Do off-pump techniques reduce the incidence of postoperative atrial fibrillation in elderly patients undergoing coronary artery bypass grafting?

Postoperative Atrial Fibrillation Following Off-Pump Coronary Artery Bypass Graft Surgery: Elderly Versus Young Patients

Background Atrial fibrillation (AF) is one of the common rhythm disturbances that occur after coronary artery bypass graft (CABG) surgery. Postoperative atrial fibrillation (POAF) can lead to thromboembolic events, hemodynamic instability, and prolonged hospital stay, affecting morbidity and influencing short and long-term outcomes after CABG. Methodology This prospective comparative study was conducted between May 2018 and April 2020. This study aimed to compare the prevalence of POAF following off-pump coronary artery bypass graft surgery (OPCAB) between elderly and young patients. Additionally, we aimed to determine the risk factors associated with POAF following OPCAB in the elderly compared to young patients. Patients aged ≥65 years were considered elderly, and those aged <65 years were considered young. A total of 120 patients (60 in the elderly group and 60 in the young group) were included in this study and evaluated to correlate the preoperative and intraoperative risk factors with postoperative outcomes during the hospital stay. Results The prevalence of POAF following OPCAB in the elderly was significantly higher compared to young patients (48.3% vs. 20%,p = 0.002). The elderly group also had a significantly longer intensive care unit stay (p = 0.001) and hospital stay (p = 0.001). In an unadjusted logistic regression model, age (odds ratio (OR) = 3.74, 95% confidence interval (CI) = 1.66-8.41, p = 0.001), preoperative plasma B-type natriuretic peptide (OR = 1.01, 95% CI = 1.00-1.01, p = 0.001), and left atrial diameter (OR = 1.10, 95% CI = 1.03-1.17, p = 0.001) were significantly associated with POAF. However, in an adjusted logistic regression model, age was found to be an independent predictor (OR = 1.31, 95% CI = 1.14-1.52, p < 0.0001) of POAF following OPCAB. Although stroke developed in the elderly (p >0.05), no mortality was observed postoperatively. Conclusions The prevalence of POAF following OPCAB in the elderly is higher than in young patients. Advancing age is an independent predictor of POAF following OPCAB.

Prevalence of Postoperative Atrial Fibrillation Following Off-Pump Coronary Artery Bypass Graft Surgery in Elderly Patients

Background Atrial fibrillation (AF) is one of the frequent complications following coronary artery bypass surgery. Postoperative atrial fibrillation (POAF) can lead to thromboembolic events and prolong hospital stays. We aimed to determine the prevalence of POAF following off-pump coronary artery bypass surgery (OPCAB) in the elderly population.  Materials and Methods  This cross-sectional study was carried out between May 2018 to April 2020. Elderly patients (age ≥65 years) admitted for isolated elective OPCAB were eligible for the study. A total of 60 elderly patients were evaluated based on the preoperative and intraoperative risk factors and postoperative outcomes during the hospital stay. Results The mean age was 67.83±4.06 years, and the prevalence of POAF in elderly adults was 48.3%. The mean number of grafts was 3.20±0.73, and ICU stays at 3.43±1.61 days. The mean duration of the hospital stays was 10.03±2.12 days. Although stroke developed in 1.7% of post-CABG patients, no mortality was observed postoperatively. Conclusion  POAF is one of the commonly encountered complications following OPCAB. Though OPCAB is a superior revascularization procedure, preoperative planning and attention are especially needed in the elderly to reduce the prevalence of POAF.

Is diabetes mellitus a risk factor for low bone density: a systematic review and meta-analysis

BACKGROUND

This systematic review aimed to investigate whether diabetes mellitus is a risk factor for low bone density, as this might be important and necessary for doctors specialized in treating patients with low bone density.

METHODS

PubMed, Embase, CINAHL, and SciELO were searched for cohort, case-control, and cross-sectional studies that investigated the effects of diabetes mellitus on bone mineral density till January 2020. Data screening and extraction are done independently, whereas the methodological quality of the studies was assessed according to the Newcastle-Ottawa Scale (NOS).

RESULTS

A total of 14 studies that met the eligibility criteria including 24,340 participants were enrolled. The overall quality of the studies had a scale of over 6 points. The overall odds ratio (OR) regarding the risk of diabetes mellitus in low bone density patients was 1.20 [95% confidence interval (CI)0.80-1.79, P = 0.30], and type 2 diabetes mellitus (T2DM) (OR = 0.69 [0.11, 4.55], P = 0.70). Subgroup analysis revealed that whether females or males, developed or developing countries, T2DM, studies after 2015, and quality over 7 points (all P values > 0.05) showed no significant differences with the risk of low bone density, except type 1 diabetes mellitus (T1DM) (OR = 3.83 [1.64, 8.96], P = 0.002), and studies before 2015 (OR = 1.76 [1.06, 2.92], P = 0.03), and quality below 7 points (OR = 2.27 [1.50, 3.43], P = 0.0001). Funnel plot showed no significant asymmetry.

CONCLUSIONS

These findings revealed no relationship between T2DM and low bone density, and also, the evidence between T1DM and low bone density is inadequate, requiring further analysis of well-designed cohort studies.

Left Atrial Appendage Velocity as a Predictor of Atrial Fibrillation After Cardiac Surgery

OBJECTIVE

To determine if there is an association between left atrial appendage velocity and the development of postoperative atrial fibrillation (POAF).

DESIGN

Single institution retrospective study performed between January 2013 and December 2013.

SETTING

Single-institution, university hospital.

PARTICIPANTS

Five hundred sixty-two adult patients undergoing cardiac surgery utilizing cardiopulmonary bypass.

INTERVENTIONS

No interventions for the purpose of this study.

