1
|
Phothikun A, Nawarawong W, Tantraworasin A, Phinyo P, Tepsuwan T. The outcomes of three different techniques of coronary artery bypass grafting: On-pump arrested heart, on-pump beating heart, and off-pump. PLoS One 2023; 18:e0286510. [PMID: 37256890 DOI: 10.1371/journal.pone.0286510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 05/17/2023] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVE Conventional coronary artery bypass grafting (CABG) or on-pump arrested heart CABG (ONCAB) is a standard and simple technique. However, adverse effects can occur due to the use of aortic cross-clamp and cardiopulmonary bypass. Performing off-pump CABG (OPCAB) aims to avoid these adverse effects but may result in incomplete revascularization. On-pump beating heart CABG (ONBHCAB) combines the benefits of both ONCAB and OPCAB. This study focuses on comparing the short- and long-term outcomes of different CABG techniques. METHOD Retrospective observational cohort included 2,028 patients who underwent ONCAB, OPCAB, and ONBHCAB. The short-term outcomes including postoperative ischemic injury, hemodynamic functions, and adverse events were compared. The long-term outcomes were overall survival and the occurrence of major adverse cardiovascular events (MACE). Propensity score matching ensured comparability among the three patient groups. RESULTS After matching, there were no differences in baseline characteristics. Regarding ischemic injury, OPCAB showed the lowest peak cardiac enzyme levels (all p≤0.001). There were no statistically significant differences in the change of hemodynamic function (cardiac index) between the three groups (p = 0.158). Ten-year survival for OPCAB, ONBHCAB, and ONCAB were 80.5%, 75.9%, and 73.7%, respectively. OPCAB was associated with a significant reduction in mortality risk and MACE when compared to others (Mortality HR = 0.33, p = 0.001, MACE HR = 0.52, p = 0.004). CONCLUSION OPCAB implementation resulted in a lower occurrence of postoperative ischemic injury than ONCAB and ONBHCAB. No differences in postoperative hemodynamic function in all three techniques were observed. OPCAB respectively were preferable techniques beneficial for long-term outcomes.
Collapse
Affiliation(s)
- Amarit Phothikun
- Faculty of Medicine, Department of Surgery, Cardiovascular and Thoracic Surgery Unit, Chiang Mai University, Chiang Mai, Thailand
- Faculty of Medicine, Clinical Epidemiology and Clinical Statistic Center, Chiang Mai University, Chiang Mai, Thailand
- Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand
| | - Weerachai Nawarawong
- Faculty of Medicine, Department of Surgery, Cardiovascular and Thoracic Surgery Unit, Chiang Mai University, Chiang Mai, Thailand
| | - Apichat Tantraworasin
- Faculty of Medicine, Clinical Epidemiology and Clinical Statistic Center, Chiang Mai University, Chiang Mai, Thailand
- Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand
- Faculty of Medicine, Department of Surgery, General Thoracic Surgery Unit, Chiang Mai University, Chiang Mai, Thailand
| | - Phichayut Phinyo
- Faculty of Medicine, Clinical Epidemiology and Clinical Statistic Center, Chiang Mai University, Chiang Mai, Thailand
- Faculty of Medicine, Department of Family Medicine, Chiang Mai University, Chiang Mai, Thailand
- Musculoskeletal Science and Translational Research (MSTR), Chiang Mai University, Chiang Mai, Thailand
| | - Thitipong Tepsuwan
- Faculty of Medicine, Department of Surgery, Cardiovascular and Thoracic Surgery Unit, Chiang Mai University, Chiang Mai, Thailand
- Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand
| |
Collapse
|
2
|
Bostan C, Kaya A, Yiğit Z. Changes in pentraxin 3 and oxidative parameters during coronary bypass grafting and factors affecting postoperative atrial fibrillation. J Int Med Res 2020; 48:300060520967561. [PMID: 33147418 PMCID: PMC7780577 DOI: 10.1177/0300060520967561] [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] [Indexed: 11/16/2022] Open
Abstract
Objective The performance of coronary bypass grafting (CBG) induces a type of subclinical systemic inflammatory response syndrome. The present study was performed to examine the changes in pentraxin 3 (PTX3) and oxidative parameters during cross-clamping in patients undergoing CBG. We also examined factors affecting the development of postoperative atrial fibrillation (POAF). Method This study involved 40 patients who underwent elective on-pump CBG (33 men, 7 women; mean age, 60.8 ± 8.0 years). Blood specimens were drawn before anaesthesia and after aortic cross-clamping. POAF was detected by analysing the rhythm records of telemetry units for 96 hours postoperatively. Results The mean PTX3 concentration prior to surgery was 176.3 ± 148.4 pg/mL. After cross-clamping, it increased to 947.7 ± 377.2 pg/mL. The increase was statistically significant. Twelve patients had POAF. The leucocyte count and change in the oxidative stress index were significantly higher in patients without than with POAF. Although the increase in PTX3 was higher in patients without POAF, the difference was not statistically significant. Conclusion The PTX3 concentration significantly increases during CBG. A significant change in the oxidative stress index and a more intense increase in the PTX3 concentration were seen in patients without POAF.
Collapse
Affiliation(s)
- Cem Bostan
- Department of Cardiology, Istanbul University-Cerrahpasa Institute of Cardiology, Istanbul, Turkey
| | - Ayşem Kaya
- Department of Cardiology, Biochemistry Laboratory, Istanbul University-Cerrahpasa Institute of Cardiology, Istanbul, Turkey
| | - Zerrin Yiğit
- Department of Cardiology, Istanbul University-Cerrahpasa Institute of Cardiology, Istanbul, Turkey
| |
Collapse
|
3
|
Chowdhury UK, Sheil A, Kapoor PM, Narang R, Gharde P, Malik V, Kalaivani M, Chaudhury A. Short-term prognostic value of perioperative coronary sinus-derived-serum cardiac troponin-I, creatine kinase-MB, lactate, pyruvate, and lactate-pyruvate ratio in adult patients undergoing open heart surgery. Ann Card Anaesth 2017; 19:439-53. [PMID: 27397448 PMCID: PMC4971972 DOI: 10.4103/0971-9784.185526] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To investigate the release pattern of different cardiac metabolites and biomarkers directly from the coronary sinus (CS) and to establish the diagnostic discrimination limits of each marker protein and metabolites to evaluate perioperative myocardial injury in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB). PATIENTS AND METHODS Sixty-eight patients undergoing first mitral and/or aortic valve replacements with/without coronary artery bypass grafting and Bentall procedure under CPB and blood cardioplegic arrest were studied. All cardiac metabolites and biomarkers were measured in serial CS-derived blood samples at pre-CPB, immediate post aortic declamping, 10 minutes post-CPB and 12 hrs post-CPB. RESULTS Receiver operating characteristic curve analysis of cardiac biomarkers indicated lactate-pyruvate ratio as the superior diagnostic discriminator of myocardial injury with an optimal "cut-off" value >10.8 immediately after aortic declamping (AUC, 0.92; 95% CI: 0.85-0.98). Lactate was the second best diagnostic discriminator of myocardial injury with an optimal "cut-off" value >2mmol/l at immediately after aortic declamping (AUC, 0.89; 95% CI: 0.80-0.96). Cardiac troponin-I was the third best diagnostic discriminator of myocardial injury with an optimal "cut-off" value >2.1ng/ml at immediately after aortic declamping (AUC, 0.88; 95% CI: 0.80-0.95). Creatine kinase-MB was the fourth best diagnostic discriminator of myocardial injury with an optimal "cut-off" value >58 log units/ml prior to decanulation (AUC, 0.85; 95% CI: 0.78-0.94). CONCLUSIONS Measurable cardiac damage exists in all patients undergoing cardiac surgery under cardioplegic arrest. The degree of myocardial injury is more in patients with poor ventricular function and those requiring longer aortic clamp time. CS-derived lactate-pyruvate ratio, lactate, cTn-I served as superior diagnostic discriminators of peri-operative myocardial damage.
