After Coronary Artery Bypass Grafting

BACKGROUND

Women undergoing coronary artery bypass grafting (CABG) have higher operative mortality than men.

OBJECTIVES

The purpose of this study was to evaluate the relationship between intraoperative anemia (nadir intraoperative hematocrit), CABG operative mortality, and sex.

METHODS

This was a cohort study of 1,434,225 isolated primary CABG patients (344,357 women) from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2022). The primary outcome was operative mortality. The attributable risk (AR) (the risk-adjusted strength of the association of female sex with CABG outcomes) for the primary outcome was calculated. Causal mediation analysis derived the total effect of female sex on operative mortality risk and the proportion of that effect mediated by intraoperative anemia.

RESULTS

Women had lower median nadir intraoperative hematocrit (22.0% [Q1-Q3: 20.0%-25.0%] vs 27.0% [Q1-Q3: 24.0%-30.0%], standardized mean difference 97.0%) than men. Women had higher operative mortality than men (2.8% vs 1.7%; P < 0.001; adjusted OR: 1.36; 95% CI: 1.30-1.41). The AR of female sex for operative mortality was 1.21 (95% CI: 1.17-1.24). After adjusting for nadir intraoperative hematocrit, AR was reduced by 43% (1.12; 95% CI: 1.09-1.16). Intraoperative anemia mediated 38.5% of the increased mortality risk associated with female sex (95% CI: 32.3%-44.7%). Spline regression showed a stronger association between operative mortality and nadir intraoperative hematocrit at hematocrit values <22.0% (P < 0.001).

CONCLUSIONS

The association of female sex with increased CABG operative mortality is mediated to a large extent by intraoperative anemia. Avoiding nadir intraoperative hematocrit values below 22.0% may reduce sex differences in CABG operative mortality.

Beating Heart Transplants-Overview and Implications for Anesthesiologists

As the demand for heart allografts for transplantation continues to rise, ex vivo organ perfusion strategies are playing an increasingly important role in the preservation of organs from donation after circulatory death and extended-criteria donors. One such method uses the Organ Care System (TransMedics, Andover, MA). Traditionally, this technique of preservation requires 2 periods of warm ischemia and subsequent cardioplegic arrest. In a novel surgical technique pioneered at the authors' institution, heart allograft implantation no longer requires a second cardioplegic arrest. This article discusses the surgical approach for this procedure, the advantages and disadvantages of this approach, and analogs to current clinical practice to theorize what impact this may have on cardiac transplantation volumes in the future.

Propensity score-matched comparison of total arterial off- and on-pump coronary artery bypass with complete revascularization

Little is known regarding the long-term (> 10 years) outcomes and risk factors of total arterial coronary artery bypass grafting (CABG). This study evaluated the long-term outcomes and risk factors for all-cause mortality and major adverse cardiac and cerebrovascular events (MACCEs) following total arterial on-pump CABG (ONCAB) or off-pump CABG (OPCAB) with complete revascularization. This retrospective cohort analysis enrolled patients with stable angina who underwent total arterial CABG with complete revascularization in our institute between July 2000 and June 2019. The endpoints were all-cause mortality and MACCE incidence, including a comparison between OPCAB and ONCAB. Long-term (10-year) outcomes were analyzed using propensity score-matched pairs, and risk factors were evaluated using univariate and multivariate analyses. Overall, 401 patients who underwent primary total arterial CABG were classified into the OPCAB (n = 269) and ONCAB (n = 132) groups. Using propensity score matching (PSM), 88 patients who underwent OPCAB were matched with 88 patients who underwent ONCAB. The mean follow-up period was 7.9 ± 6.3 years. No significant difference in all-cause mortality (hazard ratio, 1.04; 95% confidence interval, 0.53-2.04; p = 0.9138) and MACCE incidence (hazard ratio, 1.06; 95% confidence interval, 0.68-1.65; p = 0.7901) was observed between the two groups. Renal failure requiring dialysis was a significant risk factor for mortality (p < 0.0001) and MACCEs (p = 0.0003). Long-term outcomes of total arterial OPCAB and ONCAB with complete revascularization showed similar findings using PSM. Renal failure requiring dialysis was a significant risk factor for mortality and morbidity.Journal standard instruction requires an unstructured abstract; hence the headings provided in abstract were deleted. Kindly check and confirm.Thank you for your kindness.Clinical registration number 5598, Tokyo Women's Medical University Hospital.

Thirteen Years of Impactful, Minimally Invasive Coronary Surgery: Short- and Long-Term Results for Single and Multi-Vessel Disease

OBJECTIVES

Minimally invasive coronary surgery (MICS) via lateral thoracotomy is a less invasive alternative to the traditional median full sternotomy approach for coronary surgery. This study investigates its effectiveness for short- and long-term revascularization in cases of single and multi-vessel diseases.

METHODS

A thorough examination was performed on the databases of two cardiac surgery programs, focusing on patients who underwent minimally invasive coronary bypass grafting procedures between 2010 and 2023. The study involved patients who underwent either minimally invasive direct coronary artery bypass grafting (MIDCAB) for the revascularization of left anterior descending (LAD) artery stenosis or minimally invasive multi-vessel coronary artery bypass grafting (MICSCABG). Our assessment criteria included in-hospital mortality, long-term mortality, and freedom from reoperations due to failed aortocoronary bypass grafts post-surgery. Additionally, we evaluated significant in-hospital complications as secondary endpoints.

RESULTS

A total of 315 consecutive patients were identified between 2010 and 2023 (MIDCAB 271 vs. MICSCABG 44). Conversion to median sternotomy (MS) occurred in eight patients (2.5%). The 30-day all-cause mortality was 1.3% (n = 4). Postoperative AF was the most common complication postoperatively (n = 26, 8.5%). Five patients were reoperated for bleeding (1.6%), and myocardial infarction (MI) happened in four patients (1.3%). The mean follow-up time was six years (±4 years). All-cause mortality was 10.3% (n = 30), with only five (1.7%) patients having a confirmed cardiac cause. The reoperation rate due to graft failure or the progression of aortocoronary disease was 1.4% (n = 4).

CONCLUSIONS

Despite the complexity of the MICS approach, the results of our study support the safety and effectiveness of this procedure with low rates of mortality, morbidity, and conversion for both single and multi-vessel bypass surgeries. These results underscore further the necessity to implement such programs to benefit patients.

Comparative efficacy on outcomes of C-CABG, OPCAB, and ONBEAT in coronary heart disease: a systematic review and network meta-analysis of randomized controlled trials

IMPORTANCE

Coronary artery bypass grafting (CABG) remains the gold standard for the treatment of multivessel and left main coronary heart disease. However, the current evidence about the optimal surgical revascularization strategy is inconsistent and is not sufficient to allow for definite conclusions. Thus, this topic needs to be extensively discussed.

