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Yang X, Zhu L, Pan H, Yang Y. Cardiopulmonary bypass associated acute kidney injury: better understanding and better prevention. Ren Fail 2024; 46:2331062. [PMID: 38515271 PMCID: PMC10962309 DOI: 10.1080/0886022x.2024.2331062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
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.
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Affiliation(s)
- Xutao Yang
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Li Zhu
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
- The Jinhua Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, China
| | - Hong Pan
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Yi Yang
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
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Ren Q, Li G, Chu T, Liu Q, Huang Y, Liu K, Pan J, Wu Z. Off-pump Versus On-pump Coronary Artery Bypass Grafting in Diabetic patients: A Meta-analysis of Observational Studies with a Propensity-Score Analysis. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07603-y. [PMID: 38990420 DOI: 10.1007/s10557-024-07603-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE The debate between off-pump coronary artery bypass grafting (OPCAB) and on-pump coronary artery bypass grafting (ONCAB) in diabetic patients remains. This meta-analysis aimed to investigate outcomes after OPCAB versus ONCAB for patients with diabetes. METHODS Literature research was conducted up to December 2023 using Ovid Medline, EMBASE, and the Cochrane Library. Eligible studies were observational studies with a propensity-score analysis of OPCAB versus ONCAB. The primary outcomes were early mortality and mid-term survival. The secondary outcomes were cerebrovascular accidents, reoperation for bleeding, incomplete revascularization, myocardial infarction, low cardiac output, and renal replacement therapy. RESULTS Our research identified seven observational studies with a propensity-score analysis enrolling 13,085 patients. There was no significant difference between OPCAB and ONCAB for early mortality, mid-term survival, myocardial infarction, low cardiac output, and renal replacement therapy. OPCAB was associated with a lower risk of cerebrovascular accidents (OR 0.43; 95% CI, 0.24-0.76, P = 0.004) and reoperation for bleeding (OR 0.60; 95% CI, 0.41-0.88, P = 0.009). However, OPCAB was associated with a higher risk of incomplete revascularization (OR 2.07; 95% CI, 1.60-2.68, P < 0.00001). CONCLUSION Among patients with diabetes, no difference in early mortality and mid-term survival was observed. However, OPCAB was associated with a lower incidence of morbidity, including cerebrovascular accidents and reoperation for bleeding.
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Affiliation(s)
- Qiushi Ren
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Gang Li
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Tongxin Chu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Quan Liu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Yang Huang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - KaiZheng Liu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Jinyu Pan
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Zhongkai Wu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
- NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China.
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Wang C, Jiang Y, Wang Q, Wang D, Jiang X, Dong N, Chen S, Chen X. Off-pump versus on-pump coronary artery bypass grafting in elderly patients at 30 days: a propensity score matching study. Postgrad Med J 2024; 100:414-420. [PMID: 38330496 DOI: 10.1093/postmj/qgad120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/27/2023] [Accepted: 11/10/2023] [Indexed: 02/10/2024]
Abstract
BACKGROUND Elderly patients are at increased risk of perioperative morbidity and mortality after conventional on-pump coronary artery bypass grafting (ONCABG). This study was to determine whether such high-risk population would benefit from off-pump coronary artery bypass grafting (OPCABG). METHODS A retrospective analysis was performed on patients aged 65 years or older who underwent isolated coronary artery bypass grafting for the first time in Wuhan Union Hospital from January 2015 to January 2021. We used propensity score matching to adjust for differences in baseline characteristics between the ONCABG and OPCABG groups. Morbidity and mortality within 30 days after surgery were compared between the two groups. All operations were performed by experienced cardiac surgeons. RESULTS A total of 511 patients (ONCABG 202, OPCABG 309) were included. After 1:1 matching, the baseline characteristics of the two groups were comparable (ONCABG 173, OPCABG 173). The OPCABG group had higher rate of incomplete revascularization (13.9% vs. 6.9%; P = .035) than the ONCABG group. However, OPCABG reduced the risk of postoperative renal insufficiency (15.0% vs. 30.1%; P = .001) and reoperation for bleeding (0.0% vs. 3.5%; P = .030). There were no significant differences in early postoperative mortality, myocardial infarction, stroke, and other outcomes between the two groups. CONCLUSIONS OPCABG is an alternative revascularization method for elderly patients. It reduces the risk of early postoperative renal insufficiency and reoperation for bleeding.
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Affiliation(s)
- Chen Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yefan Jiang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Qingpeng Wang
- Department of Cardiovascular Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430062, China
| | - Dashuai Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xionggang Jiang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Si Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xinzhong Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
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Aeen FB, Pakzad R, Tayebi Z, Kashkooli RI, Abdi F. Clinical outcomes of off-pump coronary artery bypass graft in patients with diabetes and non-diabetics: A systematic review and meta-analysis. Diabetes Metab Syndr 2022; 16:102643. [PMID: 36279703 DOI: 10.1016/j.dsx.2022.102643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/18/2022] [Accepted: 10/11/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM Diabetes mellitus is a prevalent risk factor for developing coronary artery disease which worsens the clinical outcomes of patients undergoing coronary artery bypass grafting (CABG). This study aimed to determine the clinical outcomes of patients with diabetes and non-diabetic patients who underwent off-pump CABG surgery. METHOD Medline, Scopus, Proquest, Embase, Web of Science, and Google scholar were searched until September 10, 2021. The effect sizes including unstandardized mean difference and odds ratio with 95% confidence interval were calculated using "Metan" package. The Cochran's Q-test and I2 statistic were used to assess heterogeneity, a random-effects model was applied to estimate the pooled effect sizes, and meta-regression was used to investigate the factors affecting heterogeneity between studies. RESULTS 10 studies with 6200 sample sizes were included in the study. In groups with diabetes, Summary odds ratio (SOR) and 95% confidence interval of infection was 2.18 more than non-diabetic groups. Also, odds renal complication was 1.74 more than non-diabetic groups, and the odds cardiovascular complication in groups with diabetes was 1.30 more than non-diabetics. There were no differences in mortality, neurologic, respiratory and surgical complications between groups with diabetes and non-diabetics. Based on meta-regression results, age (Coefficient: 0.942; p = 0.009) had a significant direct relationship and sample size (Coefficient: 0.001; p = 0.009) had an indirect significant relationship with heterogeneity of neurologic outcomes. There was no significant publication bias in our results. CONCLUSION Our study revealed that off-pump CABG led to some significant outcomes in patients with diabetes compared to non-diabetics. Renal and infection complications were higher in patients with diabetes but no significant differences were seen in most of other postoperative outcomes between the two groups.
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Affiliation(s)
- Fatemeh Behesht Aeen
- Student Research Committee, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Pakzad
- Department of Epidemiology, Faculty of Health, Ilam University of Medical Sciences, Ilam, Iran
| | - Zahra Tayebi
- Faculty of Nursing and Midwifery, Alborz University of Medical Sciences, Karaj, Iran
| | - Razie Iloon Kashkooli
- Student Research Committee, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Abdi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran.
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Wang C, Jiang Y, Song Y, Wang Q, Tian R, Wang D, Dong N, Jiang X, Chen S, Chen X. Off-pump or on-pump coronary artery bypass at 30 days: A propensity matched analysis. Front Cardiovasc Med 2022; 9:965648. [PMID: 35979017 PMCID: PMC9376244 DOI: 10.3389/fcvm.2022.965648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionThis study was to determine whether coronary artery bypass grafting without cardiopulmonary bypass (off-pump CABG, OPCAB) could reduce early postoperative mortality and major complications compared with conventional coronary artery bypass grafting with cardiopulmonary bypass (on-pump CABG, ONCAB) by experienced surgeons.Material and methodsFrom January 2016 to June 2020, isolated CABG was performed in 1200 patients (ONCAB 429, OPCAB 771) in Wuhan Union Hospital. The propensity score matching was used to adjust for differences in baseline characteristics between the ONCABG and OPCABG groups. After 1:1 matching, 404 pairs for each group were selected to compare outcomes within 30 days after surgery. All the operations were completed by experienced surgeons that had completed more than 500 on-pump and 200 off-pump CABG, respectively.ResultsAfter propensity matching, the two groups were comparable in terms of preoperative characteristics. The OPCAB group had less vein graft (2.5 ± 1.0 vs. 2.7 ± 0.9; P < 0.001) and a higher rate of incomplete revascularization (12.4 vs. 8.2%; P < 0.049) than the ONCAB group. There was no significant difference in early postoperative mortality between ONCAB and OPCAB groups (2.2 vs. 2.2%; P = 1.00). However, patients in the OPCAB group had a lower risk of postoperative stroke (1.5 vs. 4.7%; P = 0.008), new-onset renal insufficiency (8.9 vs. 18.8%; P < 0.001), respiratory failure (2.2 vs. 7.2%; P = 0.001), reoperation for bleeding (0.5 vs. 2.7%; P = 0.001), and required less ventilator assistance time (33.4 ± 37.9 h vs. 51.0 ± 66.1 h; P < 0.001) and intensive care unit (ICU) time (3.7 ± 2.7 days vs. 4.8 ± 4.3 days; P < 0.001).ConclusionsIn our study, patients undergoing OPCAB had fewer postoperative complications and a faster recovery. It is a feasible and safe surgical approach to achieve revascularization when performed by experienced surgeons.