Collapse
Affiliation(s)
- Ujjwal Kumar Chowdhury
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Avneesh Sheil
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Poonam Malhotra Kapoor
- Department of Cardiovascular Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Rajiv Narang
- Department of Cardiology, CNC, All India Institute of Medical Sciences, New Delhi, India
| | - Parag Gharde
- Department of Cardiovascular Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Vishwas Malik
- Department of Cardiovascular Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Mani Kalaivani
- Department of Baiostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Arindam Chaudhury
- Department of Cardiovascular Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
4
|
On- vs. off-pump coronary artery bypass grafting: A systematic review and meta-analysis. Int J Cardiol 2016; 223:201-211. [DOI: 10.1016/j.ijcard.2016.08.250] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 08/11/2016] [Accepted: 08/12/2016] [Indexed: 12/25/2022]
|
5
|
Kowalewski M, Pawliszak W, Malvindi PG, Bokszanski MP, Perlinski D, Raffa GM, Kowalkowska ME, Zaborowska K, Navarese EP, Kolodziejczak M, Kowalewski J, Tarelli G, Taggart DP, Anisimowicz L. Off-pump coronary artery bypass grafting improves short-term outcomes in high-risk patients compared with on-pump coronary artery bypass grafting: Meta-analysis. J Thorac Cardiovasc Surg 2015; 151:60-77.e1-58. [PMID: 26433633 DOI: 10.1016/j.jtcvs.2015.08.042] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 07/27/2015] [Accepted: 08/12/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To assess the benefits and risks of off-pump coronary artery bypass (OPCAB) versus coronary artery bypass grafting (CABG) through a meta-analysis of randomized controlled trials (RCTs), and to investigate the relationship between outcomes and patient risk profile. METHODS PubMed, Embase, the Cumulative Index of Nursing and Allied Health Literature, Scopus, Web of Science, Cochrane Library, and major conference proceedings databases were searched for RCTs comparing OPCAB and CABG and reporting short-term (≤ 30 days) outcomes. Endpoints assessed were all-cause mortality, myocardial infarction (MI), and cerebral stroke. RESULTS The meta-analysis included 100 studies, with a total of 19,192 subjects. There was no difference between the 2 techniques with respect to all-cause mortality and MI (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.71-1.09; P = .25; I(2) = 0% and OR, 0.90; 95% CI, 0.77-1.05; P = .19; I(2) = 0%, respectively). OPCAB was associated with a significant 28% reduction in the odds of cerebral stroke (OR, 0.72; 95% CI, 0.56-0.92; P = .009; I(2) = 0%). A significant relationship between patient risk profile and benefits from OPCAB was found in terms of all-cause mortality (P < .01), MI (P < .01), and cerebral stroke (P < .01). CONCLUSIONS OPCAB is associated with a significant reduction in the odds of cerebral stroke compared with conventional CABG. In addition, benefits of OPCAB in terms of death, MI, and cerebral stroke are significantly related to patient risk profile, suggesting that OPCAB should be strongly considered in high-risk patients.
Collapse
Affiliation(s)
- Mariusz Kowalewski
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland; Faculty of Health Sciences, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland; Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Düsseldorf, Germany.
| | - Wojciech Pawliszak
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Pietro Giorgio Malvindi
- University Hospital Southampton NHS Foundation Trust, Wessex Cardiothoracic Centre, Southampton, United Kingdom
| | - Marek Pawel Bokszanski
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Damian Perlinski
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS - ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Magdalena Ewa Kowalkowska
- Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Düsseldorf, Germany; Department and Clinic of Obstetrics, Gynecology, and Oncological Gynecology, Collegium Medicum, Bydgoszcz, Poland
| | - Katarzyna Zaborowska
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Eliano Pio Navarese
- Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Düsseldorf, Germany; Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Michalina Kolodziejczak
- Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Düsseldorf, Germany; Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
| | - Janusz Kowalewski
- Lung Cancer and Thoracic Surgery Department, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
| | - Giuseppe Tarelli
- Department of Cardiac Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - David Paul Taggart
- Department of Cardiac Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | - Lech Anisimowicz
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| |
Collapse
|
6
|
Deppe AC, Arbash W, Kuhn EW, Slottosch I, Scherner M, Liakopoulos OJ, Choi YH, Wahlers T. Current evidence of coronary artery bypass grafting off-pump versus on-pump: a systematic review with meta-analysis of over 16 900 patients investigated in randomized controlled trials. Eur J Cardiothorac Surg 2015; 49:1031-41; discussion 1041. [DOI: 10.1093/ejcts/ezv268] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 07/02/2015] [Indexed: 01/27/2023] Open
|
7
|
Puskas JD, Martin J, Cheng DCH, Benussi S, Bonatti JO, Diegeler A, Ferdinand FD, Kieser TM, Lamy A, Mack MJ, Patel NC, Ruel M, Sabik JF, Yanagawa B, Zamvar V. ISMICS Consensus Conference and Statements of Randomized Controlled Trials of Off-Pump versus Conventional Coronary Artery Bypass Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015. [DOI: 10.1177/155698451501000401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- John D. Puskas
- Department of Cardiovascular Surgery, Icahn School of Medicine, Mount Sinai, New York, NY USA
| | - Janet Martin
- Centre for Medical Evidence, Decision Integrity, Clinical Impact (MEDICI), Department of Anesthesia & Perioperative Medicine, and Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - Davy C. H. Cheng
- Centre for Medical Evidence, Decision Integrity, Clinical Impact (MEDICI), Department of Anesthesia & Perioperative Medicine, and Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - Stefano Benussi
- Division of Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Johannes O. Bonatti
- Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Anno Diegeler
- Herz-Und Gefasse Klinik Bad Neustadt, University of Leipzig, Bad Neustadt, Germany
| | - Francis D. Ferdinand
- Division of Cardiovascular and Thoracic Surgery, Lankenau Medical Center, Wynnewood, PA USA
| | - Teresa M. Kieser
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB Canada
| | - André Lamy
- Division of Cardiac Surgery and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Michael J. Mack
- Baylor Health System, Heart Hospital Baylor Plano, Dallas, TX USA
| | - Nirav C. Patel
- Department of Cardiothoracic Surgery, Lenox Hill, New York, NY USA
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Joseph F. Sabik
- Heart Vascular Institute, Cleveland Clinic, Cleveland, OH USA
| | - Bobby Yanagawa
- Department of Cardiovascular Surgery, Icahn School of Medicine, Mount Sinai, New York, NY USA
| | - Vipin Zamvar
- Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| |
Collapse
|
8
|
ISMICS Consensus Conference and Statements of Randomized Controlled Trials of Off-Pump versus Conventional Coronary Artery Bypass Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015; 10:219-29. [DOI: 10.1097/imi.0000000000000184] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective At this consensus conference, we developed evidence-informed consensus statements and recommendations on the practice of off-pump coronary artery bypass graft (OPCAB) by systematically reviewing and performing meta-analysis of the randomized controlled trials (RCTs) comparing OPCAB and conventional coronary artery bypass (CCAB). Methods All RCTs of OPCAB versus CCAB through April 2013 were screened, and 102 relevant RCTs (19,101 patients) were included in a systematic review and meta-analysis (15 RCTs of 9551 high-risk patients; and 87 RCTs of 9550 low-risk patients) in accordance with the Cochrane Collaboration and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Consensus statements for the risks and benefits of OPCAB surgery in mortality, morbidity, and resource use were developed based on best available evidence. Results Compared to CCAB, it is reasonable to perform OPCAB to reduce risks of stroke [class IIa, level of evidence (LOE) A], renal dysfunction/failure (class IIa, LOE A), blood transfusion (class I, LOE A), respiratory failure (class I, LOE A), atrial fibrillation (class I, LOE A), wound infection (class I, LOE A), ventilation time, and ICU and hospital length of stay (class I, LOE A). However, OPCAB may be associated with a reduced number of grafts performed (class I, LOE A) and with diminished graft patency (class IIa, LOE A, with increased coronary reintervention at 1 year and beyond (class IIa, LOE A), as well as increased mortality at a median follow-up of 5 years (class IIb, LOE A). Conclusions OPCAB compared with CCAB may improve outcomes in the short-term (stroke, renal dysfunction, blood transfusion, respiratory failure, atrial fibrillation, wound infection, ventilation time, and length of stay). However, over the longer-term, OPCAB may be associated with reduced graft patency, and increased risk of cardiac re-intervention and death.