MEASUREMENTS AND MAIN RESULTS

Left atrial appendage velocity, measured by transesophageal echocardiogram, ranged from 8 cm/sec to 126 cm/sec. The development of POAF within the first 3 days after cardiac surgery was 38.3%. The authors found that patients with a lower left atrial appendage velocity had a higher risk of developing POAF. In the adjusted logistic regression model, there was an 11% decrease in the odds of POAF for each 10-unit (cm/sec) increase in the left atrial appendage velocity (p = 0.044).

CONCLUSIONS

Decreasing left atrial appendage velocity is an independent predictor of risk for the development of POAF following cardiac surgery with cardiopulmonary bypass.

Incidence of postoperative atrial fibrillation in patients undergoing on-pump and off-pump coronary artery bypass grafting

OBJECTIVE

To determine the incidence of postoperative atrial fibrillation in patients undergoing on-pump and off-pump coronary artery bypass grafting.

METHODS

A retrospective study with analysis of 230 medical records between January 2011 and October 2013 was conducted.

RESULTS

Fifty-six (24.3%) out of the 230 patients were female. The average age of patients undergoing on-pump coronary artery bypass grafting was 59.91±8.62 years old, and off-pump was 57.16±9.01 years old (P=0.0213). The average EuroSCORE for the on-pump group was 3.37%±3.08% and for the off-pump group was 3.13%±3% (P=0.5468). Eighteen (13.43%) patients who underwent off-pump coronary artery bypass grafting developed postoperative atrial fibrillation, whereas for the onpump group, 19 (19.79%) developed this arrhythmia, with no significant difference between the groups (P=0.1955).

CONCLUSION

Off-pump coronary artery bypass grafting did not reduce the incidence of atrial fibrillation in the postoperative period. Important predictors of risk for the development of this arrhythmia were identified as: patients older than 70 years old and presence of atrial fibrillation in perioperative period in both groups, and non-use of beta-blockers drugs postoperatively in the on-pump group.

Does aortic valve disease etiology predict postoperative atrial fibrillation in patients undergoing aortic valve surgery?

ABSTRACT 

Background: Postoperative atrial fibrillation (POAF) is one of the most common complications of cardiac surgery and is associated with increased mortality and morbidity. Methods: We analyzed 830 patients without prior atrial fibrillation who underwent aortic valve replacement for aortic stenosis and/or aortic regurgitation. Results: The incidence of POAF was 38%. The patients with POAF were older, predominately male and hypertensive. The incidence of POAF was significantly different according to the valve etiology. At multivariate analysis, rheumatic and degenerative aortic valve etiologies were independent predictors of POAF. Conclusion: Aortic valve disease etiology affects the development of POAF. Rheumatic and degenerative etiologies have a higher risk of developing POAF independently of other clinical, functional and hemodynamic variables.

Preoperative arrhythmias such as atrial fibrillation: cardiovascular surgery risk factor

Atrial fibrillation is still the most common arrhythmia that occurs in heart surgery. However, there is few literature data on the manner in which preoperative atrial fibrillation may influence the postoperative outcome of various heart surgery procedures. The purpose of our research is to assess the effects of preoperative atrial fibrillation on patients having undergone different heart surgery procedures. The results of our research are a review of clinical data which were collected prospectively, over a 10-year period, from all the patients who had undergone heart surgery in our Institute. The study group included 1119 heart surgery patients, who were divided as follows: the preoperative AFib group (n = 226, 20.19%) and the sinus rhythm group (n = 893, 79.80%). Major postoperative complications and hospital mortality rates were analyzed. According to our statistical analysis, preoperative atrial fibrillation significantly increased the mortality risk (P = 0.001), the patients' mechanical ventilation needs (P = 0.022), the rate of occurrence of infectious complications (P < 0.5), the rate of occurrence of complications such as acute kidney failure (P = 0.012), and the time spent by the patients in the intensive care ward (P < 0.01). In conclusion, preoperative atrial fibrillation in heart surgery patients increases the mortality and major complication risk further to heart surgery.

The evolution of cardiovascular surgery in elderly patient: a review of current options and outcomes

Due to the increase in average life expectancy and the higher incidence of cardiovascular disease with advancing age, more elderly patients present for cardiac surgery nowadays. Advances in pre- and postoperative care have led to the possibility that an increasing number of elderly patients can be operated on safely and with a satisfactory outcome. Currently, coronary artery bypass surgery, aortic and mitral valve surgery, and major surgery of the aorta are performed in elderly patients. The data available show that most cardiac surgical procedures can be performed in elderly patients with a satisfactory outcome. Nevertheless, the risk for these patients is only acceptable in the absence of comorbidities. In particular, renal dysfunction, cerebrovascular disease, and poor clinical state are associated with a worse outcome in elderly patients. Careful patient selection, flawless surgery, meticulous hemostasis, perfect anesthesia, and adequate myocardial protection are basic requirements for the success of cardiac surgery in elderly patients. The care of elderly cardiac surgical patients can be improved only through the strict collaboration of geriatricians, anesthesiologists, cardiologists, and cardiac surgeons, in order to obtain a tailored treatment for each individual patient.

Fish oil and atrial fibrillation after cardiac surgery: a meta-analysis of randomized controlled trials

Background

Influence of fish oil supplementation on postoperative atrial fibrillation (POAF) was inconsistent according to published clinical trials. The aim of the meta-analysis was to evaluate the effects of perioperative fish oil supplementation on the incidence of POAF after cardiac surgery.

Methods

Pubmed, Embase and the Cochrane Library databases were searched. Randomized controlled trials (RCTs) assessing perioperative fish oil supplementation for patients undergoing cardiac surgery were identified. Data concerning study design, patient characteristics, and outcomes were extracted. Risk ratio (RR) and weighted mean differences (WMD) were calculated using fixed or random effects models.