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Affiliation(s)
- Chen Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yefan Jiang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yu Song
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qingpeng Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rui Tian
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dashuai Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xionggang Jiang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Xionggang Jiang
| | - Si Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Si Chen
| | - Xinzhong Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Xinzhong Chen
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Siddiqui MU, Yacob O, Junarta J, Pasha AK, Mookadam F, Mamas MA, Fischman DL. Mortality after transcatheter aortic valve replacement for aortic stenosis among patients with malignancy: a systematic review and meta-analysis. BMC Cardiovasc Disord 2022; 22:210. [PMID: 35538411 PMCID: PMC9088110 DOI: 10.1186/s12872-022-02651-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With advancements in cancer treatment, the life expectancy of oncology patients has improved. Thus, transcatheter aortic valve replacement (TAVR) may be considered as a feasible option for oncology patients with severe symptomatic aortic stenosis (AS). We aim to evaluate the difference in short- and long-term all-cause mortality in cancer and non-cancer patients treated with TAVR for severe AS. METHODS Medline, PubMed, and Cochrane Central Register of Controlled Trials were searched for relevant studies. Patients with cancer who underwent treatment with TAVR for severe AS were included and compared to an identical population without cancer. The primary endpoints were short- and long-term all-cause mortality. RESULTS Of 899 studies included, 8 met inclusion criteria. Cancer patients had significantly higher long-term all-cause mortality after TAVR when compared to patients without cancer (risk ratio [RR] 1.43; 95% confidence interval (CI) 1.26-1.62; P < 0.01). Four studies evaluated short-term mortality after TAVR and demonstrated no difference in it in patients with and without cancer (RR 0.72; 95% CI 0.47-1.08; P = 0.11). CONCLUSION Patients with cancer and severe AS have higher long-term all-cause mortality after TAVR. However, we found no difference in short-term all-cause mortality when comparing patients with and without cancer. The decision to perform TAVR in cancer patients should be individualized based on life expectancy and existing co-morbidities.
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Affiliation(s)
- Muhammad Umer Siddiqui
- Department of Internal Medicine, Thomas Jefferson University Hospitals, 833 Chestnut Street, Suite 701, Philadelphia, PA, 19107, USA.
| | - Omar Yacob
- Cardiovascular Medicine, MercyOne North Iowa Heart Center, Mason City, IA, USA
| | - Joey Junarta
- Department of Internal Medicine, Thomas Jefferson University Hospitals, 833 Chestnut Street, Suite 701, Philadelphia, PA, 19107, USA
| | - Ahmed K Pasha
- Cardiovascular Medicine, UHS Wilson Medical Center, Johnson City, NY, USA
| | - Farouk Mookadam
- Cardiovascular Medicine, Mayo Clinic Health System, Phoenix, AZ, USA
| | - Mamas A Mamas
- Cardiovascular Research Group, Center for Prognosis Research, Keele University, Keele, UK
| | - David L Fischman
- Cardiovascular Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Ofoegbu CKP, Manganyi RM. Off-Pump Coronary Artery Bypass Grafting; is it Still Relevant? Curr Cardiol Rev 2022; 18:e271021197431. [PMID: 34711166 PMCID: PMC9413736 DOI: 10.2174/1573403x17666211027141043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/22/2021] [Accepted: 07/29/2021] [Indexed: 11/22/2022] Open
Abstract
Off-pump Coronary Artery Bypass Grafting (OPCAB) experienced a resurgence in the 1980s -2000s and developed steadily with improvement of the instrumentation and techniques. However questions about graft patency and long-term survival of OPCAB patients still exist. This review attempts to explore the current relevance of OPCAB.
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Affiliation(s)
- Chima K P Ofoegbu
- Chris Barnard Division of Cardiothoracic Surgery, Groote Schuur Hospital Cape Town, Cape Town 7925, South Africa
| | - Rodgers M Manganyi
- Chris Barnard Division of Cardiothoracic Surgery, Groote Schuur Hospital Cape Town, Cape Town 7925, South Africa
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Willemsen LM, Vlot EA, Janssen PWA, Visser CD, Zheng K, Kelder JC, Noordzij PG, van den Dool E, Klein P, Hackeng CM, ten Berg JM. Blood loss after coronary artery bypass by aspirin responsiveness assessed with preoperative VerifyNow aspirin testing. Res Pract Thromb Haemost 2021; 5:e12623. [PMID: 34993386 PMCID: PMC8713006 DOI: 10.1002/rth2.12623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 10/01/2021] [Accepted: 10/09/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Aspirin is important for preventing thrombotic events but also increases bleeding complications. Minimizing bleeding while preventing thrombotic events remains challenging in patients undergoing coronary artery bypass grafting (CABG). Establishing the patient's preoperative aspirin response could distinguish patients at risk for perioperative blood loss. OBJECTIVE Aim was to compare 12-h blood loss after CABG between aspirin-sensitive and aspirin-resistant patients. PATIENTS/METHODS The primary analysis of this substudy of the POPular CABG trial (NCT02352402) included patients that used aspirin monotherapy preoperatively. A preoperative platelet function test by the VerifyNow aspirin assay was performed before CABG and patients were classified as aspirin-sensitive or aspirin-resistant based on an aspirin reaction units cutoff value of 550. The primary end point was 12-hour blood loss after CABG. The secondary end point was, among others, clinical bleeding events after CABG. RESULTS A total of 128 patients were included in the primary analysis. Of these, 116 patients were aspirin sensitive and 12 were aspirin resistant. Mean blood loss 12 hours after CABG was 555 ± 278 mL in aspirin-sensitive patients and 406±110 mL in aspirin-resistant patients (P = .04). All bleeding events (n = 15; 11.7%) occurred in aspirin-sensitive patients. CONCLUSIONS In patients who are on aspirin preoperatively, aspirin sensitivity was associated with 12-hour blood loss after CABG, suggesting that preoperative VerifyNow aspirin testing could identify patients undergoing CABG at high risk for perioperative bleeding.
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Affiliation(s)
| | - Eline A. Vlot
- Department of Anesthesiology, Intensive Care, and Pain MedicineSt Antonius HospitalNieuwegeinThe Netherlands
| | | | - Claire D. Visser
- Department of Clinical Pharmacy and ToxicologyLeiden University Medical CenterLeidenThe Netherlands
| | - Kai Zheng
- Department of CardiologySt Antonius HospitalNieuwegeinThe Netherlands
| | | | - Peter G. Noordzij
- Department of Anesthesiology, Intensive Care, and Pain MedicineSt Antonius HospitalNieuwegeinThe Netherlands
| | | | - Patrick Klein
- Department of Cardiothoracic SurgerySt Antonius HospitalNieuwegeinThe Netherlands
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Imada R, Komakata T, Aryal B, Tada N, Nuruki K, Kataoka T, Hiramine K, Mukaihara K, Kinjo T. Pancreaticoduodenectomy after transcatheter aortic valve implantation in an elderly patient with severe aortic stenosis and pancreas cancer: A case report. Ann Med Surg (Lond) 2021; 62:207-210. [PMID: 33537131 PMCID: PMC7843360 DOI: 10.1016/j.amsu.2021.01.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction and importance Not only pancreatic cancer but also aortic stenosis (AS) is increasing with the aging population. There is no optimal strategy for elderly patients with both pancreatic cancer and AS. We report a case of pancreatic head cancer with severe AS undergoing pancreaticoduodenectomy (PD) after transcatheter aortic valve implantation (TAVI). Case presentation An 88-year-old woman was referred to our hospital because of severe AS with symptoms of heart failure. Preoperative examination revealed resectable pancreatic head cancer, so TAVI was performed before PD to reduce the perioperative risk. The patient underwent PD 34 days after TAVI, with no significant postoperative complications, and was transferred to the other hospital for rehabilitation on postoperative day 45. No recurrence was observed at more than 7 months without adjuvant therapy. Clinical discussion Aortic valve replacement (AVR) is recommended before non-cardiac surgery in patients with symptomatic severe AS. Surgical aortic valve replacement (SAVR) is the standard treatment. However, owing to the highly invasive procedure and increased perioperative risk, SAVR is usually avoided in elderly patients with malignancy and severe AS. We demonstrated that TAVI followed by PD could be safely performed in high-risk elderly patients presenting with both severe AS and pancreatic head cancer. To our knowledge, this is the first case report of PD after TAVI in a patient with severe AS. Conclusion We demonstrated that TAVI followed by PD could be safely performed in high-risk elderly patients presenting with severe AS and co-existing malignancy. Severe aortic stenosis (AS) is a risk factor for non-cardiac surgery. In some cases, prior treatment of AS is recommended. Minimally invasive transcatheter aortic valve implantation (TAVI) may be a treatment option for the elderly cancer patients. Preceding TAVI may be a useful therapeutic strategy for elderly cancer patients with severe AS.