Collapse
|
9
|
Perrotti A, Luporsi P, Durst C, Vernerey D, Chocron S. Early detection of asymptomatic bypass graft abnormalities using a cardiac troponin I ratio following coronary artery bypass surgery. J Card Surg 2015; 30:319-23. [PMID: 25644326 DOI: 10.1111/jocs.12517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND We sought to identify the best cardiac Troponin I (cTnI) ratio to detect asymptomatic graft or anastomoses anomalies after myocardial revascularization. METHODS Patients with a rising cTnI profile, based on measurements at 6 and 12 hours (cTnI 12 hours : 6 hours ratio >1) after the last anastomosis in off-pump surgery or after cardiopulmonary bypass in on-pump surgery, underwent a coronary angiogram, despite an uncomplicated postoperative course and absence of electrocardiogram changes. The optimal threshold value for the ratio was determined using a receiving operator characteristic (ROC) curve. RESULTS From April 2005 to May 2011, among 1693 patients undergoing isolated coronary artery bypass graft (CABG), 29 (1.7%) had a cTnI ratio >1 and underwent postoperative angiography. Twenty abnormalities were observed in 16 patients (55%). In the anastomoses, there were four occlusions and four stenosis. In the grafts, there were 12 stenosis: two of the Y graft anastomosis, two dissections, five hematomas and three kinking. TIMI flow grade based on results of the Thrombolysis In Myocardial Infarction trial was 3 in six patients, 1 in five, and 0 in five. In the 16 patients with lesions, the cTnI ratio was 2.1 ± 1.4 versus 1.4 ± 0.3 in patients with no lesions (p = 0.09). A ratio of 1.3 (p = 0.003) was determined by ROC curve analysis as having the greatest discriminant capacity, with associated sensitivity of 87.5% and specificity of 62%. CONCLUSION A cTnI 12 hours : 6 hours ratio >1.3 may be indicative of these abnormalities. Early identification of these anomalies may avoid adverse outcomes.
Collapse
Affiliation(s)
- Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | | | | | | | | |
Collapse
|
10
|
GOMES V, GOMES MB, TIBIRICA E, LESSA MA. Post-operative endothelial dysfunction assessment using laser Doppler perfusion measurement in cardiac surgery patients. Acta Anaesthesiol Scand 2014; 58:468-77. [PMID: 24617621 DOI: 10.1111/aas.12286] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND Coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB) is associated with systemic inflammatory response and endothelial dysfunction. Our hypothesis is that CPB-induced post-operative endothelial dysfunction may be detected using laser Doppler perfusion monitoring (LDPM) in the skin microcirculation. METHODS We used LDPM to investigate the subacute effects of the CPB on systemic microvascular reactivity among patients undergoing CABG surgery with CPB. Thirty patients were submitted to the study of skin microcirculation and blood sample collection at baseline (pre-surgery) and at 7 days post-surgical procedure. The skin microcirculation was evaluated by acetylcholine (ACh) and sodium nitroprusside (SNP) iontophoresis, and thermal hyperemia (TH). Plasma levels of nitrite/nitrate were also analyzed, and cytokine profiles were determined using a multiplex system. RESULTS On-pump CABG surgery induced a significant reduction of the increased microvascular dermal flux observed after cumulative doses of ACh iontophoresis and after TH. On-pump CABG surgery did not induce any significant changes in the microvascular flux after cumulative doses of SNP. Patients still presented high levels of interleukin (IL)-6, IL-8, and C-reactive protein, and low bioavailability of nitric oxide 7 days after the CABG surgery with CPB. CONCLUSION We observed a significant impairment of systemic microvascular endothelial function and well-preserved endothelium-independent vasodilatation in the skin microcirculation of patients 1 week after CABG surgery with CPB. Our results suggest that LDPM is a useful tool for the assessment of on-pump CABG-induced subacute post-operative endothelial dysfunctions.
Collapse
Affiliation(s)
- V. GOMES
- Laboratory of Cardiovascular Investigation; Oswaldo Cruz Institute/FIOCRUZ; Rio de Janeiro Brazil
| | - M. B. GOMES
- Department of Internal Medicine; Diabetes Unit; State University of Rio de Janeiro; Rio de Janeiro Brazil
| | - E. TIBIRICA
- Laboratory of Cardiovascular Investigation; Oswaldo Cruz Institute/FIOCRUZ; Rio de Janeiro Brazil
| | - M. A. LESSA
- Laboratory of Cardiovascular Investigation; Oswaldo Cruz Institute/FIOCRUZ; Rio de Janeiro Brazil
| |
Collapse
|
11
|
Kunes P, Mandak J, Holubcova Z, Kolackova M, Krejsek J. The long pentraxin PTX3: a candidate anti-inflammatory mediator in cardiac surgery. Perfusion 2013; 28:377-89. [DOI: 10.1177/0267659113483799] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Coronary artery bypass grafting (CABG) is performed with the use of cardiopulmonary bypass (CPB) and cardioplegic arrest (CA) of the heart. The advantage of this technique, alternatively referred to as “on-pump” surgery, resides, for the surgeon, in relatively easy access to and manipulation with the non-beating, bloodless heart. However, the advantage that is, thereby, gained by the patient is paid off by an increased susceptibility to postoperative systemic inflammatory response syndrome (SIRS). Under unfavorable conditions, the inflammatory syndrome may develop into life-threatening forms of MODS (multiple organ dysfunction syndrome) or even MOFS (multiple organ failure syndrome). Deliberate avoidance of CPB, also known as “off-pump” surgery, attenuates early postoperative inflammation throughout its trajectory of SIRS→MODS→MOFS, but, in the long run, there appears to be no substantial difference in the overall mortality rates. In the last years, our knowledge of the pathophysiology of surgical inflammation has increased considerably. Recent findings, highlighting the as yet rather obscure role of pentraxin 3 (PTX3) in these processes, are discussed in this review article.