OBJECTIVE

The aim of this present study was to compare the clinical outcomes of off-pump CABG (OPCAB), conventional on-pump CABG (C-CABG), and on-pump beating heart (ONBEAT) CABG via an updated systematic review and network meta-analysis of randomized controlled trials.

DATA SOURCES

PubMed, Web of Science, and the Cochrane Central Registry were searched for relevant randomized controlled trials that were published in English before 1 December 2021.

STUDY SELECTION

Published trials that included patients who received OPCAB, C-CABG, and ONBEAT CABG were selected.

DATA EXTRACTION AND SYNTHESIS

Two authors independently screened the search results, assessed the full texts to identify eligible studies and the risk of bias of the included studies, and extracted data. All processes followed the Preferred Reporting Items for Systematic Review and Meta-analysis of Individual Participant Data.

MAIN OUTCOMES AND MEASURES

The primary outcome was postoperative mortality in patients who underwent C-CABG, OPCAB, or ONBEAT CABG. The secondary outcomes were postoperative myocardial infarction, stroke, and renal impairment in the three groups. The time point for analysis of outcomes was all time periods during the postoperative follow-up.

RESULTS

A total of 39 385 patients (83 496.2 person-years) in 65 studies who fulfilled the prespecified criteria were included. In the network meta-analysis, OPCAB was associated with an increase of 12% in the risk of all-cause mortality when compared with C-CABG [odds ratio (OR): 1.12; 95% CI: 1.04-1.21], a reduction of 49% in the risk of myocardial infarction when compared with ONBEAT (OR: 0.51; 95% CI: 0.26-0.99), a reduction of 16% in the risk of stroke when compared with C-CABG (OR: 0.84; 95% CI: 0.72-0.99) and a similar risk of renal impairment when compared with C-CABG and ONBEAT.

CONCLUSIONS AND RELEVANCE

OPCAB was associated with higher all-cause mortality but lower postoperative stroke compared with C-CABG. OPCAB was associated with a lower postoperative myocardial infarction than that of ONBEAT. Early mortality was comparable among OPCAB, ONBEAT, and C-CABG.

Off-pump vs. on-pump bypass surgery grafting in diabetic patients with three-vessel disease: a propensity score matching study

Background

Controversy exists regarding the advantages and risks of off-pump vs. on-pump coronary artery bypass grafting (CABG) for patients with diabetes. We therefore compare the early clinical outcomes of off-pump vs. on-pump procedures for diabetic patients with three-vessel disease.

Materials and methods

We conducted a retrospective analysis of clinical data obtained from 548 diabetic patients with three-vessel coronary artery disease who underwent isolated CABG between January 2016 and June 2020. To adjust the differences of baseline characteristics between the off-pump CABG (OPCAB) and on-pump CABG (ONCAB) groups, propensity score matching (PSM) was used. Following 1:1 matching, we selected 187 pairs of patients for further comparison of outcomes within the first 30 days after surgery.

Results

The preoperative characteristics of the patients between the two groups were clinically comparable after PSM. The OPCAB group exhibited a significantly higher incidence of incomplete revascularization (27.3% vs. 14.4%; P = 0.002) compared with the ONCAB group. No differences were seen in mortality within 30 days between the matched groups (1.1% vs. 3.7%; P = 0.174). Notably, the OPCAB group had a lower risk of respiratory failure or infection (2.1% vs. 7.0%; P = 0.025), less postoperative stroke (1.1% vs. 4.8%; P = 0.032), and reduced postoperative ventilator assistance time (35.8 ± 33.7 vs. 50.9 ± 64.8; P = 0.005).

Conclusion

OPCAB in diabetic patients with three-vessel disease is a safe procedure with reduced early stroke and respiratory complications and similar mortality rate, myocardial infarction, and renal failure requiring dialysis to conventional on-pump revascularization.

Designing the coronary artery bypass surgery operation of the future

PURPOSE OF REVIEW

This article discusses current shortcomings in coronary artery bypass surgery and ways to overcome them.

RECENT FINDINGS

Minimally invasive coronary bypass surgery, robotic coronary bypass, and hybrid approaches aim to avoid sternotomy, employ arterial grafts, and minimize the use of cardiopulmonary bypass. Other considerations such as bypass graft validation, the optimization of guideline-directed medical therapy, and the development of coronary surgery specialists are also crucial to further the benefits of coronary artery bypass grafting on future patients.

SUMMARY

Coronary artery bypass grafting must become less invasive, be better validated, and be carried out with an even higher emphasis on quality, including graft validation and preoperative/postoperative optimization, if it is to remain the best treatment for advanced, severe coronary artery disease.

Neurologic complications after cardiopulmonary bypass - A narrative review

Neurologic complications, associated with cardiac surgery and cardiopulmonary bypass (CPB) in adults, are common and can be devastating in some cases. This comprehensive review will not only consider the broad categories of stroke and neurocognitive dysfunction, but it also summarises other neurological complications associated with CPB, and it provides an update about risks, prevention and treatment. Where appropriate, we consider the impact of off-pump techniques upon our understanding of the contribution of CPB to adverse outcomes.

Minimally invasive strategies of surgical coronary artery revascularization for the aging population

BACKGROUND

The increasing prevalence of elderly or frail patients with severe coronary disease, who are not suitable for interventional coronary revascularization, necessitates the exploration of alternative treatment options. A less invasive approach, such as minimally-invasive off-pump coronary-artery-bypass (MICS-CABG) grafting through mini-thoracotomy, which avoids both extracorporeal circulation and sternotomy, may be more appropriate for this patient population. This study, a retrospective, monocentric analysis, aimed to evaluate the long-term outcomes of these patients.

METHODS

The study included 172 patients aged 80 years or older, who underwent MICS-CABG between 2007 and 2018. The patients underwent single, double, or triple-vessel revascularization using the left internal thoracic artery, and in some cases, the radial artery or saphenous vein. Follow-up, mean duration of 50.4±30.8 months, was available for 163 patients (94.7%).

RESULTS

The mean age of the patients was 83.2±3.0 years, 77.3% of them were male. The EuroSCORE I additive was 11.0±12.1. There were no conversions to sternotomy or cardiopulmonary-bypass. The postoperative 30-day mortality rate was 2.9%, with 5 deaths. The in-hospital rate of major adverse cardiac and cerebrovascular events was 4.7% (perioperative myocardial infarction 1.2%, perioperative stroke 2.3%, repeat revascularization 1.2%). Acute renal kidney injury, (stage 3 KDOQI or more), occurred in 5 patients (2.9%) and new-onset atrial fibrillation in 6 patients (3.5%). The 1-, 3-, 5- and 8-year actuarial survival rate of the 30-day survivors was 97%, 82%, 73%, and 42%, respectively.

CONCLUSIONS

MICS-CABG grafting is associated with excellent early and long-term outcomes in eligible octogenarians.