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Affiliation(s)
- Ryo Imada
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Teruo Komakata
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Bibek Aryal
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Nobuhiro Tada
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Kensuke Nuruki
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Tetsuro Kataoka
- Department of Cardiovascular Medicine, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Kiyohisa Hiramine
- Department of Cardiovascular Medicine, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Kosuke Mukaihara
- Department of Cardiovascular Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Tamahiro Kinjo
- Department of Cardiovascular Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
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Gill C, Lee M, Balanescu DV, Donisan T, Serauto Canache AJ, Palaskas N, Lopez-Mattei J, Kim PY, Song J, Yang EH, Cilingiroglu M, Kar B, Gregoric I, Marmagkiolis K, Iakobishvili Z, Iliescu C. Transcatheter and surgical aortic valve replacement impact on outcomes and cancer treatment schedule. Int J Cardiol 2020; 326:62-70. [PMID: 32858137 DOI: 10.1016/j.ijcard.2020.08.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/01/2020] [Accepted: 08/19/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recent data suggest that transcatheter aortic valve replacement (TAVR) for the treatment of severe aortic stenosis (AS) is viable in cancer patients. TAVR may be preferred in cancer patients due to its minimally invasive nature and smaller impact on oncologic therapies compared to SAVR. Objectives We sought to determine if TAVR is an acceptable alternative to SAVR in cancer patients and whether TAVR allows for earlier initiation or resumption of anti-cancer therapies. METHODS Cancer patients in a tertiary cancer center diagnosed with severe AS were retrospectively included. Patients accepted by the heart team underwent either TAVR or SAVR, while remaining patients received medical therapy alone. Time intervals to initiation of cancer treatment and the impact of cancer treatment on the replaced valves were recorded. Logistic regression was performed to determine the impact of treatment strategy on overall survival (OS) in all 3 subgroups. RESULTS One hundred and eighty-seven cancer patients diagnosed with severe AS were identified. AVR was associated with better OS compared to medical therapy alone (p < 0.0001). TAVR was associated with better OS at 72 months (HR = 0.468, p < 0.001) compared to medical therapy alone, with no difference in OS observed between SAVR and TAVR. Time intervals to initiation of cancer treatments were shorter in the TAVR group, with no valve deterioration or infection observed in all groups. CONCLUSION Cancer patients with severe AS benefit from AVR. TAVR is a viable alternative to SAVR in high-risk cancer patients to prolong survival and allow for earlier administration or resumption of anti-neoplastic therapies.
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Affiliation(s)
- Clarence Gill
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA; Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michelle Lee
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Dinu Valentin Balanescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Teodora Donisan
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Astrid Josefina Serauto Canache
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Nicolas Palaskas
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juan Lopez-Mattei
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter Y Kim
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juhee Song
- Division of Biostatistics, Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eric H Yang
- Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Biswajit Kar
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Igor Gregoric
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - Zaza Iakobishvili
- Department of Cardiology, Tel Aviv Jaffa District, Clalit Health Fund, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Cezar Iliescu
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA.
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Off-Pump versus Conventional Coronary Artery Bypass Grafting: A Meta-Analysis and Consensus Statement from the 2004 ISMICS Consensus Conference. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019. [DOI: 10.1097/01243895-200500110-00002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background The purpose of this evidence-based consensus statement is to systematically review and meta-analyze the randomized and nonrandomized evidence comparing off-pump (OPCAB) to conventional coronary artery bypass (CCAB) surgery and to provide consensus on the role of OPCAB in low- and high-risk surgical patients. Methods and Results This consensus conference was conducted according to the American College of Cardiology (ACC)/American Heart Association (AHA) standards for development of clinical practice guidelines. The Steering Committee collated all published studies of OPCAB versus CCAB through May 2004 and developed six questions central to controversies surrounding OPCAB surgery in mortality, morbidity, and resource utilization. For mixed-risk patient populations, meta-analysis of 37 randomized clinical trials (3,369 patients, Level A) reported across a total of 53 papers, and two meta-analyses of nonrandomized trials (Level B) comparing OPCAB versus CCAB were identified. For high-risk patient populations, we performed a meta-analysis of 3 randomized and 42 nonrandomized trials (26,349 patients, Level B). Conclusion Meta-analysis of Level A and B evidence provided the basis for the following consensus statements in patients undergoing surgical myocardial revascularization: (1) OPCAB should be considered a safe alternative to CCAB with respect to risk of mortality [Class I, Level A]; (2) With appropriate use of modern stabilizers, heart positioning devices, and adequate surgeon experience, similar completeness of revascularization and graft patency can be achieved [Class IIa, Level A]; (3) OPCAB is recommended to reduce perioperative morbidity [Class I, Level A]; (4) OPCAB may be recommended to minimize midterm cognitive dysfunction [Class IIa, Level A]; (5) OPCAB should be considered as an equivalent alternative to CCAB in regard to quality of life [Class I, Level A]; (6) OPCAB is recommended to reduce the duration of ventilation, ICU and hospital stay, and resource utilization [Class I, Level A]; (7) OPCAB should be considered in high-risk patients to reduce perioperative mortality, morbidity, and resource utilization [Class IIa, Level B].
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Farina P, Gaudino M, Angelini GD. Off-pump coronary artery bypass surgery: The long and winding road. Int J Cardiol 2019; 279:51-55. [DOI: 10.1016/j.ijcard.2018.09.101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/23/2018] [Accepted: 09/25/2018] [Indexed: 11/27/2022]
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Puskas J, Cheng D, Knight J, Angelini G, DeCannier D, Diegeler A, Dullum M, Martin J, Ochi M, Patel N, Sim E, Trehan N, Zamvar V. Off-Pump versus Conventional Coronary Artery Bypass Grafting: A Meta-Analysis and Consensus Statement from the 2004 ISMICS Consensus Conference. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019. [DOI: 10.1177/155698450500100102] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- John Puskas
- Division of Cardiothoracic Surgery, Emory University, Atlanta, USA
| | - Davy Cheng
- Department of Anesthesia & Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - John Knight
- Cardiothoracic Surgical Unit, Flinders Medical Center, Bedford Park, Australia
| | | | | | - Anno Diegeler
- Herz-Und Gefasse Klinik Bad Neustadt, University of Leipzig, Bad Neustadt, Germany
| | - Mercedes Dullum
- Department of Cardiothoracic Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Janet Martin
- Department of Anesthesia & Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - Masami Ochi
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Nirav Patel
- Lenox Hill Hospital, New York, New York, USA
| | - Eugene Sim
- Department of Cardiovascular Surgery, National University Hospital, Singapore, Singapore
| | - Naresh Trehan
- Escorts Heart Institute and Research Center, New Delhi, India
| | - Vipin Zamvar
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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14
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Minamino-Muta E, Kato T, Morimoto T, Taniguchi T, Nakatsuma K, Kimura Y, Inoko M, Shirai S, Kanamori N, Murata K, Kitai T, Kawase Y, Miyake M, Izumi C, Mitsuoka H, Hirano Y, Sasa T, Nagao K, Inada T, Nishikawa R, Takeuchi Y, Yamagami S, Yamane K, Su K, Komasa A, Ishii K, Yamashita Y, Kato Y, Takabayashi K, Saito N, Minatoya K, Kimura T. Malignant disease as a comorbidity in patients with severe aortic stenosis: clinical presentation, outcomes, and management. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2018; 4:180-188. [PMID: 29596567 DOI: 10.1093/ehjqcco/qcy010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 03/19/2018] [Indexed: 01/28/2023]
Abstract
Aim To investigate the effect of malignancy on the outcomes of patients with severe aortic stenosis (AS) and the management strategy for AS with malignancy. Methods and results Using data of 3815 patients with severe AS in a retrospective multicentre registry [CURRENT AS (Contemporary outcomes after sURgery and medical tREatmeNT in patients with severe Aortic Stenosis) registry], we compared 3-year clinical outcomes among three groups based on malignancy status: with malignancy currently under treatment including best supportive care (malignancy group), with a history of malignancy without any current treatment (past history group), or without history of malignancy (no malignancy group). Patients in the malignancy group (n = 124) were more often men and had higher prevalence of low body mass index, recurrence of malignancy, anaemia, and asymptomatic status, despite comparable surgical risks and echocardiographic parameters. The malignancy group or the past history group (n = 389) had significantly higher risk for all-cause death [hazard ratio (HR) 2.49, 95% CI (95% confidence interval) 1.98-3.14; HR 1.23, 95% CI 1.04-1.46] and for malignancy-related death (HR 16.2, 95% CI 10.64-24.54; HR 3.66, 95% CI 2.43-5.52) than that of the no malignancy group (n = 3302). The excess risk for aortic valve-related death was not observed in the malignancy group (HR 0.79, 95% CI 0.48-1.29) and was lower in the past history group (HR 0.72, 95% CI 0.53-0.96). In the malignancy group, the treatment strategy (surgery: n = 16, conservative management: n = 108) was determined based on the clinical status of AS or life expectancy. Conclusions Malignancy had marked effect on all-cause death and malignancy-related death in patients with severe AS. History of malignancy also had a smaller but significant effect on mortality.