Collapse
Affiliation(s)
- P Kunes
- Deparment of Cardiac Surgery, Charles University in Prague, Medical School and University Hospital in Hradec Kralove, Czech Republic
| | - J Mandak
- Deparment of Cardiac Surgery, Charles University in Prague, Medical School and University Hospital in Hradec Kralove, Czech Republic
| | - Z Holubcova
- Deparment of Cardiac Surgery, Charles University in Prague, Medical School and University Hospital in Hradec Kralove, Czech Republic
| | - M Kolackova
- Department of Clinical Immunology, Charles University in Prague, Medical School and University Hospital in Hradec Kralove, Czech Republic
| | - J Krejsek
- Department of Clinical Immunology, Charles University in Prague, Medical School and University Hospital in Hradec Kralove, Czech Republic
| |
Collapse
|
12
|
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
|
13
|
Ait Houssa M, Moutakiallah Y, Abdou A, Selkane C, Amahzoune B, Drissi M, Raissouni M, El Bekkali Y, Azendour H, Boulahya A. [Results of coronary artery bypass grafting with left ventricular dysfunction (comparison of off-pump versus on-pump)]. Ann Cardiol Angeiol (Paris) 2012. [PMID: 23183222 DOI: 10.1016/j.ancard.2012.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The aim of this study was to compare the results of myocardial revascularisation with or without cardiopulmonary bypass in patients with impaired left ventricular function. PATIENTS AND METHODS Five hundred and sixteen consecutive patients who underwent coronary artery bypass grafting from January 2000 through December 2007 were analyzed retrospectively. One hundred and eight cases had a left ventricular EF (ejection fraction) of 45% or less. Of these patients, 78 underwent conventional coronary artery bypass (CCABG) and 30 underwent off-pump procedure (OCABG). The CCABG group received 300IU/kg of heparin while the OCABG received 100IU/kg. The off-pump coronary surgery was carried out using a tissue stabilizer Octopus II. Different pre-, per- and postoperative variables were evaluated among both groups. Statistical analysis was performed by SPSS 11.5. The variables were compared between these two groups using univariate analysis (Chi(2) test, Fisher's test exact) for qualitative variable and (Student's t test, Mann-Whitney's test) for quantitative variable. RESULTS Patients profiles and risk factors were similar among both groups except for age (CCABG: 57.8±9.2 year vs OCABG: 52±9.9 year; P=0.004) and left ventricular EF (CCABG: 37.4±6.3% vs OCABG: 34±7.8%; P=0.02). The number of grafts performed per patient was significantly more among patients who underwent extracorporeal circulation (CCABG: 2.53±0.7 graft/patient vs OCABG: 1.77±0.8 graft/patient; P<0.0001). The hospital mortality was more among CCABG group 9% vs 3.3% in OCABG but the difference was not significant (P=0.3). However, the operative time and the operative room stay were long in CCABG (252±61min vs 175±38min; P<0.0001 - 389±70min vs 298±54min; P<0.0001). The ventilation time was also long in CCABG (32.3±67hour vs 10.4±5.9hour; P=0.15). There was more postoperative myocardial infarction in CCABG (P=0.008), but the EF increased and was better in CCABG. CONCLUSION Off-pump coronary artery bypass surgery provides satisfactory operative results for most patients with reduced left ventricular function. Prospective and randomly study will be necessary before concluding.
Collapse
Affiliation(s)
- M Ait Houssa
- Service de chirurgie cardiovasculaire, hôpital militaire d'instruction Mohamed V, BP 10100, Rabat, Maroc.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
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.
Collapse
Affiliation(s)
- Christian H Møller
- Department of Cardiothoracic Surgery, RT 2152, Copenhagen University Hospital, Rigshospitalet, Copenhagen,
| | | | | | | | | |
Collapse
|
15
|
Hong DM, Jeon Y, Lee CS, Kim HJ, Lee JM, Bahk JH, Kim KB, Hwang HY. Effects of remote ischemic preconditioning with postconditioning in patients undergoing off-pump coronary artery bypass surgery--randomized controlled trial. Circ J 2012; 76:884-90. [PMID: 22301846 DOI: 10.1253/circj.cj-11-1068] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Myocardial injury is associated with an adverse outcome after off-pump coronary artery bypass graft surgery (OPCAB). The authors conducted a randomized controlled trial to evaluate whether remote ischemic preconditioning (RIPC) with remote ischemic postconditioning (RIPostC) reduces myocardial injury in patients undergoing OPCAB. METHODS AND RESULTS Seventy patients scheduled for OPCAB were randomly assigned to an RIPC+RIPostC group (n=35) or a control group (n=35). In the RIPC+RIPostC group, 4 cycles of 5-min ischemia and 5-min reperfusion were done on a lower limb before anastomoses (RIPC) and after anastomoses (RIPostC). RIPC+RIPostC significantly reduced postoperative serum troponin I levels (P=0.001). The area under the curve for postoperative troponin I was 48.7% lower in the RIPC+RIPostC group (median [interquartile range], 21.3 h·ng⁻¹·ml⁻¹, 16.5-53.1 h·ng⁻¹·ml⁻¹ vs. 41.5 h·ng⁻¹·ml⁻¹, 24.6-90.2 h·ng⁻¹·ml⁻¹, P=0.020). There was no significant difference in creatinine levels and PaO₂/F(i)O₂ ratios between the 2 groups. CONCLUSIONS RIPC+RIPostC by lower limb ischemia decreased postoperative myocardial enzyme elevation by almost half postoperatively in patients undergoing OPCAB.
Collapse
Affiliation(s)
- Deok Man Hong
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University Hospital, Seoul, Korea
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Afilalo J, Rasti M, Ohayon SM, Shimony A, Eisenberg MJ. Off-pump vs. on-pump coronary artery bypass surgery: an updated meta-analysis and meta-regression of randomized trials. Eur Heart J 2011; 33:1257-67. [DOI: 10.1093/eurheartj/ehr307] [Citation(s) in RCA: 134] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
17
|
Hong DM, Mint JJ, Kim JH, Sohn IS, Lim TW, Lim YJ, Bahk JH, Jeon Y. The effect of remote ischaemic preconditioning on myocardial injury in patients undergoing off-pump coronary artery bypass graft surgery. Anaesth Intensive Care 2010; 38:924-9. [PMID: 20865880 DOI: 10.1177/0310057x1003800518] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In several recent clinical trials on cardiac surgery patients, remote ischaemic preconditioning (RIPC) showed a powerful myocardial protective effect. However the effect of RIPC has not been studied in patients undergoing off-pump coronary artery bypass graft surgery. We evaluated whether RIPC could induce myocardial protection in off-pump coronary artery bypass graft surgery patients. Patients undergoing elective off-pump coronary artery bypass graft surgery were randomly allocated to the RIPC (n = 65) or control group (n = 65). After induction of anaesthesia, RIPC was induced by four cycles of five-minute ischaemia and reperfusion on the upper limb using a pneumatic cuff. Anaesthesia was maintained with sevoflurane, remifentanil and vecuronium. Myocardial injury was assessed by troponin I before surgery and 1, 6, 12, 24, 48 and 72 hours after surgery. There were no statistical differences in troponin I levels between RIPC and control groups (P = 0.172). Although RIPC reduced the total amount of troponin I (area under the curve of troponin increase) by 26%, it did not reach statistical significance (RIPC group 53.2 +/- 72.9 hours x ng/ml vs control group 67.4 +/- 97.7 hours x ng/ml, P = 0.281). In this study, RIPC by upper limb ischaemia reduced the postoperative myocardial enzyme elevation in off-pump coronary artery bypass graft surgery patients, but this did not reach statistical significance. Further study with a larger number of patients may be needed to fully evaluate the clinical effect of RIPC in off-pump coronary artery bypass graft surgery patients.