Five-year outcomes of off and on-pump CABG: Insights from PROMOTE Patency Trial

BACKGROUND

There are limited studies reporting follow-up outcome data comparing of off-pump coronary artery bypass (OPCAB) with on-pump (ONCAB) technique. The aim of the study was to report the 5-year clinical outcomes of OPCAB and ONCAB in a post hoc analysis of the PROMOTE patency trial.

METHODS

From March 2016 through March 2017, a total of 321 patients undergoing coronary artery bypass grafting (CABG) were randomised to either the off-pump or the on-pump technique. Data on all-cause mortality, myocardial infarction (MI), cerebrovascular accident (CVA), repeat revascularisation and need for renal replacement therapy (RRT) were recorded. The composite and each of these individual outcomes are reported at 5-year interval.

RESULTS

The mean follow-up period was 65.9 months (±3.39). A total of 275 (85.93%) patients followed up at the 5-year interval who underwent CABG by the off-pump (n  =  158) and the on-pump (n  =  162) technique. The all-cause mortality was 8.9% and 5.7% in ONCAB and OPCAB, respectively (hazard ratio [HR]  =  0.62; 95% confidence interval [CI] 0.25-1.57, p  =  0.31). The composite of all-cause mortality, non-fatal MI, non-fatal CVA, RRT and need for repeat revascularisation was comparable in both groups (7.1% vs. 11.9%, HR  =  0.57; 95% CI 0.25-1.31, p  =  0.18 in OPCAB and ONCAB, respectively). The rates of 5-year non-fatal MI (p  =  0.2), non-fatal CVA (p  =  0.36) and need for repeat revascularisation (p  =  1) were similar in both groups. A sub-group analysis did not show any significant interaction or effect modification with either of the techniques.

CONCLUSIONS

The 5-year clinical outcomes of OPCAB are comparable to ONCAB in low-risk patients undergoing CABG. Off-pump coronary artery bypass had no additional benefit in any subgroup.

Association of Hospital Volume and Outcomes Following Off-Pump Coronary Artery Bypass Grafting

BACKGROUND

Off-pump coronary artery bypass grafting (OPCAB) has been used to mitigate the negative systemic effects of cardiopulmonary bypass. Recent consortium and single-institution studies suggest an association between operator experience and long-term survival. We thus aimed to ascertain the relationship between institutional OPCAB volume and outcomes using a contemporary nationwide all-payer database.

METHODS

Adult admissions for elective isolated OPCAB were identified from the 2016-2019 Nationwide Readmissions Database. The primary outcome was major adverse events (MAE), defined as a composite of mortality, reoperation, prolonged mechanical ventilation, acute kidney injury requiring dialysis, or perioperative stroke during the index hospitalisation. Secondary outcomes included temporal trends, postoperative length of stay (pLOS), hospitalisation costs, non-home discharge, and 30-day readmission rate. High-volume hospitals (HVH) were defined to have annual caseloads >35 based on cubic spline analysis.

RESULTS

Of an estimated 41,154 patients, 59.9% were treated at HVH. The proportion of coronary artery bypass grafting operations that were OPCAB significantly decreased from 21.1% in 2016 to 18.3% in 2019. After adjustment, HVH status was associated with lower adjusted odds of MAE (adjusted odds ratio [AOR] 0.78, 95% confidence interval [CI] 0.70-0.88), compared to others. HVH were also associated with shorter pLOS (β -0.10, 95% -0.13, -0.07), reduced costs (β -US$4,900, - US$6,300, - US$3,600), non-home discharge (AOR 0.54, 95% CI 0.45-0.64), and 30-day readmission (AOR 0.86, 95% CI 0.77-0.96).

CONCLUSIONS

Our results suggest that OPCAB requires a distinct set of surgical expertise and institutional aptitude. As a result, centralisation of care to centres of excellence should be considered.

Propensity score analysis comparing off-pump versus on-pump coronary artery bypass grafting in older adults

OBJECTIVE

This study aimed to compare the results of off-pump and on-pump coronary artery bypass grafting in older adults and to examine early and late outcomes.

METHODS

This study included 226 patients aged ≥ 75 years who underwent isolated coronary artery bypass grafting. Of these, 141 and 85 patients were included in the off-pump and on-pump groups, respectively. Propensity scores were calculated for each case, matched, and compared between the two groups (68 cases in each group), along with mid-term outcomes of survival and major adverse cardiac events.

RESULTS

Operative time, red blood cell transfusion volume, and postoperative hospital stay duration were significantly higher in the on-pump group (267 vs 370 min, P < 0.001; 4.3 vs 17.2 units, P < 0.001; and 20.8 vs 35.8 days, P = 0.012, respectively). Postoperative occurrence of new atrial fibrillation was significantly higher in the on-pump group (4.4% vs 27.9%, P < 0.001), and Kaplan-Meier survival analysis showed a significantly worse prognosis in the on-pump group than in the off-pump group (3-year survival rate 90.7% vs 71.5%, log rank P = 0.007). However, there was no statistically significant difference in cardiovascular-related deaths (log rank P = 0.07).

CONCLUSIONS

On-pump coronary artery bypass grafting in an older adult population resulted in increased transfusion volume and postoperative occurrence of atrial fibrillation. The mid-term postoperative outcomes were also poorer with on-pump coronary artery bypass grafting. Off-pump coronary artery bypass grafting reduced future all-cause deaths in older adults.

Off-pump CABG surgery in left main coronary artery disease: a single-center prospective registry

Background and objective

The treatment of left main (LM) coronary artery disease (CAD) requires complex decision-making. Patients with left main multi-vessel coronary artery disease (LM CAD) have concerns regarding incomplete revascularization and reduced survival with off-pump (OPCAB) when compared with on-pump (ONCAB) coronary bypass surgery. To evaluate outcomes among high-risk LM CAD patients undergoing OPCAB, we performed a registry-based prospective study.

Methods

We performed 4868 coronary artery bypass graft (CABG) surgeries from Jan 2013 to Jun 2019 with 4662 (95.8%) OPCAB. In OPCAB cohort, we had 1323 patients (28.4%) with significant LM (> 50%) triple vessel CAD. Data regarding clinical features, extent of CAD, operative details, in-hospital outcomes, and 3-year follow-up were obtained. Descriptive statistics are reported.

Results

The study cohort (n = 1323) was aged 63 ± 9 years with men 88.4%. Tobacco use was in 328 (24.8%), diabetes 598 (45.2%), previous myocardial infarction 463 (35.0%), previous coronary intervention 40 (3.0%), and congestive heart failure in 54 (4.1%). All patients had LM (100.0%) with triple vessel disease in 99.4% (LAD, left anterior descending 100.0%; LCX, left circumflex 99.4%; RCA, right coronary artery 78.7%). Vessels bypassed/patient were 2.7 ± 0.4 with 3.2 ± 0.7 total grafts and 2.1 ± 0.8 venous grafts. In total, 1278 (96.5%) patients received left internal mammary artery (LIMA), 63(4.7%) bilateral internal mammary artery (BIMA), and 74 (5.6%) radial artery grafts. There was no patient with conversion from OPCAB to ONCAB. In-hospital major adverse cardiovascular events (MACE: all-cause deaths, myocardial infarction, and stroke) were in 21 (1.6%). At 3-year follow-up (n = 1041), MACE rates were in 84 (8.1%) and cardiovascular deaths in 28 (2.7%).