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Affiliation(s)
- Eri Minamino-Muta
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, Japan
| | - Kenji Nakatsuma
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, Japan
| | - Yuki Kimura
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Shinichi Shirai
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Norio Kanamori
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yuichi Kawase
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Makoto Miyake
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | - Chisato Izumi
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | - Hirokazu Mitsuoka
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Ikoma, Japan
| | - Yutaka Hirano
- Department of Cardiology, Kinki University Hospital, Osakasayama, Japan
| | | | - Kazuya Nagao
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Tsukasa Inada
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Ryusuke Nishikawa
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Yasuyo Takeuchi
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Shintaro Yamagami
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, Japan
| | | | - Kanae Su
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Akihiro Komasa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, Japan
| | - Katsuhisa Ishii
- Department of Cardiology, Kansai Electric Power Hospital, Osaka, Japan
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, Japan
| | - Yoshihiro Kato
- Department of Cardiology, Saiseikai Noe Hospital, Osaka, Japan
| | | | - Naritatsu Saito
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, Japan
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Tanaka T, Yahagi K, Okuno T, Horiuchi Y, Kusuhara T, Yokozuka M, Miura S, Tanabe K. Transcatheter aortic valve implantation in a patient with severe aortic valve stenosis, colon cancer, and obstructive ileus: A case report. J Cardiol Cases 2018; 17:163-166. [PMID: 30279882 DOI: 10.1016/j.jccase.2018.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/17/2017] [Accepted: 01/07/2018] [Indexed: 02/03/2023] Open
Abstract
An 82-year-old woman with symptomatic severe aortic stenosis (AS) developed an obstructive ileus caused by colon cancer. Colectomy was considered a high-risk surgery due to both the severe AS and obstructive ileus. Therefore, we planned placement of a colonic stent for the obstructive ileus. After stenting, we performed transcatheter aortic valve implantation (TAVI) instead of surgical aortic valve replacement (SAVR), because of the risk of bleeding during extracorporeal circulation and the perioperative risk of AVR (Society of Thoracic Surgery predicted risk of mortality: 7.4%). Successful colonic stenting and TAVI allowed a safer colectomy. The period from TAVI to colectomy was 12 days. TAVI could be useful for symptomatic severe AS in high-risk patients prior to non-cardiac surgery, especially for malignant tumors. <Learning objective: In patients with symptomatic severe aortic stenosis, aortic valve replacement is recommended prior to non-cardiac surgery. However, in patients with a malignancy, the complications due to the tumor and the risk of extracorporeal circulation remain a challenge in surgical aortic valve replacement. In such cases, transcatheter aortic valve implantation may be a useful option to reduce the incidence of complications and the time to surgery for the malignancy.>.
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Affiliation(s)
- Tetsu Tanaka
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Kazuyuki Yahagi
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Taishi Okuno
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Yu Horiuchi
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Takayoshi Kusuhara
- Division of Cardiovascular Surgery, Mitsui Memorial Hospital, Tokyo, Japan
| | - Motoi Yokozuka
- Division of Anesthesia, Mitsui Memorial Hospital, Tokyo, Japan
| | - Sumio Miura
- Division of Cardiovascular Surgery, Mitsui Memorial Hospital, Tokyo, Japan
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
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16
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Mangner N, Woitek FJ, Haussig S, Holzhey D, Stachel G, Schlotter F, Höllriegel R, Mohr FW, Schuler G, Linke A. Impact of active cancer disease on the outcome of patients undergoing transcatheter aortic valve replacement. J Interv Cardiol 2017; 31:188-196. [DOI: 10.1111/joic.12458] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 10/10/2017] [Accepted: 10/11/2017] [Indexed: 11/29/2022] Open
Affiliation(s)
- Norman Mangner
- Department of Cardiology; Heart Center Leipzig-University Hospital; Leipzig Germany
| | - Felix J. Woitek
- Department of Cardiology; Heart Center Leipzig-University Hospital; Leipzig Germany
| | - Stephan Haussig
- Department of Cardiology; Heart Center Leipzig-University Hospital; Leipzig Germany
| | - David Holzhey
- Department of Cardiac Surgery; Heart Center Leipzig-University Hospital; Leipzig Germany
| | - Georg Stachel
- Department of Cardiology; Heart Center Leipzig-University Hospital; Leipzig Germany
| | - Florian Schlotter
- Department of Cardiology; Heart Center Leipzig-University Hospital; Leipzig Germany
| | - Robert Höllriegel
- Department of Cardiology; Heart Center Leipzig-University Hospital; Leipzig Germany
| | | | - Gerhard Schuler
- Department of Cardiology; Heart Center Leipzig-University Hospital; Leipzig Germany
| | - Axel Linke
- Department of Cardiology; Heart Center Leipzig-University Hospital; Leipzig Germany
- Leipzig Heart Institute; Leipzig Germany
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17
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Townsley MM, Timpa JG, Davies JE, Marques MB. Do Institution-Level Blood Utilization and Blood Management Initiatives Meaningfully Impact Transfusion Practices in Cardiac Surgery? Anesth Analg 2017; 125:731-733. [PMID: 28817529 DOI: 10.1213/ane.0000000000002320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Matthew M Townsley
- From the *Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama; †Department of Cardiovascular Perfusion, Children's of Alabama, Birmingham, Alabama; ‡Department of Surgery, Division of Cardiovascular Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama; and §Department of Pathology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
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18
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Bainbridge D, Martin J, Cheng D. Off Pump Coronary Artery Bypass Graft Surgery Versus Conventional Coronary Artery Bypass Graft Surgery: A Systematic Review of the Literature. Semin Cardiothorac Vasc Anesth 2016; 9:105-11. [PMID: 15735848 DOI: 10.1177/108925320500900110] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The recent development of off-pump coronary artery bypass (OPCAB) graft surgical techniques has led to numerous observational and several randomized trials that have investigated outcomes compared with the current gold standard of conventional on-pump coronary bypass (CCAB) graft surgery. This systematic review assesses the current randomized trials that compare OPCAB and CCAB. Numerous end points were investigated, including mortality, stroke, myocardial infarction, atrial fibrillation, blood transfusions, wound infections, and renal failure. In addition to these important outcomes, resource utilization markers were also examined such as hospital length of stay, intensive care unit length of stay, and duration of intubation/ventilation. Finally, when level I evidence from randomized trials was unavailable, level II evidence was examined. This was done for subgroup analysis, where currently no randomized trials exist, looking at OPCAB in high-risk patients. Recommendations were made as to who should receive OPCAB and the potential benefits in this patient population.
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Affiliation(s)
- Daniel Bainbridge
- Department of Anesthesia & Perioperative Medicine, The University of Western Ontario, London, Ontario, Canada.
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19
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Watanabe Y, Kozuma K, Hioki H, Kawashima H, Nara Y, Kataoka A, Shirai S, Tada N, Araki M, Takagi K, Yamanaka F, Yamamoto M, Hayashida K. Comparison of Results of Transcatheter Aortic Valve Implantation in Patients With Versus Without Active Cancer. Am J Cardiol 2016; 118:572-7. [PMID: 27324159 DOI: 10.1016/j.amjcard.2016.05.052] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 05/23/2016] [Accepted: 05/23/2016] [Indexed: 10/21/2022]
Abstract
The aim of this study was to evaluate postprocedural and midterm outcomes of transcatheter aortic valve implantation (TAVI) in patients with aortic stenosis and active cancer. From October 2013 to August 2015, a total of 749 patients undergoing TAVI using the Edwards Sapien XT prosthesis (Edwards Lifesciences, Irvine, California) were prospectively included in the OCEAN-TAVI registry from 8 Japanese centers. A total of 47 patients (44.7% men; median age 83 years) had active cancer. The transfemoral approach was implemented in 85.1% of patients in the cancer group and 78.1% in the noncancer group (p = 0.22). The occurrence of major vascular complication (4.3% vs 7.5%, p = 0.24), life-threatening bleeding (2.1% vs 7.1%, p = 0.15), and major bleeding (8.5% vs 13%, p = 0.38) was similar between the cancer and noncancer groups. No significant differences were observed regarding device success (100% vs 96.2%, p = 0.17) or 30-day survival (95.7% vs 97.3%, p = 0.38). No difference in midterm survival was found between the patients with cancer and without cancer (log-rank, p = 0.42), regardless of advanced or limited cancer (log-rank, p = 0.68). In a multivariable Cox proportional hazard regression analysis, cancer metastasis was one of the most significant predictors of late mortality (hazard ratio 4.73, 95% CI 1.12 to 20.0; p = 0.035). In conclusion, patients with cancer with severe aortic stenosis who underwent TAVI had similar acute outcomes and midterm survival rates compared with patients without cancer. Cancer metastasis was associated with increased mortality after TAVI.