Collapse
Affiliation(s)
- D M Hong
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | | | | | | | | | | | | | | |
Collapse
|
18
|
Rastan AJ, Thiele H, Schuler G, Mohr FW. Stellenwert der koronaren Bypass operation in der Therapie der akuten Koronarsyndrome. Herz 2010; 35:70-8. [DOI: 10.1007/s00059-010-3327-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
19
|
Venugopal V, Ludman A, Yellon DM, Hausenloy DJ. 'Conditioning' the heart during surgery. Eur J Cardiothorac Surg 2009; 35:977-87. [PMID: 19324569 DOI: 10.1016/j.ejcts.2009.02.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Revised: 01/15/2009] [Accepted: 02/10/2009] [Indexed: 11/18/2022] Open
Abstract
Coronary heart disease (CHD) is the leading cause of death worldwide. Coronary artery bypass graft (CABG) surgery remains the procedure of choice for coronary artery revascularisation in a large number of patients with severe CHD. However, the profile of patients undergoing CABG surgery is changing with increasingly higher-risk patients being operated upon, resulting in significant morbidity and mortality in this patient group. Myocardial injury sustained during cardiac surgery, most of which can be attributed to acute myocardial ischaemia-reperfusion injury, is associated with worse short-term and long-term clinical outcomes. Clearly, new treatment strategies are required to protect the heart during cardiac surgery in terms of reducing myocardial injury and preserving left ventricular systolic function, such that clinical outcomes can be improved. 'Conditioning' the heart to harness its endogenous cardioprotective capabilities using either brief ischaemia or pharmacological agents, provides a potentially novel approach to myocardial protection during cardiac surgery, and is the subject of this review article.
Collapse
Affiliation(s)
- Vinod Venugopal
- The Hatter Cardiovascular Institute, University College London Hospital, 67 Chenies Mews, London WC1E 6HX, United Kingdom
| | | | | | | |
Collapse
|
20
|
Møller CH, Penninga L, Wetterslev J, Steinbrüchel DA, Gluud C. Clinical outcomes in randomized trials of off- vs. on-pump coronary artery bypass surgery: systematic review with meta-analyses and trial sequential analyses. Eur Heart J 2008; 29:2601-16. [PMID: 18628261 DOI: 10.1093/eurheartj/ehn335] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS To assess the clinical outcomes of off- vs. on-pump coronary artery bypass surgery in randomized trials. METHODS AND RESULTS We searched electronic databases and bibliographies until June 2007. Trials were assessed for risk of bias. Outcome measures were all-cause mortality, myocardial infarction, stroke, atrial fibrillation, and renewed coronary revascularization at maximum follow-up. We applied trial sequential analysis to estimate the strength of evidence. We found 66 randomized trials. There was no statistically significant differences regarding mortality [relative risk (RR) 0.98; 95% confidence interval (CI) 0.66-1.44], myocardial infarction (RR 0.95; 95% CI 0.65-1.37), or renewed coronary revascularization (RR 1.34; 95% CI 0.83-2.18). We found a significant reduced risk of atrial fibrillation (RR 0.69; 95% CI 0.57-0.83) and stroke (RR 0.53; 95% CI 0.31-0.91) in off-pump patients. However, when continuity correction for zero-event trials was included, the reduction in stroke became insignificant (RR 0.62; 95% CI 0.32-1.19). Trial sequential analysis demonstrated overwhelming evidence supporting that off-pump bypass surgery reduces atrial fibrillation. CONCLUSION Off-pump surgery reduces the risks of postoperative atrial fibrillation compared with on-pump surgery. For death, myocardial infarction, stroke, and renewed coronary revascularization, the evidence is still weak and more low-bias risk trials are needed.
Collapse
Affiliation(s)
- Christian H Møller
- Department of Cardio-Thoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | | | | | | | | |
Collapse
|
21
|
Chowdhury UK, Malik V, Yadav R, Seth S, Ramakrishnan L, Kalaivani M, Reddy SM, Subramaniam GK, Govindappa R, Kakani M. Myocardial injury in coronary artery bypass grafting: On-pump versus off-pump comparison by measuring high-sensitivity C-reactive protein, cardiac troponin I, heart-type fatty acid–binding protein, creatine kinase-MB, and myoglobin release. J Thorac Cardiovasc Surg 2008; 135:1110-9, 1119.e1-10. [DOI: 10.1016/j.jtcvs.2007.12.029] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2007] [Revised: 12/17/2007] [Accepted: 12/27/2007] [Indexed: 10/22/2022]
|
22
|
Raja SG, Dreyfus GD. Current Status of Off-Pump Coronary Artery Bypass Surgery. Asian Cardiovasc Thorac Ann 2008; 16:164-78. [DOI: 10.1177/021849230801600220] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
Collapse
|
23
|
Silva J, López-Farré AJ, Mateos-Cáceres PJ, González A, Maroto L, Macaya C, Rodríguez E. Proteomic pattern of plasma in off-pump coronary artery bypass surgery. Clin Chem Lab Med 2008; 46:1074-84. [DOI: 10.1515/cclm.2008.234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
24
|
Minimal Extracorporeal Circulation is a Promising Technique for Coronary Artery Bypass Grafting. Ann Thorac Surg 2007; 84:1515-20; discussion 1521. [DOI: 10.1016/j.athoracsur.2007.05.069] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2007] [Revised: 05/24/2007] [Accepted: 05/29/2007] [Indexed: 11/23/2022]
|
25
|
Paparella D, Cappabianca G, Malvindi P, Paramythiotis A, Galeone A, Veneziani N, Fondacone C, de Luca Tupputi Schinosa L. Myocardial injury after off-pump coronary artery bypass grafting operation. Eur J Cardiothorac Surg 2007; 32:481-7. [PMID: 17643993 DOI: 10.1016/j.ejcts.2007.06.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Revised: 05/29/2007] [Accepted: 06/14/2007] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Perioperative myocardial ischemia is less pronounced in off-pump coronary artery bypass (OPCAB) compared to on-pump coronary artery bypass; however, the threshold over which the postoperative release of cardiac troponin I (cTnI) release and creatine kinase-MB (CK-MB) after OPCAB should be considered clinically relevant is unknown. The study was designated to evaluate if perioperative myocardial damage, measured by means of postoperative release of cTnI and CK-MB, has an influence on short- and mid-term outcome after OPCAB operations. METHODS Two hundred and sixty-one unselected patients undergoing OPCAB had cTnI and CK-MB measured preoperatively and nine times postoperatively. Postoperative peak values were evaluated and the 80th percentiles were used to segregate the population into two groups for each marker. The following cut-offs were used: 7.1 ng/dl for cTnI peak and 36.3 ng/dl for CK-MB peak. RESULTS Patients with cTnI>7.1 ng/ml (n=51) and CK-MB>36.3 ng/ml (n=48) had a longer mechanical ventilation and ICU length of stay. Nevertheless, hospital mortality did not differ between groups. Survival after 3 years was 92.8+/-2.3% and 81.8+/-6.2 for patients with postoperative cTnI peak<or=7.1 ng/ml and >7.1 ng/ml, respectively (p=0.003). It was 93+/-2.2% and 80+/-6.8% for patients with CK-MB<or=36.3 ng/ml and >36.3 ng/ml, respectively (p=0.005). Adjusted hazard ratios for mid-term mortality were HR 2.7 (CI 1-7.6), p=0.05 for cTnI>7.1 ng/dl and HR 3.1 (CI 1-9.1), p=0.04 for CK-MB>36.3 ng/ml. CONCLUSION Perioperative myocardial damage should not be considered an innocuous event following OPCAB operations since the survival rate over 3 years is significantly worse in patients with the highest postoperative peak release of cTnI and CK-MB.