Conclusions

This study shows that off-pump CABG surgery is safe in patients with LM CAD. There is low in-hospital mortality and MACE and 3-year outcomes are similar to the published data of LM CAD patients who undergo on-pump CABG.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-023-01526-3.

Use of cardiopulmonary bypass is associated with chronic postsurgical pain among patients undergoing coronary artery bypass graft surgery: follow-up of a randomized, clinical trial

BACKGROUND

Chronic postsurgical pain (CPSP) worsens patients' mortality, morbidity, and quality of life. Cardiopulmonary bypass is mandatory for cardiac surgery, but it induces intense inflammation. The presence of inflammation is a crucial part of pain sensitization. An extreme inflammatory response due to cardiopulmonary bypass might cause a high prevalence of CPSP after cardiac surgery. We hypothesized that the prevalence and severity of CPSP are higher in patients after on-pump coronary artery bypass graft (CABG) surgery than in those after off-pump CABG surgery.

METHODS

This prospective, observational study was performed on a cohort from a randomized trial (on-pump CABG: 81 patients, off-pump CABG: 86 patients). A questionnaire about the severity of surgical wound pain that evaluated pain with the numerical rating scale (NRS) was filled out by the patients. NRS responses for current pain, peak pain in the last 4 weeks, and average pain in the last 4 weeks were evaluated. The main outcomes were the severity of CPSP as evaluated using the NRS and the prevalence of CPSP. CPSP was defined as pain with an NRS score > 0. Differences in severity between groups were analyzed using multivariate ordinal logistic regression models adjusted for age and sex, and differences in prevalence between groups were analyzed using multivariate logistic regression models adjusted for age and sex.

RESULTS

The questionnaire return rate was 77.0%. During a median follow-up of 17 years, 26 patients complained of CPSP (on-pump CABG: 20 patients, off-pump CABG: 6 patients). Ordinal logistic regression showed that the NRS response for current pain (odds ratio [OR] 2.34; 95% CI 1.12-4.92; P = 0.024) and the NRS response for peak pain in the last 4 weeks (OR 2.71; 95% CI 1.35-5.42; P = 0.005) were significantly higher in patients who underwent on-pump CABG surgery than in those who underwent off-pump CABG. Logistic regression showed that on-pump CABG surgery was an independent predictor of CPSP (OR 2.59; 95% CI 1.06-6.31; P = 0.036).

CONCLUSIONS

The prevalence and severity of CPSP are higher in patients with on-pump CABG surgery than in those with off-pump CABG surgery.

Trend and early clinical outcomes of off-pump coronary artery bypass grafting in the UK

OBJECTIVES

The popularity of off-pump coronary artery bypass grafting (CABG) varies across the world, ranging from 20% in Europe and the USA to 56% in Asia. We present the trend and early clinical outcomes in off pump in the UK.

METHODS

All patients who underwent elective or urgent isolated CABG from 1996 to 2019 were extracted from the National Adult Cardiac Surgery Audit database. The trend in operating surgeons and units volume and training in off pump were analysed. Early clinical outcomes between off- and on-pump CABG were compared using propensity score matching.

RESULTS

A total of 351 422 patients were included. The overall off-pump rate during the study period was 15.17%, it peaked in 2008 (19.8%), followed by a steady decreased to 2018 (7.63%). Its adoption varied across centres and surgeons, ranging from <1% to 48.36% and <1% to 85.5%, respectively, of total cases performed. After propensity score matching for the period 1996-2019, off pump, when compared to on pump, was associated with a lower in-hospital/30-day mortality (1.2% vs 1.5%, P < 0.001), return to theatre (3.7% vs 4.5%, P < 0.001), cerebrovascular accident (transient ischaemic attack: 0.3% vs 0.6%, stroke: 0.3% vs 0.6%, P < 0.001) and deep sternal wound infection (0.8% vs 1.2%, P ≤ 0.001). In a sub-analysis from the introduction of EuroScore II (2012-2019), there were no differences in-hospital/30-day mortality (1.0% vs 1.0%, P = 0.71). However, on pump, had a higher return to theatre (4.2% vs 2.7%, P < 0.001), cerebrovascular accident (transient ischaemic attack: 0.4% vs 0.2%, stroke: 0.5% vs 0.3%, P = 0.003) and deep sternal wound infection (1.0% vs 0.6%, P = 0.004).

CONCLUSIONS

Our data show a decreasing trend in the use of off pump in the UK since 2008. This is likely to be multifactorial and raises the question of whether it should be a specialized revascularization technique.

Impact of on-pump and off-pump coronary artery bypass grafting on 10-year mortality versus percutaneous coronary intervention

OBJECTIVES

The very long-term mortality of off-pump and on-pump coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in a randomized complex coronary artery disease population is unknown. This study aims to investigate the impact of on-pump and off-pump CABG versus PCI on 10-year all-cause mortality.

METHODS

The SYNTAX trial randomized 1800 patients with three-vessel and/or left main coronary artery disease to PCI or CABG and assessed their survival at 10 years. In this sub-study, the hazard of mortality over 10 years was compared according to the technique of revascularization: on-pump CABG (n = 725), off-pump CABG (n = 128) and PCI (n = 903).

RESULTS

There was substantial inter-site variation in the use of off-pump CABG despite baseline characteristics being largely homogeneous among the 3 groups. The crude rate of mortality was significantly lower following on-pump CABG versus PCI [25.6% vs 28.4%, hazard ratio (HR) 0.79, 95% confidence interval (CI) 0.65-0.96], while it was comparable between off-pump CABG and PCI (28.5% vs 28.4%, HR 0.98, 95% CI 0.69-1.40). After adjusting for the 9 variables included in the SYNTAX score II 2020, 10-year mortality remained significantly lower with on-pump CABG than PCI (HR 0.75 against PCI, P = 0.009).

CONCLUSIONS

In the SYNTAXES trial, 10-year mortality adjusted for major confounders was significantly lower following on-pump CABG compared to PCI. There was no evidence for unadjusted difference between off-pump CABG and PCI, although the unadjusted estimated HR had a wide CI. Site heterogeneity in the technique used in bypass surgery has had measurable effects on treatment performance.

Early and midterm outcomes after off pump coronary artery bypass surgery

Purpose

There has been debate whether off pump coronary artery bypass surgery (OPCAB) has results comparable to conventional on pump bypass surgery. This has led to the low uptake of OPCAB in the West. In India, OPCAB is the default mode of coronary revascularization. However, there is scarce data on mid-term outcomes of OPCAB in our patients. This study aims to evaluate both short and mid-term mortality and analyze factors associated with mortality.