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Affiliation(s)
- Erik WL Jansen
- Department of Cardiothoracic Surgery Heart Lung Institute University Hospital Utrecht Room E 03.406 P.O. Box 85500 Utrecht 3508 6A The Netherlands
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21
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Mehr-Aein A, Sadeghi M, Madani-civi M. Does Tranexamic Acid Reduce Blood Loss in Off-Pump Coronary Artery Bypass? Asian Cardiovasc Thorac Ann 2016; 15:285-9. [PMID: 17664199 DOI: 10.1177/021849230701500404] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The hemostatic effect of tranexamic acid on the bleeding tendency and transfusion requirements in patients undergoing off-pump coronary artery bypass surgery was assessed in a prospective randomized double-blind study. Of 66 patients undergoing elective operations, 33 were given tranexamic acid (15 mg·kg−1 before infusion of heparin and 15 mg·kg−1 after protamine infusion), and the other 33 received only saline. Postoperative bleeding, transfusions, complications, hematological variables, and plasma D-dimer levels were recorded. Postoperative blood loss was significantly less in the tranexamic acid group compared to the control group (320 ± 38 vs 480 ± 75 mL). Patients in the tranexamic acid group received significantly less allogeneic blood products (0.46 vs 0.94 units per patient), and they had lower postoperative D-dimer levels. No postoperative thrombotic complications were observed in either group. Although off-pump coronary artery bypass surgery is associated with reduced frequency of hemorrhagic disorders, defective hemostasis still occurs, and tranexamic acid effectively reduces postoperative blood loss and the need for allogeneic blood products.
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22
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Vasques F, Kinnunen EM, Pol M, Mariscalco G, Onorati F, Biancari F. Outcome of Jehovah's Witnesses after adult cardiac surgery: systematic review and meta-analysis of comparative studies. Transfusion 2016; 56:2146-53. [DOI: 10.1111/trf.13657] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/04/2016] [Accepted: 04/04/2016] [Indexed: 02/01/2023]
Affiliation(s)
- Francesco Vasques
- Department of Medicine; Anesthesia and Intensive Care Unit, Padua University Hospital; Padua Italy
| | | | - Marek Pol
- Institute of Anatomy, First Faculty of Medicine, Charles University in Prague; Prague Czech Republic
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences; University of Leicester, Glenfield Hospital; Leicester UK
| | - Francesco Onorati
- Division of Cardiac Surgery; University of Verona Medical School; Verona Italy
| | - Fausto Biancari
- Department of Surgery; Oulu University Hospital; Oulu Finland
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Davierwala PM, Verevkin A, Leontyev S, Misfeld M, Borger MA, Mohr FW. Does Timing of Coronary Artery Bypass Surgery Affect Early and Long-Term Outcomes in Patients With Non-ST-Segment-Elevation Myocardial Infarction? Circulation 2015; 132:731-40. [PMID: 26304664 DOI: 10.1161/circulationaha.115.015279] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Current guidelines do not provide recommendations for optimal timing of coronary artery bypass surgery (CABG) in patients with non-ST-segment-elevation myocardial infarction. Our study aimed to determine the impact of CABG timing on early and late outcomes in patients with non-ST-segment-elevation myocardial infarction. METHODS AND RESULTS A total of 758 patients underwent CABG within 21 days after non-ST-segment-elevation myocardial infarction between January 2008 and December 2012 at our institution. The patients were divided into 3 groups according to the time interval between symptom onset and CABG: group A, <24 hours (133 patients); group B, 24 to 72 hours (192 patients); and group C, >72 hours to 21 days (433 patients). Predictors of in-hospital and long-term mortality were identified by logistic and Cox regression analyses, respectively. Overall in-hospital mortality was 5.1% (39 patients): 6.0%, 4.7%, and 5.1% in groups A, B, and C (P=0.9), respectively. A total of 118 patients died during follow-up. The 5-year survival was 73.1±2%, with a nonsignificant trend toward better survival in groups A (78.2±4%) and C (75.4±3%) compared with group B (63.6±5%; log-rank P=0.06). Renal insufficiency and LMD were independent predictors of in-hospital (odds ratio, 3.1; P=0.001; and odds ratio, 3.1; P=0.002) and long-term mortality (hazard ratio, 1.7; P=0.004; and hazard ratio, 1.5; P=0.02), whereas administration of P2Y12 inhibitors was protective (odds ratio, 0.3; P=0.01). CONCLUSIONS Emergent CABG within 24 hours of non-ST-segment-elevation myocardial infarction is associated with in-hospital mortality and long-term outcomes similar to those of CABG performed after 3 days, despite a higher risk profile. CABG performed between 24 to 72 hours showed a nonsignificant trend toward poorer long-term outcomes. Dual antiplatelet therapy until surgery is beneficial, whereas renal insufficiency and left main disease increase the risk of early and late death.
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Affiliation(s)
- Piroze M Davierwala
- From the Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany (P.M.D., A.V., S.L., M.M., F.W.M.); and Department of Cardiac Surgery, Columbia University, New York, NY (M.A.B.).
| | - Alexander Verevkin
- From the Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany (P.M.D., A.V., S.L., M.M., F.W.M.); and Department of Cardiac Surgery, Columbia University, New York, NY (M.A.B.)
| | - Sergey Leontyev
- From the Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany (P.M.D., A.V., S.L., M.M., F.W.M.); and Department of Cardiac Surgery, Columbia University, New York, NY (M.A.B.)
| | - Martin Misfeld
- From the Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany (P.M.D., A.V., S.L., M.M., F.W.M.); and Department of Cardiac Surgery, Columbia University, New York, NY (M.A.B.)
| | - Michael A Borger
- From the Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany (P.M.D., A.V., S.L., M.M., F.W.M.); and Department of Cardiac Surgery, Columbia University, New York, NY (M.A.B.)
| | - Friedrich W Mohr
- From the Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany (P.M.D., A.V., S.L., M.M., F.W.M.); and Department of Cardiac Surgery, Columbia University, New York, NY (M.A.B.)
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24
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Demir G, Çukurova Z, Eren G, Hergünsel O. Comparison of the effects of on-pump and off-pump coronary artery bypass surgery on cerebral oxygen saturation using near-infrared spectroscopy. Korean J Anesthesiol 2014; 67:391-7. [PMID: 25558339 PMCID: PMC4280476 DOI: 10.4097/kjae.2014.67.6.391] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 07/07/2014] [Accepted: 07/15/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Central nervous system complications are the most clinically important of those affecting mortality in patients undergoing coronary artery surgery. Newly developed sophisticated techniques and surgical interventions obviating the need for cardiopulmonary pumps have facilitated avoidance of these complications. In this study, we compared the impact of on-pump and off-pump coronary artery bypass surgery on cerebral oxygenation using near-infrared spectroscopy. METHODS This study included 40 patients with no comorbidities who were scheduled for on-pump (n = 20) and off-pump (n = 20) cardiac surgery. Preoperative and postoperative Standardized Mini-Mental State Examination (SMMSE) scores, perioperative mean arterial blood pressure (MAP), hematocrit (Hct), peripheral oxygen saturation (SpO2), regional cerebral oximetry values (rSO2), body temperature, and partial pressure of carbon dioxide (PCO2) were recorded, for all patients. Intergroup and intragroup comparisons were then performed. RESULTS The mean operative time was longer in the on-pump group. SMMSE scores were similar and relevant postoperative values were lower in both groups. Perioperative MAP, PCO2, and SpO2 were similar in both groups. SpO2 and PCO2 did not differ from baseline levels in either group, while the postextubation MAP at 2 h postoperatively remained low. Hct levels decreased during the perioperative and postoperative periods, while the body temperature declined perioperatively and to a greater degree in the on-pump group. The intraoperative and postoperative rSO2 decreased in both groups. In the on-pump group, the decrease in rSO2 was more prominent during the interval between the start and closure of the sternotomy. CONCLUSIONS Physiological alterations that occur during coronary artery surgery affect cerebral oxygenation during and after the operation irrespective of the application of a cardiopulmonary pump. Cerebral oxygenation decreases to a greater extent during on-pump surgery; however, probably because of the neuroprotective effects of hypothermia, the postoperative changes resemble those of off-pump surgery.
