Early results of off-pump coronary artery bypass grafting for patients on chronic renal dialysis

Morbidity after elective surgery in patients on chronic dialysis: a systematic review and meta-analysis

BACKGROUND

Patients on chronic dialysis are at increased risk of postoperative mortality following elective surgery compared to patients with normal kidney function, but morbidity outcomes are less often reported. This study ascertains the excess odds of postoperative cardiovascular and infection related morbidity outcomes for patients on chronic dialysis.

METHODS

Systematic searches were performed using MEDLINE, Embase and the Cochrane Library to identify relevant studies published from inception to January 2020. Eligible studies reported postoperative morbidity outcomes in chronic dialysis and non-dialysis patients undergoing major non-transplant surgery. Risk of bias was assessed using the Newcastle-Ottawa Scale and the certainty of evidence was summarised using GRADE. Random effects meta-analyses were performed to derive summary odds estimates. Meta-regression and sensitivity analyses were performed to explore heterogeneity.

RESULTS

Forty-nine studies involving 10,513,934 patients with normal kidney function and 43,092 patients receiving chronic dialysis were included. Patients on chronic dialysis had increased unadjusted odds of postoperative cardiovascular and infectious complications within each surgical discipline. However, the excess odds of cardiovascular complications was attenuated when odds ratios were adjusted for age and comorbidities; myocardial infarction (general surgery, OR 1.83 95% 1.29-2.36) and stroke (general surgery, OR 0.95, 95%CI 0.84-1.06). The excess odds of infectious complications remained substantially higher for patients on chronic dialysis, particularly sepsis (general surgery, OR 2.42, 95%CI 2.12-2.72).

CONCLUSION

Patients on chronic dialysis are at increased odds of both cardiovascular and infectious complications following elective surgery, with the excess odds of cardiovascular complications attributable to being on dialysis being highest among younger patients without comorbidities. However, further research is needed to better inform perioperative risk assessment.

Postoperative mortality in patients on chronic dialysis following elective surgery: A systematic review and meta-analysis

RATIONALE & OBJECTIVE

The prognostic significance of dialysis-dependent end-stage kidney disease on postoperative mortality is unclear. This study aims to estimate the odds of postoperative mortality in patients receiving chronic dialysis undergoing elective surgery compared to patients with normal kidney function, and to examine the influence of comorbidities on the excess mortality risk.

METHODS

A systematic search of studies published up to January 2020 was conducted using MEDLINE, EMBASE and CENTRAL databases. Eligible studies reported postoperative 30-day or in-hospital mortality in chronic dialysis patients compared to patients with normal kidney function undergoing elective surgery. Two investigators independently reviewed all abstracts and performed risk of bias assessments using the Newcastle-Ottawa Scale. Quality of evidence was summarised in accordance with GRADE methodology (grading of recommendations, assessment, development and evaluation). Relative mortality risk estimates were obtained using random effects meta-analysis. Heterogeneity was explored using meta-regression. (PROSPERO CRD42017076565).

RESULTS

Forty-nine studies involving 41, 822 chronic dialysis and 10, 476, 321 non-dialysis patients undergoing elective surgery were included. Patients on chronic dialysis had a greatly increased postoperative mortality odds compared to patients with normal kidney function. The excess risk ranged from OR 10.8 (95%CI 7.3-15.9) following orthopaedic surgery to OR 4.0 (95%CI 3.2-4.9) after vascular surgery. Adjustment for age and comorbidity attenuated the excess odds but remained higher for patients on chronic dialysis, irrespective of surgical discipline. Meta-regression analysis demonstrated an inverse linear relationship between excess mortality risk and study-level mean age (slope -0.06; P = 0.001) and diabetes prevalence (slope -0.02; p = 0.001).

CONCLUSIONS

Patients on chronic dialysis have an increased odds for postoperative mortality following elective surgery across all surgical disciplines. This relationship is consistent among all studies, with the excess postoperative mortality attributable to end-stage kidney disease and chronic dialysis treatment may be lower among older patients with diabetes.

Analysis of the Use of Extracorporeal Circulation on the In-Hospital Outcomes of Dialytic Patients Who Underwent Myocardial Revascularization Surgery

BACKGROUND

Myocardial revascularization surgery is the best treatment for dyalitic patients with multivessel coronary disease. However, the procedure still has high morbidity and mortality. The use of extracorporeal circulation (ECC) can have a negative impact on the in-hospital outcomes of these patients.

OBJECTIVES

To evaluate the differences between the techniques with ECC and without ECC during the in-hospital course of dialytic patients who underwent surgical myocardial revascularization.

METHODS

Unicentric study on 102 consecutive, unselected dialytic patients, who underwent myocardial revascularization surgery in a tertiary university hospital from 2007 to 2014.