Methods

This is a single center study of all consecutive patients undergoing isolated OPCAB from October 2014 to December 2019. Patient data was collected from hospital records and follow-up was from the hospital electronic medical records and telephone interviews. Mortality and factors contributing to survival were analyzed.

Results

Operative mortality was 2.3%. Mid-term mortality was 5.5%. Preoperative renal dysfunction, post-operative renal failure, use of the intra-aortic balloon pump (IABP), re-exploration for bleeding, postoperative stroke, ventilation > 24 h, and postoperative atrial fibrillation were associated with operative mortality. Factors associated with mid-term mortality were age > 62 years, postoperative renal failure, IABP usage, ventilation time > 24 h, and postoperative atrial fibrillation. The mean survival time was 2343.55 + / - 15.27 days and 6-year survival was 88.7%.

Conclusion

OPCAB can safely be performed with satisfactory short and mid-term outcomes. Further corroborative studies from different regions of the country or a multi-center study will help to establish the suitability of the technique in Indian patients.

Intensive care unit length of stay and mortality comparison between on-pump and off-pump coronary artery bypass graft: a retrospective study

BACKGROUND

Recently, coronary artery bypass graft (CABG) techniques, both on-pump (ONCABG) and off-pump (OPCABG), were compared to seek the most effective approach to reduce the cost of prolonged intensive care unit length of stay (ICU LOS) and mortality. This study aims to compare ICU LOS and mortality in ONCABG and OPCABG.

RESULTS

Demographic data of 1569 patients show the variance of characteristics. The analysis shows significant and longer ICU LOS in OPCABG than ONCABG (2.151 ± 0.100 vs. 1.573 ± 0.246 days; p = 0.028). Similar results were demonstrated after adjustment of covariates effects (3.146 ± 0.281 vs. 2.548 ± 0.245 days; p = 0,022). Logistic regression shows no significant difference in mortality in OPCABG and ONCABG, both in the unadjusted (OR [CI 95%] 1.133 [0.485-2.800]; p = 0.733) and the adjusted models (OR [CI 95%] 1.133 [0.482-2.817]; p = 0,735).

CONCLUSION

ICU LOS was significantly longer in OPCABG patients than in ONCABG patients in the author's centre. There was no significant difference in mortality between the two groups. This finding highlights a discrepancy between recently published theories and the practices observed in the author's centre.

A Delphi Study to Prioritize Evidence-Based Strategies for Cardiovascular Disease Care in India

Providing quality cardiovascular disease (CVD) care in low resource setting requires understanding of priority and effective interventions. This study aimed to identify and prioritize evidence-based quality improvement strategies for CVD care in India using a modified two-round Delphi process in which, we asked 46 experts (clinicians, researchers, program implementers and policy makers) to rate 25 proven CVD care strategies grouped into: (1) patient support, (2) information communication technology (ICT) for health, (3) group problem solving, (4) training, and (5) multicomponent strategy on a scale of 1 (highest/best)-5 (lowest/worst) on priority, relative advantage, and feasibility. Subsequently, we convened an expert consensus panel of 32 members to deliberate and achieve consensus regarding the prioritized set of strategies for CVD care. The Delphi study found that group problem solving strategies achieved the best score for priority (1.80) but fared poorly on feasibility (2.88). Compared to others, multicomponent strategies were rated favorably across all domains (priority = 1.84, relative advantage = 1.94, and feasibility = 2.40). The ICT for health strategies achieved the worst scores for priority = 2.01, relative advantage = 2.31, and feasibility = 2.85. Training and patient support strategies scored moderately across all domains. The expert panel narrowed the selection of a multicomponent strategy consisting of (1) electronic health records with clinical decision-support system, (2) non-physician health worker facilitated care, (3) patient education materials, (4) text-message based reminders for healthy lifestyle, and (5) audit and feedback report for providers. Future research will evaluate the real-world feasibility and effectiveness of the multicomponent strategy in patients with CVD in a low- and middle-income country setting.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43477-023-00087-2.

The outcomes of three different techniques of coronary artery bypass grafting: On-pump arrested heart, on-pump beating heart, and off-pump

OBJECTIVE

Conventional coronary artery bypass grafting (CABG) or on-pump arrested heart CABG (ONCAB) is a standard and simple technique. However, adverse effects can occur due to the use of aortic cross-clamp and cardiopulmonary bypass. Performing off-pump CABG (OPCAB) aims to avoid these adverse effects but may result in incomplete revascularization. On-pump beating heart CABG (ONBHCAB) combines the benefits of both ONCAB and OPCAB. This study focuses on comparing the short- and long-term outcomes of different CABG techniques.

METHOD

Retrospective observational cohort included 2,028 patients who underwent ONCAB, OPCAB, and ONBHCAB. The short-term outcomes including postoperative ischemic injury, hemodynamic functions, and adverse events were compared. The long-term outcomes were overall survival and the occurrence of major adverse cardiovascular events (MACE). Propensity score matching ensured comparability among the three patient groups.

RESULTS

After matching, there were no differences in baseline characteristics. Regarding ischemic injury, OPCAB showed the lowest peak cardiac enzyme levels (all p≤0.001). There were no statistically significant differences in the change of hemodynamic function (cardiac index) between the three groups (p = 0.158). Ten-year survival for OPCAB, ONBHCAB, and ONCAB were 80.5%, 75.9%, and 73.7%, respectively. OPCAB was associated with a significant reduction in mortality risk and MACE when compared to others (Mortality HR = 0.33, p = 0.001, MACE HR = 0.52, p = 0.004).

CONCLUSION

OPCAB implementation resulted in a lower occurrence of postoperative ischemic injury than ONCAB and ONBHCAB. No differences in postoperative hemodynamic function in all three techniques were observed. OPCAB respectively were preferable techniques beneficial for long-term outcomes.

Acute clinical and financial outcomes of on- versus off-pump coronary artery bypass grafting in octogenarians

BACKGROUND

Coronary artery bypass surgery in octogenarians is associated with increased postoperative morbidity. Off-pump coronary artery bypass surgery eliminates potential complications of cardiopulmonary bypass, but its use remains controversial. This study aimed to evaluate the clinical and financial impact of off-pump coronary artery bypass surgery compared to conventional coronary artery bypass surgery among this high-risk population.

METHODS

Patients ≥80 years undergoing first-time, isolated, elective coronary artery bypass surgery were identified using the 2010-2019 Nationwide Readmissions Database. Patients were grouped into off-pump or conventional coronary artery bypass surgery cohorts. Multivariable models were developed to assess the independent associations between off-pump coronary artery bypass surgery and key outcomes.

