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Bassano C, Nardi P, Buioni D, Asta L, Pisano C, Bertoldo F, Altieri C, Ruvolo G. Long-Term Follow-Up of Device-Assisted Clampless Off-Pump Coronary Artery Bypass Grafting Compared with Conventional On-Pump Technique. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:275. [PMID: 35010535 PMCID: PMC8750984 DOI: 10.3390/ijerph19010275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/20/2021] [Accepted: 12/25/2021] [Indexed: 06/14/2023]
Abstract
STUDY OBJECTIVE To evaluate the long-term outcomes of clampless off-pump coronary artery bypass grafting (C-OPCAB) compared with conventional on-pump double clamping coronary artery bypass grafting (C-CABG). METHODS From October 2006 to December 2011, 366 patients underwent isolated coronary artery bypass grafting. After propensity score matching of preoperative variables, 143 pairs were selected who received C-OPCAB with the use of device-assisted PAS-Port proximal venous graft anastomoses or C-CABG, performed by the same surgeon experienced in both techniques. Data of the two groups of patients were retrospectively analyzed up to 14 years of follow-up. RESULTS As compared with C-OPCAB, in the C-CABG patients, the performed number of grafts per patient was higher (2.9 ± 0.5 vs. 2.6 ± 0.6, p-value 0.0001). At 14 years, overall survival, including in-hospital death, was 64 ± 4.7% for the C-OPCAB vs. 55 ± 5.5% for the C-CABG, freedom from overall MACCEs 51 ± 6.2% vs. 41 ± 7.7%, and from late cardiac death 94 ± 2.4% vs. 96 ± 2.2% (p-value not significant, for all comparisons). No significant statistical differences were observed in the actual rates of adverse events during follow-up. Independent predictors of survival were advanced age at operation (p-value 0.001) and a lower mean value of preoperative left ventricular ejection fraction (p-value 0.015). CONCLUSIONS Our single-center study analysis suggests that clampless OPCAB using device-assisted proximal anastomoses proved to be not inferior to double-clamping CABG in the long-term follow-up, provided that involved surgeons are familiar with both techniques. These conclusions are supported by a large and long-term follow-up period, eliminating potential bias, i.e., by means of the propensity score matching and analyzing single-surgeon experience.
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2
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Seese L, Sultan I, Wang Y, Navid F, Kilic A. Off‐pump coronary artery bypass surgery lacks a longitudinal survival advantage in patients with left ventricular dysfunction. J Card Surg 2020; 35:1793-1801. [DOI: 10.1111/jocs.14688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Laura Seese
- Division of Cardiac Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Yisi Wang
- Division of Cardiac Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Forozan Navid
- Division of Cardiac Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Arman Kilic
- Division of Cardiac Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
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3
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Kirmani BH, Guo H, Ahmadyur O, Bittar MN. Long-term survival following on-pump and off-pump coronary artery bypass graft surgery: a propensity score-matched analysis. Eur J Cardiothorac Surg 2019; 56:1147-1153. [PMID: 31740974 DOI: 10.1093/ejcts/ezz250] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 08/01/2019] [Accepted: 08/19/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Recent studies have once again brought into focus the long-term survival following off-pump coronary artery bypass grafting (OPCAB) compared with conventional on-pump coronary artery bypass grafting surgery (ONCAB). The aim of this study was to compare the long-term risk-adjusted survival rates in patients undergoing coronary artery bypass grafting (CABG) using these 2 techniques. METHODS We undertook a propensity score-matched analysis of 10 293 patients who underwent CABG at our single institution between 2000 and 2016. A logistic regression model was fitted using 14 covariates and their 2-way interactions to calculate an estimated propensity score [area under curve (AUC) 0.69], from which 1:1 nearest neighbour matching was performed. Patient survival was assessed using the Kaplan-Meier method and log-rank test. RESULTS Of the total cohort, 8319 patients had ONCAB and 1974 had OPCAB. Prior to matching, the OPCAB group had marginally higher EuroSCORE [3.7 ± 2.7 vs 3.5 ± 3, median (interquartile range) 3 (2-5) vs 3 (2-5), P = 0.016] and significantly lower average number of grafts per patient (2.39 ± 0.72 vs 2.75 ± 0.48, P < 0.001). Post-matching distributions between OPCAB and ONCAB showed a substantial improvement in balance in preoperative patient characteristics. The 2 surgery groups differed significantly in survival (P < 0.001). OPCAB demonstrated improved long-term survival at 10 years [84.8%, 95% confidence interval (CI) (82.7-86.9%) vs 75.8%, 95% CI (73.4-78.2%)] and 15 years [65.4%, 95% CI (61.4-69.6%) vs 58.5%, 95% CI (54.9-62.3%)]. Results of sensitivity analysis for 1:2 and 1:3 matched data were in concordance with these findings of survival. CONCLUSION At our institution, selected patients who underwent OPCAB had lower in-hospital morbidity and improved long-term survival when compared with a matched population of ONCAB patients.