Results

Eight RCTs involving 2687 patients were included. Perioperative supplementation of fish oil did not significantly reduce the incidence of POAF (RR = 0.86, 95%CI 0.71 to 1.03, p = 0.11) or length of hospitalization after surgery (WMD = 0.10 days, 95% CI: 0.48 to 0.67 days, p = 0.75). Fish oil supplementation also did not affect the perioperative mortality, incidence of major bleeding or the length of stay in the intensive care unit. Meta-regression and subgroup analyses indicated mean DHA dose in the supplements may be a potential modifier for the effects of fish oil for POAF. For supplements with DHA >1 g/d, fish oil significantly reduced the incidence of POAF; while it did not for the supplements with a lower dose of DHA.

Conclusions

Current evidence did not support a preventative role of fish oil for POAF. However, relative amounts of DHA and EPA in fish oil may be important for the prevention of POAF.

Myocardial revascularization for the elderly: current options, role of off-pump coronary artery bypass grafting and outcomes

The increase in life expectancy has confronted cardiac surgery with a rapidly growing population of elderly patients requiring surgical myocardial revascularization. Recent advances in surgical and anesthetic techniques and improvements in postoperative care have made coronary artery bypass grafting an established therapeutic option for the treatment of coronary artery disease in this group of patients. However, conventional coronary artery bypass grafting on cardiopulmonary bypass is associated with significant risk and related morbidity and mortality in the elderly. In recent years off-pump coronary artery bypass grafting has emerged as a safe and less invasive strategy for surgical myocardial revascularization. Off-pump coronary artery bypass grafting by avoiding the deleterious effects of cardiopulmonary bypass can offer potential benefits to elderly patients requiring surgical myocardial revascularization. This review article provides an overview of the age-related cardiovascular changes, epidemiology of coronary artery disease in the elderly and focuses on outcomes of surgical myocardial revascularization with special emphasis on the impact of off-pump coro-nary artery bypass surgery in the elderly.

The occurrence of postoperative atrial fibrillation according to different surgical settings in cardiac surgery patients

OBJECTIVES

Atrial fibrillation is the most common arrhythmia after cardiac surgery. The pathogenesis of postoperative atrial fibrillation is multifactorial. The aim of the study was to analyse preoperative, intraoperative and postoperative factors and their relationships with the occurrence and duration of atrial fibrillation.

METHODS

One hundred and ninety-six patients with coronary heart disease (152 men, age 62.7 ± 10.1 years) underwent surgical revascularization. Extracorporeal circulation was used in 64 patients and minimal extracorporeal circulation was used in 75 patients. Fifty-seven patients underwent surgery without extracorporeal circulation. During the first three postoperative days, subjects were monitored for the duration and incidence of atrial fibrillation, laboratory markers of inflammation (C-reactive protein, leucocytes) and serum potassium.

RESULTS

Demographic data and associated cardiovascular diseases in the groups were not statistically different. The overall incidence of atrial fibrillation was 56% (110 patients). The highest incidence of atrial fibrillation was found in the extracorporeal circulation subgroup, with a significantly lower incidence using minimal extracorporeal circulation, and in patients operated on without extracorporeal circulation (75 vs 47 vs 46%, P <0.001). The longest duration of atrial fibrillation was found in patients operated on with extracorporeal circulation compared with minimal extracorporeal circulation, and without extracorporeal circulation (9.7 ± 11.6 vs 4.9 ± 8.3 vs 3.1 ± 5.2, P ≤0.001). The incidence of postoperative atrial fibrillation significantly correlated with elevation of inflammatory markers (C-reactive protein, leucocytes) compared with patients who were free of atrial fibrillation (P ≤0.001, P ≤0.05). The values of serum potassium were not significantly different. The relationship between postoperative atrial fibrillation and echocardiographic parameters was not confirmed.

CONCLUSIONS

The use of extracorporeal circulation leads to a higher incidence of postoperative atrial fibrillation compared with the use of minimal extracorporeal circulation or with surgery without extracorporeal circulation, probably due to enhanced systemic inflammatory response.

Effect of Preoperative Atrial Fibrillation on Postoperative Outcome following Cardiac Surgery

Atrial fibrillation remains the commonest arrhythmia encountered in cardiac surgery. Data on the effect of preoperative atrial fibrillation on postoperative outcome remain limited. We sought to assess the effects preoperative atrial fibrillation on patients' outcome following cardiac surgery. This is a retrospective review of prospectively collected departmental data of all patients who underwent cardiac surgery over 8-year period. Our cohort consisted of 3777 consecutive patients divided into atrial fibrillation (n = 413, 11%) and sinus rhythm (n = 3364, 89%). Postoperative complications and in-hospital mortality were analysed. Univariate analysis showed significantly increased mortality and major complications in atrial fibrillation compared to sinus rhythm patients. Using multiple logistic regression analysis and after accounting for Euro SCORE as a confounding variable, we found that preoperative atrial fibrillation significantly increases the risk of mortality (OR 1.7), low cardiac output state (OR 1.3), prolonged ventilation (OR 1.4), infective complication (OR 1.5), gastrointestinal complications (OR 2.0), and intensive care unit readmission (OR 1.6). Preoperative atrial fibrillation in cardiac surgery patients increases their risk of mortality and major complications following cardiac surgery. Surgical strategies such as Cox-Maze procedure may be beneficial in these patients.