RESULTS

Sixty-three patients underwent surgery with ECC and 39 without ECC. A high prevalence of cardiovascular risk factors was found in both groups, without statistically significant difference between them. The group "without ECC" had greater number of revascularizations (2.4 vs. 1.7; p <0.0001) and increased need for blood components (77.7% vs. 25.6%; p <0.0001) and inotropic support (82.5% vs 35.8%; p <0.0001). In the postoperative course, the group "without ECC" required less vasoactive drugs, (61.5% vs. 82.5%; p = 0.0340) and shorter time of mechanical ventilation (13.0 hours vs. 36,3 hours, p = 0.0217), had higher extubation rates in the operating room (58.9% vs. 23.8%, p = 0.0006), lower infection rates (7.6% vs. 28.5%; p = 0.0120), and shorter ICU stay (5.2 days vs. 8.1 days; p = 0.0054) as compared with the group with ECC surgery. No difference in mortality was found between the groups.

CONCLUSION

Myocardial revascularization with ECC in patients on dialysis resulted in higher morbidity in the perioperative period in comparison with the procedure without ECC, with no difference in mortality though.

Is diabetic nephropathy a predicted risk factor?--Kaplan-Meier and multivariate analysis of confounding risk factors in off-pump coronary artery bypass grafting for chronic dialysis patients

BACKGROUND

The purpose of this study was to investigate the preoperative risk factors of performing off-pump coronary artery bypass grafting (OPCAB) in patients on chronic dialysis.

METHODS AND RESULTS

The 41 consecutive patients on chronic dialysis who underwent OPCAB from February 2000 to April 2006 at the National Cardiovascular Center were studied retrospectively. Of them, 29 had diabetic nephropathy (DN group) and the remaining 12 did not (NDN group). There were significant differences in the duration of dialysis before surgery (9.1 +/-7.5 years in NDN vs 4.2 +/-5.5 years in DN, P=0.028) and low cardiac function (left ventricular ejection fraction <30%), which was recognized only in the DN group (7/29, P=0.048). The early mortality rate was 6.9% (2/29) in the DN group and 16.7% (2/12) in the NDN group (P=0.349). The actuarial survival rates in the DN group were 85% at 1 year, 45% at 3 years, and 30% at 5 years, whereas in the NDN group they were 71%, 49%, and 49%, respectively (P=0.789). arteriosclerosis obliterans (ASO) and age (>65 YEARS) were independent risk factors of late death.

CONCLUSIONS

For patients on chronic dialysis ASO and aging were predicted risk factors for OPCAB, whereas diabetic nephropathy was not.

Off-pump coronary artery bypass grafting improves in-hospital mortality in patients with dialysis-dependent renal failure

OBJECTIVE

Patients with chronic dialysis-dependent end-stage renal disease are increasingly referred for coronary artery bypass grafting (CABG) and their early outcome is less favorable. Off-pump CABG (OPCAB) has achieved encouraging results in high-risk patients. Therefore, we designed this retrospective study to test the hypothesis that OPCAB reduced surgical risks in dialysis patients.

METHODS

From January 2000 to December 2005, 294 dialysis-dependent patients received isolated CABG at the Washington Hospital Center. Among them, 168 underwent OPCAB (off-pump group), and 126, CABG with cardiopulmonary bypass (CPB) (on-pump group). The in-hospital outcomes were analyzed.

RESULTS

The two groups were comparable in terms of preoperative characteristics. The Parsonnet's Bedside Score of the off-pump group was similar to that of the on-pump group (32.0 vs. 32.0, P=.57). The in-hospital mortality of the off-pump group was significantly lower than that of the on-pump group (5.4% vs. 11.9%, P=.04). Although the percentage of patients who received transfusions was similar, the on-pump group received more total transfusions. Logistic regression analysis revealed that use of CPB independently predicted in-hospital mortality [odds ratio (OR), 5.0; 95% confidence interval, 1.78-13.85; P<.01] and perioperative myocardial infarction (MI; OR, 5.1; 95% confidence interval, 1.18-22.40; P=.03). No significant difference in long-term survival at 4 years was absorbed between the two groups of hospital survivors.

CONCLUSIONS

Our data suggest that OPCAB is a safe alternative to on-pump CABG in dialysis patients. Avoiding CPB resulted in less perioperative blood utilization, MI, and hospital mortality.

Impact of off-pump coronary artery bypass surgery on postoperative renal dysfunction: current best available evidence

Renal dysfunction is a serious complication after coronary artery bypass surgery with cardiopulmonary bypass. Cardiopulmonary bypass-related non-pulsatile flow, hypothermia, haemolysis, systemic inflammatory reactions and emboli are mentioned as possible causes for this postoperative renal dysfunction. In an attempt to avoid these deleterious effects of cardiopulmonary bypass, off-pump coronary artery bypass surgery has been rediscovered. Resurgence of interest in off-pump coronary artery bypass surgery is associated with the expectation that avoiding deleterious effects of the cardiopulmonary bypass leads to better outcomes and possibly decreased costs and resource use. We are currently practising in an era of evidence-based medicine that mandates the prospective randomized controlled trial as the most accurate tool for determining a treatment benefit compared with a control population. The present review article attempts to evaluate the current best available evidence from randomized controlled trials on the impact of off-pump coronary artery bypass surgery on postoperative renal dysfunction.