Collapse
Affiliation(s)
- Domenico Paparella
- Division of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Aron A, Klinger TA, McConnell TR. Cardiac rehabilitation outcomes no different after on-pump versus off-pump coronary artery bypass surgery. J Cardiopulm Rehabil Prev 2007; 27:35-41. [PMID: 17474642 DOI: 10.1097/01.hcr.0000265018.11037.1a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Clinical evidence supports lower morbidity with off-pump coronary revascularization surgery as well as superior short- and mid-term outcomes, equivalent graft patency, and reduced cost. The purpose of this study was to compare cardiac rehabilitation (CR) outcomes between patients undergoing on-pump versus off-pump coronary artery bypass surgery. METHODS Data were retrospectively examined for patients who participated in CR between 1996 and 2004. Two hundred ninety-five patients who underwent bypass surgery and completed at least 80% of their 36 required sessions were divided into on-pump and off-pump groups. Pre- and post-CR measures included grip strength, flexibility, energy expended during class, quality of life, and self-efficacy. RESULTS Both groups were similar with respect to age, sex, ejection fraction, and mean number of grafts. There were no statistical differences between the on-pump and off-pump groups (P > .05) for weight, abdominal and hip circumferences, grip strength, flexibility, and total energy expenditure. In addition, there were no between-group differences regarding quality of life and self-efficacy. Grip strength, flexibility, and energy expenditure during class improved with CR regardless of the surgical procedure (P = .001). Quality of life (P = .001) and self-efficacy (P = .001) also improved. CONCLUSIONS The present data support the concept that although there are clinical advantages to off-pump surgery, there is no benefit over on-pump surgery regarding CR. Subsequently, patients undergoing off-pump surgery should be managed similarly as their on-pump counterparts.
Collapse
Affiliation(s)
- Adrian Aron
- Department of Exercise Science and Athletics, Bloomsburg University, Bloomsburg, PA, USA.
| | | | | |
Collapse
|
27
|
Ozkara C, Guler N, Batyraliev T, Okut H, Agirbasli M. Does off-pump coronary artery bypass surgery reduce secretion of plasminogen activator inhibitor-1? Int J Clin Pract 2007; 61:763-7. [PMID: 17343662 DOI: 10.1111/j.1742-1241.2006.00952.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Prior studies showed that postoperative increase in plasminogen activator inhibitor-1 (PAI-1) levels is associated with an increased risk of graft occlusion after coronary artery bypass surgery (CABG). This prospective study aimed to compare the changes of PAI-1 antigen levels after off-pump and on-pump CABG. Forty-four patients admitted for elective CABG were randomised to on-pump (n=22) or off-pump (n=22) surgery. Serum samples were collected for estimation of PAI-1 and tissue plasminogen activator (t-PA) antigen levels preoperatively and 2 h after the operation. The groups were similar in terms of age, weight, gender ratio and extent of coronary disease, left ventricular function and number of grafts per patient. Fibrinogen and t-PA levels increased postoperatively in both the groups when compared with baseline values. After operation, statistical analysis revealed that increase of PAI-1 values was higher in off-pump group (44.1+/-9.1 vs. 25.3+/-6.9) than on-pump group (37.2+/-5.5 vs. 27.3+/-7.8, p=0.002). This study shows that increase in PAI-1 antigen values in patients who undergo off-pump (beating heart) CABG is significantly higher than in those who undergo conventional CABG with cardiopulmonary bypass.
Collapse
Affiliation(s)
- C Ozkara
- Department of Cardiovascular Surgery, Corlu Sifa Hospital, Tekirdag, and Department of Cardiology of Medical Faculty, Yuzuncu Yil University, Van, Turkey
| | | | | | | | | |
Collapse
|
28
|
Elahi MM, Khan JS. Revascularization with off-pump coronary artery surgery: what appears new is actually the old rediscovered. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2007; 8:52-9. [PMID: 17293269 DOI: 10.1016/j.carrev.2006.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2006] [Accepted: 09/12/2006] [Indexed: 10/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- Maqsood M Elahi
- Wessex Cardiothoracic Centre, General Hospital/BUPA, Southampton SO16 6YD, United Kingdom.
| | | |
Collapse
|
29
|
Di Stefano S, Casquero E, Bustamante R, Gualis J, Carrascal Y, Bustamante J, Fulquet E, Florez S, Echevarria JR, Fiz L. Plasma Troponins as Markers of Myocardial Damage during Cardiac Surgery with Extracorporeal Circulation. TOHOKU J EXP MED 2007; 213:63-9. [PMID: 17785954 DOI: 10.1620/tjem.213.63] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
All types of cardiac surgery involve considerable injury to the myocardium. However, it is difficult to differentiate, in the immediate post-operative state, between ischemic alterations associated with the cardiac surgery itself and the pathological alterations of a peri-operative myocardial infarction. The diagnosis of damaged myocardium, classically performed with the enzymatic markers creatine kinase (CK) and its muscle fraction (CK-MB), has become more precise with the option of measuring cardiac troponins T and I. We measured these markers in 58 patients undergoing elective cardiac surgery with extra-corporeal circulation (ECC). The patients included 37 cases undergoing valve surgery, 14 for coronary revascularization, 6 for mixed procedures, and 1 for closure of an inter-atrial communication. The markers were measured in plasma at baseline (at anesthesia initiation), 5 min post-ECC commencement, following aorta de-clamping, during the surgical closure, and 6, 18 and 42 hrs after surgery. All the markers were increased significantly relative to the baseline values. Troponin I, CK and CK-MB values peaked between 6 and 18 hrs after surgery, troponin T between 18 and 42 hrs, and myoglobin at the surgical closure. The values of all markers were higher in patients undergoing coronary surgery compared to those in patients undergoing valve surgery. In the evaluation of myocardial damage after surgery, the measurement of classical markers such as CK and myoglobin remain valid, but other markers such as troponins provide significant additional diagnostic benefit and, thus, need to be included in the routine biochemical measurements for monitoring myocardial damage associated with the surgical procedure.