Pulmonary embolism prophylaxis with inferior vena cava filters in trauma patients: a systematic review using the meta-analysis of observational studies in epidemiology (MOOSE) guidelines

Prophylactic inferior vena cava filters (pIVCFs) for the prevention of pulmonary embolism (PE) are controversial. Current practice guidelines (EAST and ACCP) are based on the critical appraisal of observational studies. As a result, their recommendations are conflicting and may account for practice pattern variation. The purpose of this study is to critically review the available literature and ascertain the level of evidence both for and against the use of pIVCFs for PE prophylaxis in trauma patients. We searched PubMed and Web of Science for publications from 1950 until July 2010 that assessed the efficacy of PE prevention with pIVCFs in the trauma population. We followed the MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines for design, implementation, and reporting. The Newcastle-Ottawa Score was used for quality and comparability assessment. Seven observational studies met inclusion criteria for this meta-analysis, representing 1,900 patients. Only one study was published in this decade. The rate of PE was statistically lower in the IVCF group compared to a matched control group without IVCFs (OR 0.21, 95% CI 0.09-0.49). There was no significant difference in DVT. Using the MOOSE criteria these results show a decreased likelihood of PE among trauma patients who receive pIVCFs. Although these results could favor the placement of pIVCFs, the lack of contemporary use of pharmacologic prophylaxis across studies does not allow us to make firm conclusions either for or against the routine use of pIVCFs. Prospective randomized trials are needed to determine the role of pIVCFs in high-risk trauma patients.

Short- and Long-Term Outcomes in Octogenarian Patients Undergoing Off-Pump Coronary Artery Bypass Grafting Compared with On-Pump Coronary Artery Bypass Grafting

Objective

Coronary artery bypass grafting (CAB) on elderly patients presenting with multivessel coronary artery disease has become routine in modern day operating rooms. The aim of our study was to compare short- and long-term outcomes in octogenarian patients undergoing off-pump CAB (OPCAB) versus on-pump CAB (ONCAB).

Methods

A propensity-adjusted, retrospective review of patients older than 80 years who underwent primary CAB from January 1996 to September 2008 at our institution's hospitals was performed. Nine hundred thirty-seven patients were divided into two groups: OPCAB (n = 540) or ONCAB (n = 397). A propensity score was calculated based on 29 preoperative risk factors to adjust for selection bias when comparing the groups for differences in death, stroke, myocardial infarction incidence, and their composite (major adverse cardiac events). Long-term survival status was determined by cross-referencing patient records with the Social Security Death Index. Logistic regression analysis and Cox proportional hazards analysis were used to determine group differences in short- and long-term survival, respectively, adjusted for the propensity score. Kaplan-Meier curves were fit to estimate 10-year survival.

Results

The mean age (OPCAB: 82.9 ± 2.8 years vs ONCAB: 82.3 ± 2.4, P = 0.003) and male sex (OPCAB: 292/540, 54.1% vs ONCAB: 220/397, 55.4%, P = 0.68) were clinically similar between groups. Although the ejection fraction (OPCAB: 52.1 ± 12.5% vs ONCAB: 50.6 ± 13.1, P = 0.10) were similar between groups, the mean number of distal anastomoses [OPCAB: 2.7 ± 1.0 (median 3) vs ONCAB: 3.4 ± 0.9 (median 3), P < 0.001] were less in the OPCAB group. The median postoperative length of stay was 7 days for OPCAB group and 6 for the ONCAB group (P = 0.31). The Society of Thoracic Surgery predicted risk of in-hospital mortality was similar for OPCAB (5.4%) and ONCAB (5.3%) patients (P = 0.81). However, observed in-hospital mortality was improved for patients in the OPCAB group (OPCAB: 15/540, 2.8% vs ONCAB: 37/397, 9.3%, P = 0.007). Ten-year survival was similar between groups (OPCAB: 28.8% vs ONCAB: 26.3%, P = 0.22).

Conclusions

In this series, OPCAB reduced the incidence of in-hospital mortality compared with ONCAB. Long-term mortality was similar between groups.

Off-pump coronary artery revascularization in octogenarians: is it better?

PURPOSE OF REVIEW

Octogenarians are the fastest growing stratum of the population and have the highest prevalence of coronary artery disease. In the past, physicians have been reluctant to provide these patients with optimal care. Seniors are frequently excluded from large randomized trials and generally not included in published guidelines. The purpose of this review is to revisit the demography and epidemiology of coronary artery disease in this population as well as therapeutic strategies used.

RECENT FINDINGS

Recent publications have shown significant advancement in medical and invasive treatment of coronary artery disease in elderly, with special focus on the potential benefit of off-pump coronary artery bypass (OPCAB) surgery.

SUMMARY

Although OPCAB surgery has gained popularity over the past 15 years, its benefit regarding operative mortality and major complications has not been clearly defined in the general population. There is a body of literature supporting its benefit in the elderly population. OPCAB surgery has the potential of decreasing operative mortality and major postoperative complications such as stroke, delirium, atrial fibrillation, and decline in neurocognitive functions in these patients. Off-pump surgery is technically more demanding and has been blamed for providing less complete revascularization and lower graft patency rate, especially in less experienced hands. However, with the upcoming demographic explosion of senior citizens in western societies, OPCAB surgery has definitely to be a part of the armamentarium of modern cardiac surgeons.