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Affiliation(s)
- Guray Demir
- Department of Anesthesiology and Reanimation, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Zafer Çukurova
- Department of Anesthesiology and Reanimation, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Gülay Eren
- Department of Anesthesiology and Reanimation, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Oya Hergünsel
- Department of Anesthesiology and Reanimation, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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Validation of rotational thromboelastometry during cardiopulmonary bypass: A prospective, observational in-vivo study. Eur J Anaesthesiol 2014; 31:68-75. [PMID: 23867776 DOI: 10.1097/eja.0b013e328363171a] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Rotational thromboelastometry (ROTEM) is a whole blood point-of-test used to assess the patient's coagulation status. Three of the available ROTEM tests are EXTEM, INTEM and HEPTEM. In the latter, heparinase added to the INTEM reagent inactivates heparin to reveal residual heparin effect. Performing ROTEM analysis during cardiopulmonary bypass (CPB) might allow the anaesthesiologist to anticipate the need for blood products. OBJECTIVE The goal of this study was to validate ROTEM analysis in the presence of very high heparin concentrations during CPB. DESIGN Prospective, observational trial. SETTING Single University Hospital. PARTICIPANTS Twenty patients undergoing coronary artery bypass grafting. MAIN OUTCOME MEASURE ROTEM analysis was performed before heparin administration (T0), 10 min after heparin (T1), at the end of CPB (T2) and 10 min after protamine (T3). The following tests were performed: EXTEM, INTEM, and HEPTEM. Heparin concentrations were measured at T1 and at the end of bypass (T2). RESULTS At T1, EXTEM differed from baseline for coagulation time: +26.7 s (18.4 to 34.9, P < 0.0001), α: -3° (1.0 to 5.4, P = 0.006) and A10: -4.4 mm (2.3 to 6.5, P = 0.0004). INTEM at T0 was different from HEPTEM at T1 for coagulation time: + 47 s (34.3 to 59.6, P > 0.0001), A10: -2.3 mm (0.5 to 4.0, P = 0.01) and α -2° (1.0 to 3.0; P = 0.0007). At T2, all parameters in EXTEM and HEPTEM related to fibrin-platelet interaction deteriorated significantly compared to T1. At T3, EXTEM and INTEM were comparable to EXTEM and HEPTEM at T2. CONCLUSION HEPTEM and EXTEM measurements are valid in the presence of very high heparin concentrations and can be performed before protamine administration in patients undergoing cardiac surgery with CPB. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01455454.
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Lee CH, Kim U. Revascularization for patients with idiopathic thrombocytopenic purpura and coronary artery disease. Korean Circ J 2014; 44:264-7. [PMID: 25089139 PMCID: PMC4117848 DOI: 10.4070/kcj.2014.44.4.264] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 04/24/2014] [Accepted: 06/12/2014] [Indexed: 11/11/2022] Open
Abstract
Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder with a low platelet count characterized by premature platelet destruction and suppression of platelet production mediated by autoantibodies, which may predispose to bleeding. Although the prevalence of coronary artery disease (CAD) in ITP seems to be rare, their co-occurrence is not unusual. Patients with ITP have increased risks for thrombosis and atherosclerosis associated with hemostatic factors, endothelial damage, and the negative effects of steroid and immunoglobulin therapies. Thus, the coexistence of ITP and CAD presents complex problems requiring a balance between hemorrhagic risk and prevention of thrombosis. Here, the authors present two patients with ITP, who were revascularized in different ways for CAD. Although the optimal management of thrombocytopenic patients with CAD is uncertain, individualized treatment modalities can be useful in patients with ITP and CAD.
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Affiliation(s)
- Chan-Hee Lee
- Division of Cardiology, Yeungnam University Medical Center, Daegu, Korea
| | - Ung Kim
- Division of Cardiology, Yeungnam University Medical Center, Daegu, Korea
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Abstract
Coronary artery disease is one of the leading causes of illness for both men and women. However, women are 3 times more likely to die for coronary artery disease as they are of breast cancer. There are an increasing prevalence of coronary artery disease in women and thus facing the need for surgical revascularization. It has long being accepted that women carry a high risk of coronary surgery than men. Many investigators have suggested that female itself is predictive of poor outcome after on pump coronary surgery. We thought to search the litlature to investigate whether women who undergo off-pump surgery receive any benefits compared with women undergoing on-pump surgery.
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Tashiro T, Wada H, Nishimi M, Minematsu N. Off-pump coronary artery bypass: techniques, pitfalls, and results. Gen Thorac Cardiovasc Surg 2013; 61:429-34. [DOI: 10.1007/s11748-013-0240-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Indexed: 11/24/2022]
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Sandoughdaran S, Sarzaeem MR, Bagheri J, Jebelli M, Mandegar MH. Predictors of blood transfusion in patients undergoing coronary artery bypass grafting surgery. Int Cardiovasc Res J 2013; 7:25-8. [PMID: 24757615 PMCID: PMC3987423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Revised: 02/23/2013] [Accepted: 03/02/2013] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of this retrospective study is to identify intraoperative patient's characteristics predicting the need for blood transfusion during CABG in our local cardiac surgical service. METHODS This study included 1835 consecutive patients, 1311 males and 524 females with mean age 58.8±9.9 years, undergoing coronary artery bypass grafting. Risk factors detected by univariate study were entered in a multivariate logistic regression model of the relationship between preoperative variables and blood transfusion. RESULTS Blood transfusion was used in 435 patients (29.9%). Univariate analysis identified hemoglobin, smoking, hypertension, sex, diabetes, BMI and use of cardiopulmonary bypass (CPB) as significant predictors. Multivariate analysis revealed hemoglobin (OR: 0.8; CI: 0.74-0.86; P<0.001), CPB use (OR: 12.2; CI: 8.2-18.1; P<0.001) and female gender (OR: 2.29; CI:1.72-3.04; P<0.001) as independent risk factors for blood transfusion. CONCLUSIONS The predictors of RBC transfusion after isolated CABG were performing CPB, preoperative hemoglobin and female gender. These factors can be used as a clinical tool to preserve blood bank resources without increasing patient's risk.
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Affiliation(s)
- Saleh Sandoughdaran
- Cardiac Surgery and Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Mahmood Reza Sarzaeem
- Cardiac Surgery and Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, IR Iran,Corresponding author: Mahmood Reza Sarzaeem, Cardiac Surgery and Transplantation Research Center, Dr. Shariati Hospital, North Karegar Ave.,Tehran, IR Iran PO: 1411713137. Tel: +98-9125268001, Fax: +9821-44453449, E-mail:
| | - Jamshid Bagheri
- Cardiac Surgery and Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Mohammad Jebelli
- Cardiac Surgery and Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Mohammad Hossein Mandegar
- Cardiac Surgery and Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, IR Iran
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Momeni M, Carlier C, Baele P, Watremez C, Van Dyck M, Matta A, Kahn D, Rennotte MT, Glineur D, de Kerchove L, Jacquet LM, Thiry D, Grégoire A, Eeckhoudt S, Hermans C. Fibrinogen Concentration Significantly Decreases After On-Pump Versus Off-Pump Coronary Artery Bypass Surgery: A Systematic Point-of-Care ROTEM Analysis. J Cardiothorac Vasc Anesth 2013; 27:5-11. [DOI: 10.1053/j.jvca.2012.07.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2012] [Indexed: 11/11/2022]
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Scrascia G, Rotunno C, Guida P, Conte M, Amorese L, Margari V, Schinosa LDLT, Paparella D. Haemostasis alterations in coronary artery bypass grafting: comparison between the off-pump technique and a closed coated cardiopulmonary bypass system. Interact Cardiovasc Thorac Surg 2013; 16:636-42. [PMID: 23335652 DOI: 10.1093/icvts/ivs525] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To compare coagulation and fibrinolysis activation in off-pump coronary artery bypass operation and in patients in whom a closed phosphorylcholine-coated cardiopulmonary bypass system was applied. Cardiopulmonary bypass induces activation of coagulative and fibrinolytic systems, which together with intraoperative haemodilution augment the risk of postoperative bleeding and transfusion of blood products. METHODS Thirty-six off-pump coronary artery bypass and 36 coronary artery bypass grafting patients in whom a closed, phosphorylcholine-coated cardiopulmonary bypass system with a closed-collapsible venous reservoir (Physio group) was used were prospectively enrolled. Activation of coagulation and fibrinolytic systems was assessed evaluating the release of prothrombin fragment 1.2 and plasmin-antiplasmin complex preoperatively (T0), 30 min after heparin administration (T1), 15 min after protamine administration (T2), 3 h after protamin administration (T3) and on postoperative days 1 (T4) and 5 (T5). Platelet function was evaluated through Platelet Function Analyzer 100(®). RESULTS During the operation, prothrombin fragment 1.2 and plasmin-antiplasmin levels were slightly higher in the Physio group, the difference being not statistically significant. In the off-pump coronary artery bypass group, prothrombin fragment 1.2 was significantly higher at T3 (618.7 ± 282.7 vs 416.6 ± 250.2 pmol/l; P = 0.006), T4 (416.7 ± 278.8 vs 310.2 ± 394.6 pmol/l; P < 0.001) and T5 (629.3 ± 295.2 vs 408.4 ± 409.7 pmol/l; P = 0.002), and plasmin-antiplasmin was significantly higher at T4 (731.1 ± 790 vs 334 ± 300.8 ng/ml; P = 0.019) and T5 (1744.4 ± 820.7 vs 860.1 ± 488.4 ng/ml; P = 0.003). Platelet Function Analyzer 100® closure time values were significantly higher in the Physio group patients at T3 (131.3 ± 105.7 vs 215.6 ± 58.9 s; P = 0.002). The off-pump coronary artery bypass patients had greater chest tube drainage (874.3 ± 371.5 vs 629.1 ± 334.5 ml; P = 0.005). The mean priming volume was 1240 ± 215 ml in the Physio group. Much more Physio patients received red blood cell transfusions (14 vs 25 patient; P = 0.009), because of higher intraoperative transfusion rates (6 vs 15 patients; P = 0.016). Despite similar preoperative haemoglobin levels (13 ± 1.2 vs 12.6 ± 1.4 g/dl; P = 0.2), postoperative haemoglobin levels were significantly lower in the Physio group. CONCLUSIONS The Physio cardiopulmonary bypass approach does not significantly alter haemostasis during the operation compared with off-pump coronary artery bypass providing a reduced activation in the postoperative period reducing also chest tube drainage. However, further priming volume reduction is required to decrease intraoperative red blood cell transfusion.