Collapse
Affiliation(s)
- Salvatore Di Stefano
- Department of Cardiac Surgery, Heart Institute (ICICOR), Avenida Ramón y Cajal 3, 47005 Valladolid, Spain.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Elahi MM, Khan JS. Living with off-pump coronary artery surgery: evolution, development, and clinical potential for coronary heart disease patients. Heart Surg Forum 2006; 9:E630-7. [PMID: 16687345 DOI: 10.1532/hsf98.2006-1026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- Maqsood M Elahi
- Department of Cardiothoracic Surgery, Faculty of Medicine and Surgery (PIC), Lahore, Pakistan.
| | | |
Collapse
|
31
|
Sedrakyan A, Wu AW, Parashar A, Bass EB, Treasure T. Off-Pump Surgery Is Associated With Reduced Occurrence of Stroke and Other Morbidity as Compared With Traditional Coronary Artery Bypass Grafting. Stroke 2006; 37:2759-69. [PMID: 17008617 DOI: 10.1161/01.str.0000245081.52877.f2] [Citation(s) in RCA: 140] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
There is growing enthusiasm for coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB). Although deleterious effects of CPB are known, it remains to be proven that avoiding CPB will result in reduction in morbidity. We sought to determine whether off-pump surgery is associated with reduced occurrence of adverse outcomes as compared with CABG with CPB.
Methods—
Studies were identified by searching the MEDLINE, EMBASE and the Cochrane Register 1980 to 2006 (February). We also searched the reference lists of randomized clinical trials (RCT) and reviews to look for additional studies. Study selection: RCTs comparing off-pump surgery to CABG with CPB. No restriction applied on the size of the trial or end point reports. Data extraction: 2 reviewers independently searched for studies, read abstracts and abstracted all data. Data synthesis: combined estimates were obtained using fixed or random effect meta-analyses. Relative risks and risk differences were calculated. Heterogeneity was assessed using χ
2
and I
2
values.
Results—
There were 3996 patients enrolled in 41 RCTs (mean age 62, 22% female). No study reported information on race. Off-pump CABG was associated with a 50% reduction in the relative risk of stroke (95% CI, 7% to 73%), 30% reduction in atrial fibrillation (AF; 95% CI, 16% to 43%) and 48% reduction in wound infection (95% CI, 26% to 63%) with no heterogeneity among RCTs. This translated into avoidance of 10 strokes, 80 cases of AF and 40 infections per 1000 CABG. Fewer distal grafts were performed and there was evidence for >10 reinterventions per 1000 with off-pump CABG. Long-term follow-up is not yet reported in the trials.
Conclusions—
Off-pump CABG is associated with reduced risk of stroke, AF and infections as compared with CABG with CPB. Evidence should be generalized taking into account RCT enrollment limitations, drawbacks related to training requirements, propensity to perform fewer grafts and likely reinterventions after off-pump surgery.
Collapse
Affiliation(s)
- Artyom Sedrakyan
- Center for Outcomes and Evidence, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850, USA.
| | | | | | | | | |
Collapse
|
32
|
Guerin V, Ayed SB, Varnous S, Golmard JL, Leprince P, Beaudeux JL, Gandjbakhch I, Bernard M. Release of Brain Natriuretic-Related Peptides (BNP, NT-proBNP) and Cardiac Troponins (cTnT, cTnI) in On-pump and Off-pump Coronary Artery Bypass Surgery. Surg Today 2006; 36:783-9. [PMID: 16937281 DOI: 10.1007/s00595-006-3247-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2005] [Accepted: 05/16/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND We studied the kinetic release of cardiac troponins (cTnI and cTnT) and B-type natriuretic peptides (BNP and NT-proBNP) in patients undergoing off-pump or on-pump coronary artery bypass surgery. METHODS Twenty-five consecutive patients were prospectively enrolled. The patients were divided into three groups: beating heart (I), and cardiopulmonary bypass (CPB) with warm (II) or cold cardioplegia (III). Plasma samples were obtained before anesthesia induction until the sixth day after surgery. RESULTS AND CONCLUSIONS The data were analyzed first for off-pump versus the CPB procedures and second for warm versus cold cardioplegia. The plasma troponin releases appeared to be significantly higher in the CPB groups in comparison to the beating heart group (P < 0.001 and P < 0.002 for cTnI and cTnT peak values, respectively). The peak of the B-type natriuretic peptide release appeared to be more delayed in the groups undergoing CPB than in the beating heart group (day 6 versus days 2 and 4 for NT-proBNP and BNP, respectively). Taken together, our results indicated that the new generation of cTnT assays seemed to be more sensitive than the cTnI assays for the diagnosis of myocardium injury. A lower increase in the cTnT values in the warm cardioplegic group indicated less damage of the myocardium than with cold cardioplegia. Our data also confirm better preservation of the myocardium with off-pump cardiac surgery than with CPB.
Collapse
Affiliation(s)
- Valérie Guerin
- Department of Cardiothoracic Surgery, CHU Pitié-Salpêtrière, Pitié-Salpêtrière Hospital, AP-HP, 47-83 Boulevard de l'Hôpital, 75651 Paris, Cedex 13, France
| | | | | | | | | | | | | | | |
Collapse
|
33
|
Rastan AJ, Eckenstein JI, Hentschel B, Funkat AK, Gummert JF, Doll N, Walther T, Falk V, Mohr FW. Emergency Coronary Artery Bypass Graft Surgery for Acute Coronary Syndrome: Beating Heart Versus Conventional Cardioplegic Cardiac Arrest Strategies. Circulation 2006; 114:I477-85. [PMID: 16820622 DOI: 10.1161/circulationaha.105.001545] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aim of this study was to compare the outcome of beating heart versus conventional coronary artery bypass graft (CABG) strategies in acute coronary syndromes for emergency indications. METHODS AND RESULTS 638 consecutive patients with acute coronary syndrome (ACS) receiving emergency CABG surgery via midline sternotomy from January 2000 to September 2005 were evaluated. Propensity score analysis was used to predict the probability of undergoing beating heart (BH) (n=240) versus cardioplegic cardiac arrest (CA) (n=398) strategies. Patients presented with stable hemodynamics (n=531) or in cardiogenic shock (CS) (n=107). Hospital and follow-up outcome was compared by propensity score adjusted multiregression analysis. BH included 116 on-pump and 124 off-pump (OPCAB) procedures. There was a propensity to operate CS patients on the beating heart (multivariate odds ratio [OR], 3.8; P=0.001). Under stable hemodynamics significant predictors for BH selection were logEuroSCORE >20% (OR, 2.05), creatinine >1.8 mg/dL (OR, 4.12), complicated percutaneous coronary intervention (OR, 1.88), ejection fraction <30% (OR, 2.64), whereas left main disease (OR, 0.68), circumflex artery (OR, 0.32), and 3-vessel disease (OR, 0.67) indicated preference for cardioplegic arrest. Time from skin incision to culprit lesion revascularization was significantly reduced in BH patients. BH surgery led to a significant benefit in terms of less drainage loss, less transfusion requirement, less inotropic support, shorter ventilation time, lower stroke rate, and shorter intensive care unit stay. In CS, BH was associated with lower incidence of stroke, inotropic support, acute renal failure, new atrial fibrillation and sternal wound healing complications. In CS patients, hospital mortality rate was reduced when using beating heart strategies (P=0.048). Overall survival, major adverse cerebral and cardiovascular event rate, and repeated revascularization was comparable during a 5-year follow-up. CONCLUSIONS Beating heart strategies are associated with an improved hospital outcome and comparable long-term results for high-risk patients presenting acute coronary syndrome with or without CS.