Prevention of atrial fibrillation in cardiac surgery: time to consider a multimodality pharmacological approach

Atrial fibrillation (AF) is very common within the first 5 days of cardiac surgery. It is associated with significant morbidity including stroke, ventricular arrhythmias, myocardial infarction, heart failure, acute kidney injury, prolonged hospital stay, and also short- and long-term mortality. The underlying mechanisms of developing AF after cardiac surgery are multifactorial; risk factors may include advanced age, withdrawal of beta-blockers and angiotensin-converting-enzyme inhibitors, valve surgery, obesity, increased left atrial size, and diastolic dysfunction. There are many pharmacological options in preventing AF, but none of them are effective for all patients and they all have significant limitations. Beta-blockers may reduce the incidence of AF by more than a third, but bradycardia, hypotension, or exacerbation of heart failure often limit their utility postoperatively. Recent evidence suggests that class III antiarrhythmic drugs, sotalol and amiodarone, are more effective than beta-blockers, but they both share similar hemodynamic side effects of beta-blockers. Magnesium, antiinflammatory drugs such as statins, omega fatty acids, and low-dose corticosteroids also have some efficacy and they have the advantages of not causing significant hemodynamic side effects. Data on effectiveness of calcium channel blockers, digoxin, alpha-2 agonists, sodium nitroprusside, and N-acetylcysteine are more limited. Because the pathogenesis of AF is multifactorial, a combination of drugs with different pharmacological actions may have additive or synergistic effect in preventing AF after cardiac surgery. Randomized controlled trials evaluating the effectiveness of a multimodality pharmacological approach in patients at high-risk of AF after cardiac surgery are needed.

Postoperative Care of the Cardiac Surgical Patient

The subspecialty of interventional cardiology began in 1977. Since then, the discipline of interventional cardiology has matured rapidly, particularly with regards to ischemic heart disease. As a result, more patients are undergoing percutaneous catheter interventional therapy for ischemic heart disease and fewer patients are undergoing surgical myocardial revascularization. Those patients referred for surgical revascularization are generally older and have more complex problems. Furthermore, as the population ages more patients are referred to surgery for valvular heart disease. The result of these changes is a population of surgical patients older and sicker than previously treated.

The effects of atorvastatin on the occurrence of postoperative atrial fibrillation after off-pump coronary artery bypass grafting surgery

BACKGROUND

Atrial fibrillation (AF) after coronary artery bypass graft (CABG) surgery is still the most common arrhythmic complication. This study evaluated whether pretreatment with atorvastatin protects against AF after off-pump CABG.

METHODS

One hundred twenty-four patients without a history of AF or previous statin use, who were scheduled to undergo elective off-pump CABG, were enrolled. Patients were randomized to control group (n = 62) or to atorvastatin group (n = 62) who were administered atorvastatin 20 mg/d for 3 days before the surgery. Primary outcome was the incidence of postoperative AF. Secondary outcomes were major adverse cardiac and cerebrovascular events, persistent AF at 1 month, and identification of the markers to predict inhospital postoperative AF.

RESULTS

The incidence of AF was significantly lower in the atorvastatin group than in the control group (13% vs 27%, P = .04). The incidence of major adverse cardiac and cerebrovascular events and persistent AF at 1 month was similar in comparisons between the groups. Postoperative peak N-terminal pro-brain natriuretic peptide levels were significantly higher in the patients with AF (P = .03). Multivariate analysis identified pretreatment with atorvastatin as an independent factor associated with a significant reduction in postoperative AF (odds ratio 0.34, P = .04). Higher postoperative peak N-terminus pro-B-type natriuretic peptide levels were associated with the development of postoperative AF (odds ratio 1.02 per 100 pg/mL, P = .03).

CONCLUSIONS

Pretreatment with atorvastatin significantly reduced the occurrence of postoperative AF after off-pump CABG.

Current Status of Off-Pump Coronary Artery Bypass Surgery

The expanding indications for angioplasty coupled with the successful short and mid-term results of randomized controlled trials of drug-eluting stents have already had an unquestionable impact on the practice of coronary revascularization operations. However, coronary artery bypass grafting remains a major mode of therapy for coronary artery disease. It is likely that surgery will continue to be preferred for more complex subsets and that surgeons will have to continue to maintain good results in patients with more complex problems. Concerns regarding morbidity associated with conventional surgical myocardial revascularization on cardiopulmonary bypass have led to a resurgence of interest in off-pump bypass surgery during the last decade, with the expectation that it would be safer if cardiopulmonary bypass could be avoided. This review summarizes the impact of off-pump bypass surgery in reducing the morbidity and mortality associated with conventional coronary artery bypass on cardiopulmonary bypass by evaluating the current best-available evidence from randomized controlled trials and meta-analyses comparing off-pump surgery with conventional bypass grafting.

Brain natriuretic peptide concentration in pericardial fluid is independently associated with atrial fibrillation after off-pump coronary artery bypass surgery

OBJECTIVES

Postoperative atrial fibrillation is associated with the increased incidence of morbidities and mortality. Predisposing determinants of atrial fibrillation development after off-pump coronary artery bypass grafting remain unclear. We hypothesized that pericardial fluid natriuretic peptide concentrations have a predictive value for developing postoperative atrial fibrillation in patients who have undergone off-pump coronary artery bypass grafting.

METHODS

We prospectively measured atrial natriuretic peptide and brain natriuretic peptide concentrations in plasma and pericardial fluid in 42 consecutive patients undergoing off-pump coronary artery bypass grafting, then continuously observed the occurrence of atrial fibrillation following off-pump coronary artery bypass grafting until the time of discharge.

RESULTS

Postoperative atrial fibrillation was documented in nine patients (21%, atrial fibrillation group), and not in 33 patients (no atrial fibrillation group). Between the groups, there was neither significant difference in plasma atrial natriuretic peptide concentrations nor in pericardial atrial natriuretic peptide concentrations. Plasma brain natriuretic peptide concentrations were comparable in both groups [56.2 (interquartile range 42.7-102.8) vs. 35.2 pg/ml (13.8-75.0), P=0.07]. Pericardial fluid brain natriuretic peptide concentrations were significantly higher in the atrial fibrillation group than in the no atrial fibrillation group [188.0 (124.8-411.0) vs. 39.3 pg/ml (10.0-88.4), P=0.0001]. In a multivariable logistic regression model, pericardial brain natriuretic peptide concentration was significantly associated with a higher risk of postoperative atrial fibrillation (odds ratio=3.0 every 50 pg/ml increase; 95% confidence interval, 1.1-8.6; P=0.04).