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Affiliation(s)
- Giuseppe Scrascia
- Division of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy
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Off pump versus conventional on pump coronary artery bypass: a review. Indian J Thorac Cardiovasc Surg 2012. [DOI: 10.1007/s12055-012-0163-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
The optimal strategy for coronary revascularization remains controversial. Currently, most surgical revascularizations are performed with the use of cardiopulmonary bypass (ONCAB), yet over the past 20 years off-pump coronary artery bypass grafting (OPCAB) has been increasingly used because of the increased awareness of the deleterious effects of cardiopulmonary bypass (CPB) and aortic manipulation. Small, prospective, randomized controlled trials have lacked sufficient sample size to demonstrate differences in early and long-term outcomes. Larger observational studies that are better powered to statistically compare outcomes have shown more favorable in-hospital outcomes and equivalent long-term outcomes with OPCAB and ONCAB. The benefits of OPCAB techniques may be more apparent for patients at high risk for complications associated with CPB and aortic manipulation. Recent studies have demonstrated improved outcomes in higher-risk patients undergoing OPCAB, as well as improved neurological outcomes. The purpose of this review is to outline the recent literature comparing OPCAB with ONCAB, and to demonstrate efficacy of OPCAB as a useful technique for coronary revascularization.
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Affiliation(s)
- Marek Polomsky
- Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Murzi M, Caputo M, Aresu G, Duggan S, Miceli A, Glauber M, Angelini GD. On-pump and off-pump coronary artery bypass grafting in patients with left main stem disease: A propensity score analysis. J Thorac Cardiovasc Surg 2012; 143:1382-8. [DOI: 10.1016/j.jtcvs.2011.07.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 02/02/2011] [Accepted: 07/19/2011] [Indexed: 10/28/2022]
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Møller CH, Penninga L, Wetterslev J, Steinbrüchel DA, Gluud C. Off-pump versus on-pump coronary artery bypass grafting for ischaemic heart disease. Cochrane Database Syst Rev 2012:CD007224. [PMID: 22419321 DOI: 10.1002/14651858.cd007224.pub2] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is performed both without and with cardiopulmonary bypass, referred to as off-pump and on-pump CABG respectively. However, the preferable technique is unclear. OBJECTIVES To assess the benefits and harms of off-pump versus on-pump CABG in patients with ischaemic heart disease. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 1, 2011), MEDLINE (OVID, 1950 to February 2011), EMBASE (OVID, 1980 to February 2011), Science Citation Index Expanded on ISI Web of Science (1970 to February 2011) and CINAHL (EBSCOhost, 1981 to February 2011) on 2 February 2011. No language restrictions were applied. SELECTION CRITERIA Randomised clinical trials of off-pump versus on-pump CABG irrespective of language, publication status and blinding were selected for inclusion. DATA COLLECTION AND ANALYSIS For statistical analysis of dichotomous data risk ratio (RR) and for continuous data mean difference (MD) with 95% confidence intervals (CI) were used. Trial sequential analysis (TSA) was used for analysis to assess the risk of random error due to sparse data and to multiple updating of accumulating data. MAIN RESULTS Eighty-six trials (10,716 participants) were included. Ten trials (4,950 participants) were considered to be low risk of bias. Pooled analysis of all trials showed that off-pump CABG increased all-cause mortality compared with on-pump CABG (189/5,180 (3.7%) versus 160/5144 (3.1%); RR 1.24, 95% CI 1.01 to 1.53; P =.04). In the trials at low risk of bias the effect was more pronounced (154/2,485 (6.2%) versus 113/2,465 (4.6%), RR 1.35,95% CI 1.07 to 1.70; P =.01). TSA showed that the risk of random error on the result was unlikely. Off-pump CABG resulted in fewer distal anastomoses (MD -0.28; 95% CI -0.40 to -0.16, P <.00001). No significant differences in myocardial infarction, stroke, renal insufficiency, or coronary re-intervention were observed. Off-pump CABG reduced post-operative atrial fibrillation compared with on-pump CABG, however, in trials at low risk of bias, the estimated effect was not significantly different. AUTHORS' CONCLUSIONS Our systematic review did not demonstrate any significant benefit of off-pump compared with on-pump CABG regarding mortality, stroke, or myocardial infarction. In contrast, we observed better long-term survival in the group of patients undergoing on-pump CABG with the use of cardiopulmonary bypass and cardioplegic arrest. Based on the current evidence, on-pump CABG should continue to be the standard surgical treatment. However, off-pump CABG may be acceptable when there are contraindications for cannulation of the aorta and cardiopulmonary bypass. Further randomised clinical trials should address the optimal treatment in such patients.
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Affiliation(s)
- Christian H Møller
- Department of Cardiothoracic Surgery, RT 2152, Copenhagen University Hospital, Rigshospitalet, Copenhagen,
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Bleeding-associated outcomes with preoperative clopidogrel use in on- and off-pump coronary artery bypass. J Thromb Thrombolysis 2012; 34:56-64. [DOI: 10.1007/s11239-012-0694-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Raja SG, Akhtar S. Hypercoagulable state after off-pump coronary artery bypass grafting: evidence, mechanisms and implications. Expert Rev Cardiovasc Ther 2011; 9:599-608. [PMID: 21615323 DOI: 10.1586/erc.11.51] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
During the past decade, there has been a dramatic resurgence in the adoption of off-pump technology in coronary artery bypass surgery. This has inspired remarkable advances in the techniques of localized tissue stabilization and a greater understanding of the physiology of beating-heart mobilization and exposure. An avalanche of reports in the literature has demonstrated the early safety and efficacy of the procedure. However, despite abundant evidence validating the safety and efficacy of off-pump coronary artery bypass surgery, considerable controversy still persists regarding the long-term outcomes of this approach to myocardial revascularization. One area of concern, and even greater uncertainty, surrounds the issue of the existence of a hypercoagulable state after off-pump coronary artery bypass surgery. This article evaluates the current best evidence available from randomized controlled trials to assess the impact of off-pump coronary artery bypass surgery on coagulation, fibrinolysis and platelet activation, discusses the issue of hypercoagulability with emphasis on the mechanisms responsible for this actual or potential hypercoagulability, and explores the implications of this issue for clinical practice.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, Harefield, London, UB9 6JH, UK.