RESULTS

Of ∼56,158 patients, 13,940 (24.8%) underwent off-pump coronary artery bypass surgery. On average, the off-pump cohort was more likely to undergo single-vessel bypass (37.3 vs 19.7%, P < .001). After adjustment, undergoing off-pump coronary artery bypass surgery was associated with similar odds of in-hospital mortality (adjusted odds ratio 0.90, 95% confidence interval 0.73-1.12) relative to conventional bypass. Additionally, the off-pump and conventional coronary artery bypass surgery groups were comparable in odds of postoperative stroke (adjusted odds ratio 1.03, 95% confidence interval 0.78-1.35), cardiac arrest (adjusted odds ratio 0.99, 95% confidence interval 0.71-1.37), ventricular fibrillation (adjusted odds ratio 0.89, 95% confidence interval 0.60-1.31), tamponade (adjusted odds ratio 1.21, 95% confidence interval 0.74-1.97), and cardiogenic shock (adjusted odds ratio 0.94, 95% confidence interval 0.75-1.17). However, the off-pump coronary artery bypass surgery cohort was linked with an increased likelihood of ventricular tachycardia (adjusted odds ratio 1.23, 95% confidence interval 1.01-1.49) and myocardial infarction (adjusted odds ratio 1.34, 95% confidence interval 1.16-1.55). Furthermore, those undergoing off-pump coronary artery bypass surgery demonstrated reduced odds of non-home discharge (adjusted odds ratio 0.91, 95% confidence interval 0.83-0.99) and a decrement in hospitalization expenditures ($-1,290, 95% confidence interval -$2,370 to $200).

CONCLUSION

Off-pump coronary artery bypass surgery was linked with increased odds of ventricular tachycardia and myocardial infarction, but no difference in mortality. Our findings point to the safety of conventional coronary artery bypass surgery in octogenarians. Yet, future work is needed to consider long-term outcomes in this complex surgical cohort.

Elevated troponin I is associated with a worse long-term prognosis in patients undergoing beating-heart coronary surgery

OBJECTIVES

The impacts of elevated troponin I levels after coronary artery bypass grafting (CABG) on long-term outcomes were investigated.

METHODS

A total of 996 patients who underwent elective isolated CABG for stable or unstable angina were enrolled. Patients were divided into higher and lower groups based on 80th percentile postoperative peak troponin I (ppTnI) levels. The relationship between ppTnI and long-term clinical outcomes was analysed.

RESULTS

The median ppTnI was 1.55 (2.74) ng/ml and was significantly higher in the conventional CABG subgroup than in the beating-heart CABG subgroup: 4.04 (4.71) vs 1.24 (1.99) ng/ml, P < 0.001. The 80th percentile of ppTnI was 3.3 ng/ml in the beating-heart CABG subgroup and 8.9 ng/ml in the conventional CABG subgroup. In the conventional CABG subgroup (n = 150), 10-year overall survival showed no significant difference between the higher (≥8.9 ng/ml) and lower (<8.9 ng/ml) ppTnI groups: 71% (10%) vs 76% (5%), P = 0.316. However, the beating-heart CABG subgroup (n = 846) showed significantly worse 10-year overall survival in the higher ppTnI group (≥3.3 ng/ml) than in the lower ppTnI group (<3.3 ng/ml): 64% (6%) vs 73% (3%), P = 0.010. In the beating-heart CABG subgroup, multivariable analysis showed that ppTnI exceeding the 80th percentile was a risk factor for overall death (hazard ratio: 1.505, 95% confidence interval: 1.019-2.225, P = 0.040).

CONCLUSIONS

Higher ppTnI over the 80th percentile was associated with worse long-term survival in beating-heart CABG, but not in conventional CABG.

Five-Year Hospital Readmission After Coronary Artery Bypass Surgery and the Association With Off-Pump Surgery and Sex

Background Limited data exist on long-term readmission and its association with patient and procedural characteristics after coronary artery bypass grafting. We aimed to investigate 5-year readmission after coronary artery bypass grafting and specifically focus on the role of sex and off-pump surgery. Methods and Results We performed a post hoc analysis of the CORONARY (Coronary Artery Bypass Grafting [CABG] Off or On Pump Revascularization) trial, involving 4623 patients. The primary outcome was all-cause readmission, and the secondary outcome was cardiac readmission. Cox models were used to investigate the association of outcomes with sex and off-pump surgery. Hazard function for sex was studied over time using a flexible, fully parametric model, and time-segmented analyses were performed accordingly. Rho coefficient was calculated for the correlation between readmission and long-term mortality. Median follow-up was 4.4 years (interquartile range, 2.9-5.4 years). The cumulative incidence rates of all-cause and cardiac readmission were 29.4% and 8.2% at 5 years, respectively. Off-pump surgery was not associated with either all-cause or cardiac readmission. The hazard for all-cause readmission in women over time was constantly higher than the hazard for men (hazard ratio [HR], 1.21 [95% CI, 1.04-1.40]; P=0.011). Time-segmented analyses confirmed the higher risk for all-cause (HR, 1.21 [95% CI, 1.05-1.40]; P<0.001) and cardiac (HR, 1.26 [95% CI, 1.03-1.69]; P=0.033) readmission in women after the first 3 years of follow-up. All-cause readmission was strongly correlated with long-term all-cause mortality (Rho, 0.60 [95% CI, 0.48-0.66]), whereas cardiac readmission was strongly correlated with long-term cardiovascular mortality (Rho, 0.60 [95% CI, 0.13-0.86]). Conclusions Readmission rates are substantial at 5 years after coronary artery bypass grafting and are higher in women but not with off-pump surgery. Registration URL: http://www.clinicaltrials.gov/; Unique identifier: NCT00463294.

Early and mid-term outcomes of off-pump versus on-pump coronary artery bypass surgery in patients with triple-vessel coronary artery disease: a randomized controlled trial

BACKGROUND AND AIM OF THE STUDY

Several studies have compared early and late outcomes of on-pump coronary artery bypass grafting (CABG) and off-pump CABG. However, there is still an ongoing debate on this matter, especially in patients with triple-vessel coronary artery disease (3VD).

METHODS

We randomly assigned 274 consecutive patients with 3VD to two equal groups to undergo on-pump CABG or off-pump CABG. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), including all-cause mortality, acute coronary syndrome, stroke or transient ischemic attack, and the need for repeat revascularization. The secondary outcomes were postoperative infection, ventilation time, ICU admission duration, hospital stay length, and renal failure after surgery.

RESULTS

The median follow-up duration was 31.2 months (range 24.6-35.2 months). The mean age of patients was 61.4 ± 9.3 years (range: 38-86), and 207 (78.7%) were men. There were 15 (11.2%) and 9 (7.0%) MACCE occurrences in on-pump and off-pump groups, respectively (P value = 0.23). MACCE components including all-cause death, non-fatal MI, CVA, and revascularization did not significantly differ between on-pump and off-pump groups. We observed no difference in the occurrence of MACCE between off-pump and on-pump groups in multivariable regression analysis (HR = 0.57; 95% CI 0.24-1.32; P value = 0.192). There were no statistical differences in postoperative outcomes between the off-pump and on-pump CABG groups.