CONCLUSION

Our results suggested that pericardial fluid brain natriuretic peptide concentration is independently associated with the development of atrial fibrillation after off-pump coronary artery bypass grafting.

Deleterious effects of cardiopulmonary bypass in coronary artery surgery and scientific interpretation of off-pump's logic

Cardiopulmonary bypass (CPB) has been suggested to be a cause of complex systemic inflammatory response that significantly contributes to several adverse postoperative complications. In the last few years, off-pump coronary artery bypass grafting (OPCAB) has gained widespread attention as an alternative technique to conventional on-pump coronary artery bypass grafting (ONCAB). However, a degree of uncertainty regarding the relative merits of ONCAB and OPCAB continues to be a significant issue. Surgeons supporting off-pump surgery, state that the avoidance of the CPB leads to significantly reduced myocardial ischemia-reperfusion injury, postoperative systemic inflammatory response and other biological derangements, a feature that may improve the clinical outcomes. However, perfection in perioperative care, surgical technique and methods of attenuating the untoward effects of CPB has resulted in better clinical outcome of ONCAB as well. Possible reasons of these controversial opinions are that high-quality studies have not comprehensively examined relevant patient outcomes and have enrolled a limited range of patients. Some studies may have been too small to detect clinically important differences in patient outcomes between these two modalities. We present a review of the available scientific interpretation of the literature on OPCAB with regard to safety, hemodynamic changes, inflammation, myocardial preservation and oxidative stress. We also sought to determine from different reported retrospective and randomized control studies, the initial and the long-term benefits of this approach, despite the substantial learning curve associated with OPCAB.

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.

Early outcomes of coronary artery bypass with and without cardiopulmonary bypass in octogenarians

BACKGROUND

Off-pump coronary artery bypass (OPCAB) surgery has been successfully used in diverse patient populations and has been postulated to be safer than conventional coronary artery bypass (CCAB) surgery in some high-risk patients, including the elderly.

OBJECTIVE

To compare the safety of OPCAB surgery versus CCAB surgery in the octogenarian population of two large southwestern Ontario cardiac surgical units.

RESULTS

Two hundred thirty-six consecutive octogenarians underwent primary isolated coronary artery bypass surgery from November 2000 to March 2005. Patients undergoing OPCAB surgery tended to have higher Parsonnet scores, while patients undergoing CCAB surgery had a greater number of emergent operations. The Canadian Cardiovascular Network predicted that mortality risk was similar in both groups. In-hospital mortality was similar between groups, as was postoperative myocardial infarction and new onset of renal dysfunction. However, in the OPCAB group, there was a decreased incidence of postoperative neurological dysfunction (2.3% in the OPCAB group versus 10.5% in the CCAB group, P=0.01), in particular cerebrovascular accidents (1.5% in the OPCAB group versus 7.6% in the CCAB group, P=0.05), and a decreased incidence of prolonged intubation (5.3% in the OPCAB group versus 13.3% in the CCAB group, P=0.04). Multivariable analysis found that cardiopulmonary bypass had no significant impact on mortality or length of stay.

CONCLUSIONS

In octogenarian patients, OPCAB surgery is as safe as CCAB surgery in terms of mortality and major morbidity. Furthermore, a significant reduction in neurological dysfunction and prolonged intubation was seen in the OPCAB group compared with the CCAB group.

Homograft Implantation Techniques in the Aortic Position: To Preserve or Replace the Aortic Root?

BACKGROUND

One determinant of durability of the homograft in the aortic position is the implantation technique. This study uses meta-analytical techniques to evaluate the differences in early and long-term outcomes of patients undergoing aortic homograft implantation with either a root replacement or a root preserving technique.

METHODS

A systematic review of the literature (1965-2005) reporting results after homograft implantation in the aortic position with emphasis in the implantation technique was performed. Random and fixed-effects models were used. Cumulative and influential meta-analysis, graphic exploration, and sensitivity analysis were carried out to explain the heterogeneity between studies and to investigate potential publication bias.

RESULTS

Eleven studies were included. None of the studies was randomized. There was no significant difference in early mortality between root replacement and root preserving groups (odds ratio = 2.57 with 95% confidence interval [CI] 0.68-9.72 in random-effects model) and the root replacement group had a significantly lower rate of reoperation during long-term follow-up (hazard ratio = 0.55 with 95% CI 0.38-0.80 in random-effects model). Subgroup analysis focusing on patients having the subcoronary technique for homograft implantation showed similar results. Significant heterogeneity between studies can be detected. No publication bias was found.

CONCLUSIONS

There was no significant difference in early mortality between root replacement and root preserving groups. However, the root replacement technique group had a significantly lower rate of reoperation during long-term follow-up. Excluding outliers identified in a funnel plot reduced the heterogeneity and reached a similar conclusion.

Meta-analysis of observational studies of ileorectal versus ileal pouch-anal anastomosis for familial adenomatous polyposis

BACKGROUND

Surgery for familial adenomatous polyposis (FAP) aims to minimize cancer risk while providing good functional outcome. Colectomy with ileorectal anastomosis and proctocolectomy with ileal pouch-anal anastomosis both offer this, but there is no clear consensus about which is better.

METHODS

This is a meta-analysis of comparative studies published between 1991 and 2003 reporting early and late postoperative adverse events, functional outcomes and quality of life.