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Puskas JD, Williams WH, O'Donnell R, Patterson RE, Sigman SR, Smith AS, Baio KT, Kilgo PD, Guyton RA. Off-Pump and On-Pump Coronary Artery Bypass Grafting Are Associated With Similar Graft Patency, Myocardial Ischemia, and Freedom From Reintervention: Long-Term Follow-Up of a Randomized Trial. Ann Thorac Surg 2011; 91:1836-42; discussion 1842-3. [DOI: 10.1016/j.athoracsur.2010.12.043] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 12/12/2010] [Accepted: 12/16/2010] [Indexed: 10/18/2022]
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Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP, Song HK, Clough ER, Shore-Lesserson LJ, Goodnough LT, Mazer CD, Shander A, Stafford-Smith M, Waters J, Baker RA, Dickinson TA, FitzGerald DJ, Likosky DS, Shann KG. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91:944-82. [PMID: 21353044 DOI: 10.1016/j.athoracsur.2010.11.078] [Citation(s) in RCA: 874] [Impact Index Per Article: 67.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 11/20/2010] [Accepted: 11/29/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND Practice guidelines reflect published literature. Because of the ever changing literature base, it is necessary to update and revise guideline recommendations from time to time. The Society of Thoracic Surgeons recommends review and possible update of previously published guidelines at least every three years. This summary is an update of the blood conservation guideline published in 2007. METHODS The search methods used in the current version differ compared to the previously published guideline. Literature searches were conducted using standardized MeSH terms from the National Library of Medicine PUBMED database list of search terms. The following terms comprised the standard baseline search terms for all topics and were connected with the logical 'OR' connector--Extracorporeal circulation (MeSH number E04.292), cardiovascular surgical procedures (MeSH number E04.100), and vascular diseases (MeSH number C14.907). Use of these broad search terms allowed specific topics to be added to the search with the logical 'AND' connector. RESULTS In this 2011 guideline update, areas of major revision include: 1) management of dual anti-platelet therapy before operation, 2) use of drugs that augment red blood cell volume or limit blood loss, 3) use of blood derivatives including fresh frozen plasma, Factor XIII, leukoreduced red blood cells, platelet plasmapheresis, recombinant Factor VII, antithrombin III, and Factor IX concentrates, 4) changes in management of blood salvage, 5) use of minimally invasive procedures to limit perioperative bleeding and blood transfusion, 6) recommendations for blood conservation related to extracorporeal membrane oxygenation and cardiopulmonary perfusion, 7) use of topical hemostatic agents, and 8) new insights into the value of team interventions in blood management. CONCLUSIONS Much has changed since the previously published 2007 STS blood management guidelines and this document contains new and revised recommendations.
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Schultz SC, Woodward S, Ebra G. Resource utilization in off-pump versus conventional coronary artery bypass grafting in a community hospital: a comparative analysis using propensity scoring. Heart Surg Forum 2011; 14:E81-6. [PMID: 21521681 DOI: 10.1532/hsf98.201011115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND At a time when cost containment in health care is under increased scrutiny, coronary artery bypass grafting remains the most widely performed cardiac surgical procedure in the world. This study compares 30-day mortality, morbidity, and resource use for off-pump coronary artery bypass (OPCAB) versus conventional coronary artery bypass (CCAB) revascularization. METHODS From January 2000 through December 2008, 1003 patients underwent OPCAB grafting by a single surgeon (S.C.S.). Data were prospectively collected, entered into a Society of Thoracic Surgeons adult cardiac surgery database, and analyzed retrospectively. We used propensity-matching techniques to match this cohort to a group of 1003 patients who underwent CCAB. RESULTS The hospital mortality rate was lower for the OPCAB patients than for the CCAB patients: 2.0% (20/1003) versus 2.8% (28/1003). Predictors of hospital mortality for the entire cohort included age (P = .001), cardiogenic shock (P = .001), congestive heart failure (P = .019), history of myocardial infarction (P = .001), and reoperation (P = .007). The overall incidence of morbidity was lower for the OPCAB patients (reoperation for bleeding, P = .011; prolonged ventilation, P = .035; stroke, P = .045; cardiac arrest, P = .004). OPCAB patients experienced significantly reduced procedure times (P = .001), postoperative ventilation times (P = .035), post-operative lengths of stay (P = .035), and blood product use (intraoperative, P = .001; postoperative, P = .001). CONCLUSION These outcomes clearly demonstrate that OPCAB is a safe and effective procedure for myocardial revascularization. This retrospective, nonrandomized observational study has shown that the patients who underwent OPCAB had reduced morbidity and mortality, as well as decreased resource use, compared with those who underwent CCAB.
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Affiliation(s)
- Scot C Schultz
- Gulf Coast Cardiothoracic and Vascular Surgeons, Naples, Florida Naples Community Hospital, Naples, FL, USA.
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Garcia L, Avramovich A, Paparcuri G, Karras R, Salerno TA. Off-pump coronary artery bypass graft without systemic heparin in a Jehovah Witness patient. J Card Surg 2011; 26:282-3. [PMID: 21443737 DOI: 10.1111/j.1540-8191.2011.01235.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A Jehovah Witness patient with renal failure on dialysis, with low hemoglobin, underwent urgent off-pump coronary artery bypass grafting without systemic heparinization. The pros, cons, and details of the technique used are discussed.
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Affiliation(s)
- Lester Garcia
- Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
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Emmert MY, Salzberg SP, Theusinger OM, Felix C, Plass A, Hoerstrup SP, Falk V, Gruenenfelder J. How good patient blood management leads to excellent outcomes in Jehovah's witness patients undergoing cardiac surgery. Interact Cardiovasc Thorac Surg 2011; 12:183-8. [DOI: 10.1510/icvts.2010.242552] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Edmunds LH. Managing fibrinolysis without aprotinin. Ann Thorac Surg 2010; 89:324-31. [PMID: 20103278 DOI: 10.1016/j.athoracsur.2009.10.043] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Revised: 10/12/2009] [Accepted: 10/12/2009] [Indexed: 01/10/2023]
Abstract
Cardiopulmonary bypass increases perioperative bleeding and produces a consumptive coagulopathy, which is defined as the simultaneous production of thrombin and fibrinolysis. Thrombin formation and fibrinolysis primarily occur in the surgical wound and peak at the time heparin is reversed by protamine. Neither aprotinin nor lysine analogs successfully control bleeding in many complex procedures, reoperations, aortic resections, or in implantations of mechanical circulatory devices. This analysis reviews the mechanisms involved and current treatment protocols, with the conclusion that changes in treatment protocols rather than use of a specific anti-fibrinolytic drug may provide better control of bleeding in these patients.
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Affiliation(s)
- L Henry Edmunds
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104-3325, USA.
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Barkan H. Reply to the Editor. J Thorac Cardiovasc Surg 2010. [DOI: 10.1016/j.jtcvs.2009.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Preoperative very short-term, high-dose erythropoietin administration diminishes blood transfusion rate in off-pump coronary artery bypass: A randomized blind controlled study. J Thorac Cardiovasc Surg 2010; 139:621-6; discussion 626-7. [DOI: 10.1016/j.jtcvs.2009.10.012] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Revised: 09/09/2009] [Accepted: 10/04/2009] [Indexed: 11/19/2022]
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Velissaris T, Jonas MM, Ohri SK. Hemodynamic advantages of right heart decompression during off-pump surgery. Asian Cardiovasc Thorac Ann 2010; 18:17-21. [PMID: 20124291 DOI: 10.1177/0218492309355493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cardiac maneuvering during off-pump coronary artery bypass surgery can compress the right ventricle, causing temporary dysfunction and hemodynamic instability. The hemodynamic impact of a decompression technique comprising right pleurotomy and pericardial release was investigated during cardiac elevation. Intraoperative continuous real-time monitoring of cardiac index and stroke volume index was carried out using the PulseCO system in 12 consecutive patients with normal ventricular function who underwent off-pump coronary artery bypass by a single surgeon. A pulmonary artery catheter was used to monitor pulmonary artery pressure and systemic venous O(2) saturation. Hemodynamic changes during vertical displacement of the heart were measured before and after performing a right pleurotomy and pericardial release. Following right heart decompression, stroke volume index, cardiac index, mean arterial pressure, and systemic venous O(2) saturation were significantly better preserved during cardiac elevation. This demonstrates that right heart decompression via pleurotomy and pericardial release significantly improves hemodynamic stability during cardiac manipulation. We recommend the use of this procedure in off-pump coronary artery bypass when cardiac tilting is required.
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Affiliation(s)
- Theodore Velissaris
- Department of Cardiothoracic Surgery, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK.
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Paparella D, Semeraro F, Scrascia G, Galeone A, Ammollo CT, Kounakis G, de Luca Tupputi Schinosa L, Semeraro N, Colucci M. Coagulation-Fibrinolysis Changes During Off-Pump Bypass: Effect of Two Heparin Doses. Ann Thorac Surg 2010; 89:421-7. [DOI: 10.1016/j.athoracsur.2009.10.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Revised: 10/15/2009] [Accepted: 10/15/2009] [Indexed: 11/29/2022]
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Kim DH, Daskalakis C, Silvestry SC, Sheth MP, Lee AN, Adams S, Hohmann S, Medvedev S, Whellan DJ. Aspirin and clopidogrel use in the early postoperative period following on-pump and off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg 2009; 138:1377-84. [DOI: 10.1016/j.jtcvs.2009.07.027] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Revised: 05/20/2009] [Accepted: 07/06/2009] [Indexed: 10/20/2022]
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Ela Y, Emmiler M, Kocogullari CU, Terzi Y, Sivaci RG, Cekirdekci A. Advantages of Autologous Blood Transfusion in Off-Pump Coronary Artery Bypass. Heart Surg Forum 2009; 12:E261-5. [DOI: 10.1532/hsf98.20081115] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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