CONCLUSIONS

Off-pump CABG is an equal option to on-pump CABG for 3VD patients with similar rates of MACCE and postoperative complications incidence when surgery is performed in the same setting by an expert surgeon in both methods. (IRCT20190120042428N1).

Algorithms of Perioperative Management of High-Risk Cardiac Surgery Patients with Coronary Artery Disease and Polymorbidity

The aim. To analyze the effectiveness of the developed algorithms for the perioperative management of high-risk cardiac surgery patients with coronary artery disease (CAD) and polymorbidity. Materials and methods. We analyzed perioperative management of 354 high-risk cardiac surgery patients with CAD with EuroSCORE II predicted mortality >5%, among which 194 (54.8%) underwent isolated coronary artery bypass grafting, and 160 (45.2%) had surgical myocardial revascularization with accompanying valvular pathology correction or left ventricular postinfarction aneurysm resection. All the patients were discharged after cardiac surgery performed at the Department of Surgical Treatment of CAD of the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine in the period from 2009 to 2019. As part of the study, general clinical examinations, electrocardiography, echocardiography, coronary angiography, cardiosurgical treatment were provided, and perioperative patient management protocols were developed and implemented. Results. Based on the conducted detailed analysis, it was established that the success of surgical revascularization of the myocardium depends not only on cardiac factors, but also on the compensation of concomitant diseases, the work of an experienced cardiac team consisting of a cardiologist, an interventionist, an anesthesiologist, a cardiac surgeon, and an intensivist. Treatment and prevention measures should be personalized and aimed at timely response to changes in laboratory and hemodynamic indicators of patients at all stages of their management, as well as stabilization of concomitant diseases. An important point in the preoperative preparation of cardiac surgery patients is verification of concomitant diseases with the aim of their timely compensation. The implemented algorithm for searching for comorbid conditions made it possible to improve the diagnosis of initial disorders of glucose metabolism, abnormal uric acid levels and cerebrovascular disease. Lowering the glucose level according to the developed algorithm of management of patients with impaired glucose metabolism in the perioperative period made it possible to reduce the number of postoperative wound infections by 3.4% and arrhythmological complications by 19.4%. Correction of drug therapy taking into account the glomerular filtration rate made it possible to avoid postoperative hemodialysis. Preventive prescription of therapeutic doses of proton pump inhibitors against the background of dual antiplatelet therapy, according to the developed protocol, led to a decrease in postoperative gastroduodenal complications from 5.1% to 0.3%. Conclusions. Implementation of the system of personalized treatment and preventive management of patients in the perioperative period made it possible to reduce postoperative complications from 16.7% to 4% (p=0.0190).

Predictive role of arterial lactate in acute kidney injury associated with off-pump coronary artery bypass grafting

Objectives

This observational study aims to explore the predictive role of postoperative arterial lactate in off-pump coronary artery bypass grafting (CABG)-associated acute kidney injury (AKI).

Materials and methods

A total of 500 consecutive patients who underwent off-pump CABG from August 2020 to August 2021 at the Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, were included. Logistic regression analysis was used to confirm the independent risk factors of off-pump CABG-associated AKI. Receiver operating characteristic (ROC) curve was performed to evaluate the discrimination ability and Hosmer–Lemeshow goodness of fit test was performed to evaluate the calibration ability.

Results

The incidence of off-pump CABG-associated AKI was 20.6%. Female gender, preoperative albumin, baseline serum creatinine, 12 h postoperative arterial lactate and duration of mechanical ventilation were independent risk factors. The area under the ROC curve (AUC) of 12 h postoperative arterial lactate for predicting off-pump CABG-associated AKI was 0.756 and the cutoff value was 1.85. The prediction model that incorporated independent risk factors showed reliable predictive ability (AUC = 0.846). Total hospital stay, intensive care unit stay, occurrence of other postoperative complications, and 28-day mortality were all significantly higher in AKI group compared to non-AKI group.

Conclusion

12 h postoperative arterial lactate was a validated predictive biomarker for off-pump CABG-associated AKI. We constructed a predictive model that facilitates the early recognition and management of off-pump CABG-associated AKI.

Impact of Surgeon Experience and Centre Volume on Outcome After Off-Pump Coronary Artery Bypass Surgery: Results From the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) Registry

AIM

The aim of this study was to assess the impact of surgeon experience and centre volume on early operative outcomes in patients undergoing off-pump coronary artery bypass (OPCAB) surgery.

METHOD

Of 7,352 patients in the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry, 1,549 underwent OPCAB and were included in the present analysis. Using adjusted regression analysis, we compared major early adverse events after procedures performed by experienced OPCAB surgeons (i.e., ≥20 cases per year; n=1,201) to those performed by non-OPCAB surgeons (n=348). Furthermore, the same end points were compared between procedures performed by OPCAB surgeons in high OPCAB volume centres (off-pump technique used in >50% of cases; n=894) and low OPCAB volume centres (n=307).

RESULTS

In the experienced OPCAB surgeon group, we observed shorter procedure times (β -43.858, 95% confidence interval [CI] -53.322 to -34.393; p<0.001), a lower rate of conversion to cardiopulmonary bypass (odds ratio [OR] 0.284, 95% CI 0.147-0.551; p<0.001), a lower rate of prolonged inotrope or vasoconstrictor use (OR 0.492, 95% CI 0.371-0.653; p<0.001), a lower rate of early postprocedural percutaneous coronary interventions (OR 0.335, 95% CI 0.169-0.663; p=0.002), and lower 30-day mortality (OR 0.423, 95% CI 0.194-0.924; p=0.031). In high OPCAB volume centres, we found a lower rate of prolonged inotrope use (OR 0.584, 95% CI 0.419-0.814; p=0.002), a lower rate of postprocedural acute kidney injury (OR 0.382, 95% CI 0.198-0.738; p=0.004), shorter duration of intensive care unit (β -1.752, 95% CI -2.240 to -1.264; p<0.001) and hospital (β -1.967; 95% CI -2.717 to -1.216; p<0.001) stays, and lower 30-day mortality (OR 0.316, 95% CI 0.114-0.881; p=0.028).

CONCLUSIONS

Surgeon experience and centre volume may play an important role on the early outcomes after OPCAB surgery.

15-year outcomes of the JOCRI study (JOCRIED study): a randomised comparison of off-pump and on-pump multiple arterial coronary revascularisation

OBJECTIVE

The Japanese Off-Pump Coronary Revascularization Investigation (JOCRI) study reported a non-significant difference in early outcomes and graft patency between off-pump coronary artery bypass grafting and on-pump coronary artery bypass grafting in 2005. The JOCRIED study aimed to review the long-term outcomes of the JOCRI study participants.