Revascularization with off-pump coronary artery surgery: what appears new is actually the old rediscovered

The enormous progress in interventional cardiology during the last 10 years has resulted in a major change in the spectrum of patients referred for coronary artery bypass grafting. Several large retrospective analyses, meta-analyses, and the randomized trials that addressed different aspects of ONCAB and OPCAB to date have compared the two surgical strategies. It is suggested that patients may achieve an excellent outcome with either type of procedure, and individuals' outcomes more likely depend on factors other than whether they underwent ONCAB or OPCAB. Nevertheless, there appear to be trends in most studies. These trends include less blood loss and need for transfusion, less myocardial enzyme release up to 24 h, less early neurocognitive dysfunction, and less renal insufficiency after OPCAB and propensity to lower costs, thereafter proving OPCAB to be safe and clinically effective. Here, we review the physiological advantages and clinical outcomes of OPCAB for myocardial revascularization and examine whether either strategy is superior and in which patients.

Living with off-pump coronary artery surgery: evolution, development, and clinical potential for coronary heart disease patients

The enormous progress in interventional cardiology during the last 10 years has resulted in a major change in the spectrum of patients referred for coronary bypass surgery. These patients are older and sicker and frequently have had previous percutaneous coronary interventions. Consequently, cardiac surgery is responding by adding new surgical techniques: off-pump open-chest coronary bypass surgery (OPCAB), minithoracotomy bypass surgery, videothoracoscopic (robotic) procedures, etc. Several registries published to date have proved OPCAB to be safe and clinically effective. Randomized studies and meta-analysis research in this field provide scientific support and suggest that myocardial, renal, and neurological functions, amongst others, are better preserved by OPCAB than by classic techniques that use a cardiopulmonary bypass pump (CPB). Moreover, avoidance of CPB yields significantly reduced oxidative stress and systemic inflammatory response. This results in higher safety for ischemic heart disease patients undergoing revascularization, thus offsetting the propensity to lower costs. The present review examines the physiological advantages and clinical outcomes of this simple mode of myocardial revascularisation and evaluates the wider implications arising from its evolution.

Off-Pump Coronary Artery Bypass Grafting for Acute Myocardial Infarction

BACKGROUND

The aim of this study was to evaluate the surgical results of off-pump coronary artery bypass grafting (OPCAB) for patients with acute myocardial infarction (AMI) within 14 days of the infarction.

METHODS AND RESULTS

From April 2000 to January 2005 among 841 patients who underwent OPCAB, 43 consecutive patients (5.1%) were examined. Mean age at operation was 69.5 years and mean time from the onset of AMI to surgery was 4.6 days. Seventeen patients (39.5%) had left main trunk disease. Three patients (7.0%) underwent OPCAB following unsuccessful percutaneous coronary intervention, and 1 patient (2.3%) underwent redo procedure 9 years after previous coronary artery bypass grafting (CABG). Six patients (14%) were admitted in cardiogenic shock. Intraaortic balloon pumping was inserted preoperatively in 20 patients (46.5%). The average maximum creatine kinase-myocardial band was 139+/-181 (U/L). The mean number of grafts was 3.2 and the rate of complete revascularization was 91%. Two of six patients with preoperative cardiogenic shock were converted to on-pump beating CABG due to ventricular arrythmia. The early graft patency rate was 98%. All patients survived except 2 with preoperative cardiogenic shock.

CONCLUSIONS

OPCAB can be performed after AMI as a relatively low-risk procedure with an acceptable mortality rate, even within 14 days of the infarction.

Physiological comparison of off-pump and on-pump coronary artery bypass grafting in patients on chronic hemodialysis

OBJECTIVES

Despite the long-term benefit, the operative results of conventional coronary artery bypass grafting for chronic hemodialysis patients remain unsatisfactory. The efficacy of off-pump coronary artery bypass grafting for hemodialysis patients is yet to be determined. The purpose of this study was to investigate the postoperative physiology of off-pump coronary artery bypass grafting for hemodialysis patients.

METHODS

Twenty-five hemodialysis cases who underwent isolated coronary artery bypass grafting were reviewed. Fifteen of these patients underwent off-pump coronary artery bypass grafting (off-group) and 10 underwent on-pump coronary artery bypass grafting (on-group). Comparisons were made in cardiac function (cardiac index and stroke volume index), respiratory function (AaDO2), hemodialysis management (blood urea nitrogen, creatinine, right atrial pressure, pulmonary wedge pressure), and bleeding tendency (postoperative blood loss and blood transfusion).

RESULTS

There was no operative mortality, but 3 major postoperative complications occurred (2 sternal wound infections in the off-group and 1 pneumonia in the on-group). There was no difference in cardiac index or stroke volume index. AaDO2 was significantly lower in the off-group. Plasma concentrations of blood urea nitrogen and creatinine were similar between groups. Right atrial pressure was lower and pulmonary wedge pressure tended to be lower in the off-group. Postoperative bleeding and blood transfusion were similar between groups.

CONCLUSION

Our study confirmed that off-pump coronary artery bypass grafting is feasible for hemodialysis patients. Physiologic data showed that off-pump coronary artery bypass grafting might be effective in preserving postoperative lung oxygenation.