Collapse
Affiliation(s)
- Ardawan Julian Rastan
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Struempellstr. 39, 04289 Leipzig, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Chen JS, Ko WJ, Yu HY, Lai LP, Huang SC, Chi NH, Tsai CH, Wang SS, Lin FY, Chen YS. Analysis of the outcome for patients experiencing myocardial infarction and cardiopulmonary resuscitation refractory to conventional therapies necessitating extracorporeal life support rescue*. Crit Care Med 2006; 34:950-7. [PMID: 16484889 DOI: 10.1097/01.ccm.0000206103.35460.1f] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To analyze the results of acute myocardial infarction (AMI) complicated with refractory shock necessitating extracorporeal life support (ECLS) rescue and to search for associated risk factors. DESIGN Retrospective review of our 9-yr experience with patients initially presenting with AMI with shock necessitating ECLS rescue; analysis of patient outcomes. SETTING A university-affiliated tertiary referral medical center. PATIENTS Between 1994 and 2003 inclusively, 36 consecutive patients (age [mean +/- sd], 57 +/- 10 yrs) with AMI complicated by refractory shock and undergoing cardiopulmonary resuscitation (CPR) necessitating emergent ECLS rescue were enrolled in this study. INTERVENTION All patients underwent CPR before ECLS, although 30 patients (83.3%) received ECLS during CPR because spontaneous circulation failed to return. All patients underwent intraaortic counterpulsation either before or following rescue. Seven patients underwent angioplasty only, and one underwent heart transplantation without any intervention. Twenty-eight patients underwent coronary artery bypass grafting (CABG), in which the beating-heart technique was used for 20 patients. MEASUREMENTS AND MAIN RESULTS The pre-ECLS blood lactate level was high (13.4 +/- 8.5 mmol/L), as was the inotropic score (121.4 +/- 117.3 microg/kg/min). Twenty-five patients (69.4%) were successfully weaned off ECLS, and 12 (48%) survived to discharge (one had a neurologic deficit). The overall mortality rate was 66.7%. A lower inotropic score, reduced blood lactate level, shorter CPR duration, surgical revascularization, and a reduced total maximal Sepsis-related Organ Failure Assessment (SOFA) score were noted among survivors. Liver failure, central nervous system failure, and renal failure mainly occurred in nonsurvivors after ECLS. The technique used for surgical revascularization (beating heart or arrested heart) did not influence the outcome. ECLS is associated with a lower mortality rate than that expected (>90%) from the resultant total maximal SOFA score (16.6 +/- 3.0). CONCLUSIONS : AMI complicated with refractory shock remains associated with a high mortality rate, even following ECLS rescue, although ECLS might afford a better chance of survival. The SOFA score can be applied to ECLS condition as a reference point for predicting outcome.
Collapse
Affiliation(s)
- Jer-Shen Chen
- Division of Cardiovascular Surgery, Cardiovascular Center, Far Eastern Memorial Hospital, Taipei, Taiwan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Brown JM, Poston RS, Gammie JS, Cardarelli MG, Schwartz K, Sikora JAH, Yi S, Pierson RN, Griffith BP. Off-Pump Versus On-Pump Coronary Artery Bypass Grafting in Consecutive Patients: Decision-Making Algorithm and Outcomes. Ann Thorac Surg 2006; 81:555-61; discussion 561. [PMID: 16427851 DOI: 10.1016/j.athoracsur.2005.06.081] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2004] [Revised: 06/27/2005] [Accepted: 06/28/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND Debate continues between on-pump or off-pump approach for coronary artery bypass grafting (CABG). We used off-pump coronary artery bypass grafting (OPCAB) as a tool within a decision-making algorithm driven by the patient-related factors of coronary anatomy and comorbidity. Our analysis presents this decision algorithm and describes outcomes using this approach. METHODS From January 2000 to December 2003, 592 consecutive patients undergoing isolated CABG were assigned by one surgeon to a technique: on-pump CABG or OPCAB according to (1) anatomy and (2) predicted risk. Anatomic factors against OPCAB were target vessel size less than 1.25 mm, calcification, poor quality, intramyocardial location, and multiple stenoses. Given that OPCAB could be performed safely, patients in the moderate risk range, ie, those elderly with multiple comorbidities, were preferentially treated using OPCAB. RESULTS The OPCAB group had higher predicted 30-day mortality compared with the on-pump CABG group, consistent with the protocol's intent. However, morbidity and mortality were similar between on-pump CABG and OPCAB. The OPCAB patients received the same number of internal mammary artery grafts but fewer distal grafts. Mortality and observed to expected ratios were favorable for both groups and below those The Society of Thoracic Surgeons' predicted for OPCAB. CONCLUSIONS Matching surgical strategy to patient-related factors and needs resulted in excellent outcomes. Our data support the use of a protocol based on patient characteristics to drive the surgeon's choice between an on-pump CABG or OPCAB approach. As such, OPCAB can be viewed as a tool to be used by the surgeon developing a best practice in treating coronary artery disease.
Collapse
Affiliation(s)
- James M Brown
- Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland 21201, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Monassier F, Mattei C, Gavra G, Dallemand R, Lallemant P, Olteane C, Semenescu A, Durasnel P, Monassier JP, Bischoff N. [Off-pump coronary artery bypass: analysis of 1080 patients]. Ann Cardiol Angeiol (Paris) 2005; 54:299-304. [PMID: 17183823 DOI: 10.1016/j.ancard.2005.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
A consecutive cohort including 1080 patients undergoing "off-pump" myocardial revascularization was reviewed. An average of 2.22 bypass/patients was performed. The death-rate during the first 30 days after surgery was 0.65%. Four cases needed cross-over to on-pump. The postoperative events were: need of inotropic drugs (2.7%), atrial fibrillation (12.4%), myocardial infarction (6.6%). The extubation was performed before the first postoperative 24 h in 91.9% of cases. The majority of patients was discharged from hospital before 8 days after surgery. Off pump coronary artery bypass surgery exhibit good results for most of the patients even if they present multiple vessel disease and high operating risk.
Collapse
Affiliation(s)
- F Monassier
- Service de chirurgie cardiovasculaire, UF 3321, CHU de Strasbourg, 1, place de l'hôpital, 67000 Strasbourg, France.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Wijeysundera DN, Beattie WS, Djaiani G, Rao V, Borger MA, Karkouti K, Cusimano RJ. Off-Pump Coronary Artery Surgery for Reducing Mortality and Morbidity. J Am Coll Cardiol 2005; 46:872-82. [PMID: 16139139 DOI: 10.1016/j.jacc.2005.05.064] [Citation(s) in RCA: 160] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2005] [Revised: 05/15/2005] [Accepted: 05/31/2005] [Indexed: 10/25/2022]
Abstract
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.
Collapse
|