RESULTS

Twelve studies containing 1002 patients (53.4 per cent ileal pouch, 46.6 per cent ileorectal anastomosis) were identified. Bowel frequency (weighted mean difference 1.62 (95 per cent confidence interval (c.i.) 1.05 to 2.20)), night defaecation (odds ratio (OR) 6.64 (95 per cent c.i. 2.99 to 14.74)) and use of incontinence pads (OR 2.72 (95 per cent c.i. 1.02 to 7.23)) were significantly less in the ileorectal group, although faecal urgency was reduced with the ileal pouch (odds ratio 0.43 (95 per cent c.i. 0.23 to 0.80)). Reoperation within 30 days was more common after ileal pouch construction (23.4 versus 11.6 per cent; OR 2.11 (95 per cent c.i. 1.21 to 3.70)). There was no significant difference between the techniques in terms of sexual dysfunction, dietary restriction, or postoperative complications. Rectal cancer was a diagnosis only in the ileorectal group (5.5 per cent).

CONCLUSION

Ileal pouch and ileorectal anastomoses have individual merits. Further research is needed to determine which most benefits patients with FAP.

Laparoscopic versus open surgery for rectal cancer: a meta-analysis

BACKGROUND

Laparoscopic rectal cancer surgery aims to provide patients with curative resection while minimizing postoperative morbidity and mortality. This study used meta-analytical techniques to compare laparoscopic and open surgery as the primary treatment for patients with rectal cancer with regard to short-term and long-term outcomes.

METHODS

A literature search was performed on all studies between 1993 and 2004 comparing laparoscopic and open surgery for rectal cancer. Subgroup analysis was performed on patients undergoing abdominoperineal excision of the rectum. The following end points were evaluated: operative outcomes, postoperative recovery, and early and late adverse events.

RESULTS

Twenty studies matched the selection criteria and reported on 2071 subjects, of whom 909 (44%) underwent laparoscopic and 1162 (56%) underwent open surgery for rectal cancer. Time to stomal function (weighted mean difference [WMD], -1.52; 95% confidence interval [95% CI], -2.20, -1.01), first bowel movement (WMD, -.72; 95% CI, -1.21, -.22), feeding solids (WMD, -.92; 95% CI, -1.35, -.50), and length of hospital stay (WMD, -2.67; 95% CI, -3.81, -1.54) were all significantly reduced after laparoscopic surgery. In patients who underwent abdominoperineal excision of the rectum, wound infection (odds ratio, .15; 95% CI, .03, .73) and requirement for postoperative parenteral analgesia (WMD, -.63; 95% CI, -1.22, -.04) were also significantly reduced. There was no difference between groups in the extent of oncological clearance.

CONCLUSIONS

Laparoscopic rectal cancer surgery results in an earlier postoperative recovery and a resected specimen that is oncologically comparable to open surgery. Results from randomized trials reporting long-term outcomes such as cancer recurrence (local and metastatic) and 5-year survival are eagerly awaited.

Laparoscopic versus open appendectomy in children: a meta-analysis

OBJECTIVE

This study aims to use meta-analysis to compare laparoscopic and open appendectomy in a pediatric population.

SUMMARY BACKGROUND DATA

Meta-analysis is a statistical tool that can be used to evaluate the literature in both qualitative and quantitative ways, accounting for variations in characteristics that can influence overall estimate of outcomes of interest. Meta-analysis of laparoscopic versus open appendectomy in a pediatric population has not previously been performed.

METHODS

Comparative studies published between 1992 and 2004 of laparoscopic versus open appendectomy in children were included. Endpoints were postoperative pyrexia, ileus, wound infection, intra-abdominal abscess formation, operative time, and postoperative hospital stay.

RESULTS

Twenty-three studies including 6477 children (43% laparoscopic, 57% open) were included. Wound infection was significantly reduced with laparoscopic versus open appendectomy (1.5% versus 5%; odds ratio [OR] = 0.45, 95% confidence interval [CI], 0.27-0.75), as was ileus (1.3% versus 2.8%; OR = 0.5, 95% CI, 0.29-0.86). Intra-abdominal abscess formation was more common following laparoscopic surgery, although this was not statistically significant. Subgroup analysis of randomized trials did not reveal significant difference between the 2 techniques in any of the 4 complications. Operative time was not significantly longer in the laparoscopic group, and postoperative stay was significantly shorter (weighted mean difference, -0.48; 95% CI, -0.65 to -0.31). Sensitivity analysis identified lowest heterogeneity when only randomized studies were considered, followed by prospective, recent, and finally large studies.

CONCLUSIONS

The results of this meta-analysis suggest that laparoscopic appendectomy in children reduces complications. However, we also see the need for further high-quality randomized trials comparing the 2 techniques, matched not only for age and sex but also for obesity and severity of appendicitis.

Coronary artery surgery: conventional coronary artery bypass grafting versus off-pump coronary artery bypass grafting

PURPOSE OF REVIEW

Coronary revascularization has become the principal treatment modality in patients with severe coronary artery disease. The broader application of percutaneous coronary interventions in patients with multivessel disease and the recent introduction of drug-eluting stents have both lead to a decline in the number of patients referred for surgical revascularization. Conventional coronary artery bypass grafting using cardiopulmonary bypass is an excellent treatment, however less invasive surgical approaches such as off-pump coronary artery bypass grafting have appeared in the past few years. The exact role of off-pump coronary artery bypass grafting is still vaguely defined and being critically evaluated. Our aim is to provide an objective review of the recent literature in regard to surgical outcomes.

RECENT FINDINGS

A critical review of all relevant clinical series from May 2003 to May 2005 was conducted. Current prospective data suggests that both techniques have similar rates of mortality, in regard to morbidity, multiple prospective studies suggest a decrease in stroke rates for off-pump coronary artery bypass grafting. The incidence of postoperative myocardial infarction does not appear to differ between techniques. When analyzed carefully, the results presented herein seem to indicate that both techniques provide similar rates for long-term patency and freedom from surgical reintervention.