METHOD AND RESULTS

The JOCRIED study enrolled 123 of the JOCRI study participants completing the clinical follow-up between August 2018 and August 2020; 61 patients in the off-pump group and 62 patients in the on-pump group. The follow-up period was 13.8 ± 2.8 years. The groups were compared regarding mortality, the incidence of major adverse cardiac and cerebrovascular events and repeat revascularisation. The 15-year cumulative survival rate (off-pump vs on-pump, respectively; 77.7% vs 75.3%; p = 0.85), major adverse events-free survival rate (62.5% vs 55.6%; p = 0.27) and repeat revascularisation-free rate (84.8% vs 78.0%; p = 0.16) were not significantly different between the two groups. Revascularisation was the most common major adverse events in the JOCRIED participants. Although percutaneous coronary intervention was performed in 8 patients (13%) in the off-pump group and in 14 patients (23%) in the on-pump group (p = 0.23), no patients underwent redo coronary artery bypass grafting.

CONCLUSIONS

Off-pump coronary artery bypass grafting provides comparable 15-year outcomes to on-pump coronary artery bypass grafting.

Vein Graft Use and Long-Term Survival Following Coronary Bypass Grafting

BACKGROUND

Although placement of at least 1 arterial graft during coronary artery bypass grafting (CABG) has a proven survival benefit, it is unknown what degree of revascularization with saphenous vein grafting (SVG) is associated with improved survival.

OBJECTIVES

The authors sought to determine whether undergoing surgery performed by a surgeon who is liberal with vein graft utilization is associated with improved survival in patients undergoing single arterial graft CABG (SAG-CABG).

METHODS

This was a retrospective, observational study of SAG-CABG performed in Medicare beneficiaries from 2001 to 2015. Surgeons were stratified by number of SVG utilized per SAG-CABG into conservative (≥1 SD below mean), average (within 1 SD of mean), and liberal (≥1 SD above mean). Long-term survival was estimated using Kaplan-Meier analysis and compared among surgeon groups before and after augmented inverse-probability weighting.

RESULTS

There were 1,028,264 Medicare beneficiaries undergoing SAG-CABG from 2001 to 2015 (mean age 72.0 ± 7.9 years, 68.3% male). Over time, 1-vein and 2-vein SAG-CABG utilization increased, whereas 3-vein and ≥4-vein SAG-CABG utilization decreased (P < 0.001). Surgeons who were conservative vein graft users performed a mean 1.7 ± 0.2 vein grafts per SAG-CABG, whereas those who were liberal vein graft users performed a mean 2.9 ± 0.2 vein grafts per SAG-CABG. Weighted analysis demonstrated no difference in median survival among patients undergoing SAG-CABG by liberal vs conservative vein graft users (adjusted median survival difference 27 days).

CONCLUSIONS

Among Medicare beneficiaries undergoing SAG-CABG, there is no association between surgeon proclivity for vein graft utilization and long-term survival, suggesting that a conservative approach to vein graft utilization is reasonable.

Simultaneous Hybrid Coronary Revascularization vs Conventional Strategies for Multivessel Coronary Artery Disease: A 10-Year Follow-Up

BACKGROUND

Although evidence is sufficient to confirm that hybrid coronary revascularization (HCR) is safe and effective in the short term, its value in the long run is debatable.

OBJECTIVES

This study sought to compare the long-term outcomes of HCR with coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multivessel disease.

METHODS

Three groups of patients, 540 each, receiving HCR, CABG, or PCI between June 2007 to September 2018, were matched using propensity score matching. Patients were stratified by EuroSCORE (European System for Cardiac Operative Risk Evaluation) II (low ≤0.9; 0.9 < medium <1.5; high ≥1.5) and SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (low ≤22; 22 < medium <33; high ≥33). Major adverse cardiac and cerebrovascular events (MACCE) and Seattle Angina Questionnaire (SAQ) scores were compared among the 3 groups.

RESULTS

In terms of MACCE and SAQ, HCR performed similarly to off-pump CABG but significantly outperformed PCI (P < 0.001). In the low-to-medium EuroSCORE II and medium-to-high SYNTAX score tertiles, MACCE rates in the HCR group were significantly lower than those in the PCI (EuroSCORE II: low, 30.7% vs 41.2%; P = 0.006; medium, 31.3% vs 41.7%; P = 0.013; SYNTAX score: medium, 27.6% vs 41.2%; P = 0.018; high, 32.4% vs 52.7%; P = 0.011) but were similar to those in the CABG group. In the high EuroSCORE II stratum, HCR had a lower MACCE rate than CABG (31.9% vs 47.0%; P = 0.041) and PCI (31.9% vs 53.7%; P = 0.015).

CONCLUSIONS

Compared with conventional strategies, HCR provided satisfactory long-term outcomes in MACCE and functional status for multivessel disease.

Coronary artery bypass surgery for acute coronary syndrome: A network meta-analysis of on-pump cardioplegic arrest, off-pump, and on-pump beating heart strategies

BACKGROUND

Coronary artery bypass grafting (CABG) in the setting of an acute coronary syndrome is a high-risk procedure, and the best strategy for myocardial revascularisation remains debated. This study compares the 30-day mortality benefit of on-pump CABG (ONCAB), off-pump CABG (OPCAB), and on-pump beating heart CABG (OnBHCAB) strategies.

METHODS

A systematic search of three electronic databases was conducted for studies comparing ONCAB with OPCAB or OnBHCAB in patients with acute coronary syndrome (ACS). The primary outcome, 30-day mortality, was compared using a Bayesian hierarchical network meta-analysis (NMA). A random effects consistency model was applied, and direct and indirect comparisons were made to determine the relative effectiveness of each strategy on postoperative outcomes.

RESULTS

One randomised controlled trial and eighteen observational studies fulfilling the inclusion criteria were identified. A total of 4320, 5559, and 1962 patients underwent ONCAB, OPCAB, and OnBHCAB respectively. NMA showed that OPCAB had the highest probability of ranking as the most effective treatment in terms of 30-day mortality (odds ratio [OR], 0.50; 95% credible interval [CrI], 0.23-1.00), followed by OnBHCAB (OR, 0.62; 95% CrI, 0.20-1.57), however the 95% CrI crossed or included unity. A subgroup NMA of nine studies assessing only acute myocardial infarction (AMI) patients demonstrated a 72% reduction in likelihood of 30-day mortality after OPCAB (CrI, 0.07-0.83). No significant increase in rate of stroke, renal dysfunction or length of intensive care unit stay was found for either strategy.

CONCLUSIONS

Although no single best surgical revascularisation approach in ACS patients was identified, the significant mortality benefit with OPCAB seen with AMI suggests high acuity patients may benefit most from avoiding further myocardial injury associated with cardiopulmonary bypass and cardioplegic arrest.