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Affiliation(s)
- Bilal H Kirmani
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Hui Guo
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester, UK
| | - Omaid Ahmadyur
- School of Medicine, University of Manchester, Manchester, UK
| | - Mohamad N Bittar
- Department of Cardiothoracic Surgery, Blackpool Victoria Hospital, Blackpool, UK
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4
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Parmeshwar N, Fero KE, Manecke G, Coletta JM. Off-Pump Versus On-Pump: Long-Term Outcomes After Coronary Artery Bypass in a Veteran Population. J Cardiothorac Vasc Anesth 2019; 33:1187-1194. [DOI: 10.1053/j.jvca.2018.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Indexed: 11/11/2022]
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5
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Gaudino M, Angelini GD, Antoniades C, Bakaeen F, Benedetto U, Calafiore AM, Di Franco A, Di Mauro M, Fremes SE, Girardi LN, Glineur D, Grau J, He G, Patrono C, Puskas JD, Ruel M, Schwann TA, Tam DY, Tatoulis J, Tranbaugh R, Vallely M, Zenati MA, Mack M, Taggart DP. Off-Pump Coronary Artery Bypass Grafting: 30 Years of Debate. J Am Heart Assoc 2018; 7:e009934. [PMID: 30369328 PMCID: PMC6201399 DOI: 10.1161/jaha.118.009934] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Mario Gaudino
- Department of Cardio‐Thoracic SurgeryWeill Cornell MedicineNew York CityNY
| | | | | | | | | | | | - Antonino Di Franco
- Department of Cardio‐Thoracic SurgeryWeill Cornell MedicineNew York CityNY
| | | | - Stephen E. Fremes
- Schulich Heart CentreSunnybrook Health ScienceUniversity of TorontoCanada
| | - Leonard N. Girardi
- Department of Cardio‐Thoracic SurgeryWeill Cornell MedicineNew York CityNY
| | - David Glineur
- Division of Cardiac SurgeryOttawa Heart InstituteOttawaCanada
| | - Juan Grau
- Division of Cardiac SurgeryOttawa Heart InstituteOttawaCanada
| | - Guo‐Wei He
- TEDA International Cardiovascular HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeTianjinChina
| | - Carlo Patrono
- Department of PharmacologyCatholic University School of MedicineRomeItaly
| | - John D. Puskas
- Department of Cardiovascular SurgeryIcahn School of Medicine at Mount SinaiNew York CityNY
| | - Marc Ruel
- University of Ottawa Heart InstituteOttawaCanada
| | | | - Derrick Y. Tam
- Schulich Heart CentreSunnybrook Health ScienceUniversity of TorontoCanada
| | - James Tatoulis
- Department of SurgeryUniversity of MelbourneParkvilleAustralia
| | - Robert Tranbaugh
- Department of Cardio‐Thoracic SurgeryWeill Cornell MedicineNew York CityNY
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6
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Filardo G, Hamman BL, da Graca B, Sass DM, Machala NJ, Ismail S, Pollock BD, Collinsworth AW, Grayburn PA. Efficacy and effectiveness of on- versus off-pump coronary artery bypass grafting: A meta-analysis of mortality and survival. J Thorac Cardiovasc Surg 2017; 155:172-179.e5. [PMID: 28958597 DOI: 10.1016/j.jtcvs.2017.08.026] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 07/24/2017] [Accepted: 08/09/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Despite many studies comparing on- versus off-pump coronary artery bypass graft (CABG), there is no consensus as to whether one of these techniques offers patients better outcomes. METHODS We searched PubMed from inception to June 30, 2015, and identified additional studies from bibliographies of meta-analyses and reviews. We identified 42 randomized controlled trials (RCTs) and 31 rigorously adjusted observational studies (controlling for the Society of Thoracic Surgeons-recognized risk factors for mortality) reporting mortality for off-pump versus on-pump CABG at specified time points. Trial data were extracted independently by 2 researchers using a standardized form. Differences in probability of mortality (DPM) were estimated for the RCTs and observational studies separately and combined, for time points ranging from 30 days to 10 years. RESULTS RCT-only data showed no significant differences at any time point, whereas observational-only data and the combined analysis showed short-term mortality favored off-pump CABG (n = 1.2 million patients; 36 RCTs, 26 observational studies; DPM [95% confidence interval (CI)], -44.8% [-45.4%, -43.8%]) but that at 5 years it was associated with significantly greater mortality (n = 60,405 patients; 3 RCTs, 5 observational studies; DPM [95% CI], 10.0% [5.0%, 15.0%]). At 10 years, only observational data were available, and off-pump CABG showed significantly greater mortality (DPM [95% CI], 14.0% [11.0%, 17.0%]). CONCLUSIONS Evidence from RCTs showed no differences between the techniques, whereas rigorously adjusted observational studies (with >1.1 million patients) and the combined analysis indicated that off-pump CABG offers lower short-term mortality but poorer long-term survival. These results suggest that, in real-world settings, greater operative safety with off-pump CABG comes at the expense of lasting survival gains.