SUMMARY

Coronary artery bypass grafting and off-pump coronary artery bypass grafting are both safe and beneficial in patients with multivessel coronary artery disease. It appears that elderly patients with additional co-morbid risk factors may benefit most from off-pump coronary artery bypass grafting. It has become increasingly apparent that off-pump coronary artery bypass grafting can be performed safely in reference centers.

A comparison of open vs. laparoscopic abdominal rectopexy for full-thickness rectal prolapse: a meta-analysis

PURPOSE

Using meta-analytical techniques, this study was designed to compare open and laparoscopic abdominal procedures used to treat full-thickness rectal prolapse in adults.

METHODS

Comparative studies published between 1995 and 2003, cited in the literature of open abdominal rectopexy vs. laparoscopic abdominal rectopexy, were used. The primary end points were recurrence and morbidity, and the secondary end points assessed were operative time and length of hospital stay. A random effect model was used to aggregate the studies reporting these outcomes, and heterogeneity was assessed.

RESULTS

Six studies, consisting of a total of 195 patients (98 open and 97 laparoscopic) were included. Analysis of the data suggested that there is no significant difference in recurrence and morbidity between laparoscopic abdominal rectopexy and open abdominal rectopexy. Length of stay was significantly reduced in the laparoscopic group by 3.5 days (95 percent confidence interval, 3.1-4; P < 0.01), whereas the operative time was significantly longer in this group, by approximately 60 minutes (60.38 minutes; 95 percent confidence interval, 49-71.8).

CONCLUSIONS

Laparoscopic abdominal rectopexy is a safe and feasible procedure, which may compare equally with the open technique with regards to recurrence and morbidity and favorably with length of stay. However large-scale randomized trials, with comparative, sound methodology are still needed to ascertain detailed outcome measures accurately.

Off-Pump Coronary Artery Surgery for Reducing Mortality and Morbidity

OBJECTIVES

The purpose of this study was to assess the effects of off-pump coronary bypass surgery (OPCAB) on mortality and morbidity.

BACKGROUND

Despite its potential for reducing morbidity and mortality, OPCAB's role in clinical practice remains controversial.

METHODS

A meta-analysis of 37 randomized controlled trials (RCTs) (n = 3,449) and 22 risk-adjusted (logistic regression or propensity-score) observational studies (n = 293,617) was performed. Two reviewers performed literature searches (MEDLINE, EMBASE, PubMed, reference lists), quality assessment, and data extraction. Treatment effects were calculated as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

In RCTs, OPCAB was associated with reduced atrial fibrillation (OR 0.59; 95% CI 0.46 to 0.77) and trends toward reduced 30-day mortality (OR 0.91 95% CI 0.45 to 1.83), stroke (OR 0.52; 95% CI 0.25 to 1.05), and myocardial infarction (OR 0.79; 95% CI 0.50 to 1.25). Observational studies showed OPCAB to be associated with reduced 30-day mortality (OR 0.72; 95% CI 0.66 to 0.78), stroke (OR 0.62; 95% CI 0.55 to 0.69), infarction (OR 0.66; 95% CI 0.50 to 0.88), and atrial fibrillation (OR 0.78; 95% CI 0.74 to 0.82). At one to two years, OPCAB was associated with trends toward reduced mortality, but also increased repeat revascularization (RCT: OR 1.75, 95% CI 0.78 to 3.94; Observational: OR 1.35, 95% CI 0.76 to 2.39).

CONCLUSIONS

Randomized controlled trials did not find, aside from atrial fibrillation, the statistically significant reductions in short-term mortality and morbidity demonstrated by observational studies. These discrepancies might be due to differing patient-selection and study methodology. Future studies must focus on improving research methodology, recruiting high-risk patients, and collecting long-term data.

Análisis de las arritmias en el postoperatorio inmediato de cirugía cardiovascular

Cardiac arrhythmias are one of the most frequent complications in the immediate post-operatory period of cardiac surgery with extracorporeal circulation, this occurring in between 35% and 50% of the patients subjected to this therapeutic intervention. Among the causal factors, electrolytic alterations, direct surgical aggression on the heart tissue and alterations secondary to ischemic cell damage that is produced in the myocardial during extracorporeal circulation are found. Due to the frequency of appearance of arrhythmias, we decided to study them and know them in depth. Thus, the objective of our study was to know the incidence and prevalence of arrhythmias during the immediate post-operatory period of cardiovascular surgery. Out of all those admitted to the unit, all the patients who had undergone valvular and coronary surgery with a stay in the intensive care unit of the University Hospital Marques de Valdecilla that did not exceed 7 days were selected. This means 258 patients, the most frequent alterations during the post-operative period being right branch blockage (16%), atrial fibrillation (12%), ventricular tachycardy (7%), atrial ventricular block (4%), among other rhythm and conduction alterations. As conclusions, we stress that the most frequent alterations during the immediate post-operative period were branch blocks, arrhythmia being more prevalent than atrial fibrillation. A total of 85% of the patients undergoing valvular replacement and 89% of those operated on for coronary derivation plus valvular replacement had more arrhythmia episodes than the rest.

Controversies in off-pump coronary artery surgery

Motivated by a desire to reduce the morbidity of a well-established and effective procedure for coronary artery disease, up to 25% of coronary artery bypass operations are being performed without the use of a heart-lung pump. Concerns remain about the quality of the coronary anastomoses and the completeness of revascularization. Randomized trials have not revealed the significant reduction in morbidity or mortality that the early enthusiasts had hoped for. Yet a number of non-randomized studies have shown clinical benefit from the avoidance of an extracorporeal circulation, but these have been criticized for potential bias in patient selection and management.A majority of surgeons have not yet adopted this technique and are waiting for the accumulation of more evidence.