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Affiliation(s)
- Giovanni Filardo
- Department of Epidemiology, Baylor Scott & White Health, Dallas, Tex; Robbins Institute for Health Policy and Research, Baylor University, Waco, Tex; Department of Statistics, Southern Methodist University, Dallas, Tex.
| | - Baron L Hamman
- Department of Cardiothoracic Surgery, Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Tex
| | - Briget da Graca
- Center for Clinical Effectiveness, Baylor Scott & White Health, Dallas, Tex; Robbins Institute for Health Policy and Research, Baylor University, Waco, Tex
| | - Danielle M Sass
- Department of Epidemiology, Baylor Scott & White Health, Dallas, Tex
| | - Natalie J Machala
- Department of Epidemiology, Baylor Scott & White Health, Dallas, Tex
| | - Safiyah Ismail
- Department of Epidemiology, Baylor Scott & White Health, Dallas, Tex
| | - Benjamin D Pollock
- Department of Epidemiology, Baylor Scott & White Health, Dallas, Tex; Robbins Institute for Health Policy and Research, Baylor University, Waco, Tex
| | - Ashley W Collinsworth
- Center for Clinical Effectiveness, Baylor Scott & White Health, Dallas, Tex; Robbins Institute for Health Policy and Research, Baylor University, Waco, Tex
| | - Paul A Grayburn
- Department of Cardiology, Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Tex
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7
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Miao N, Yang F, Du Z, Jiang C, Hao X, Wang J, Jiang Y, Yang X, Xie H, Hou X. Mortality risk factors from converting off-pump coronary artery bypass to on-pump coronary artery bypass. Perfusion 2017; 32:554-560. [PMID: 28425317 DOI: 10.1177/0267659117705193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: A number of large-scale retrospective studies revealed that off-pump coronary artery bypass (OPCAB) was superior to on-pump coronary artery bypass (ONCAB). The aim of the study was to investigate risk factors for mortality when OPCAB is converted to ONCAB. Methods: Patients who underwent OPCAB conversion to ONCAB at the Beijing Anzhen Hospital between January 2003 and January 2013 were assigned to the non-survivor and survivor groups. Background demographics, illness history and preoperative, intraoperative and postoperative variables were compared. Results: Of the 247 cases, 15.4% of the patients died. Patients in the non-survivor group were older and more frequently had diabetes mellitus (DM), arrhythmia, myocardial infarction (MI) in the past 30 days (all p<0.05) and MI combined with mitral regurgitation (p<0.0001); they more frequently had bigger left ventricular end-diastolic dimension (p=0.0019), greater fall in blood pressure, ventricular fibrillation for longer periods, longer conversion time and bypass graft occlusion. All patients in the non-survivor group received intra-aortic balloon pump compared to 89.5% in the survivor group and extracorporeal membrane oxygenation was more common. Left main coronary artery disease (OR=4.431, 95%CI: 2.440-8.048, p<0.0001), blood pressure decline ⩽40 mmHg (OR=0.509, 95%CI: 0.447-0.580, p<0.0001) and time for conversion to ONCAB ⩾20 min were independently associated with mortality. Rates of postoperative complications, such as renal failure, cerebral infarction or hemorrhage, MI and redo sternotomy, were higher in the non-survivor group. Conclusions: Conversion from OPCAB to ONCAB is associated with high mortality. Risk factors include left main artery disease and duration of blood pressure decline >40 min.
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Affiliation(s)
- Na Miao
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Feng Yang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Zhongtao Du
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Chunjing Jiang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Xing Hao
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Jinhong Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Yu Jiang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Xiaofang Yang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Haixiu Xie
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
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Chivasso P, Guida GA, Fudulu D, Bruno VD, Marsico R, Sedmakov H, Zakkar M, Rapetto F, Bryan AJ, Angelini GD. Impact of off-pump coronary artery bypass grafting on survival: current best available evidence. J Thorac Dis 2016; 8:S808-S817. [PMID: 27942399 DOI: 10.21037/jtd.2016.10.13] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The superiority of either off-pump (OPCAB) or on-pump (ONCAB) coronary artery bypass grafting (CABG) remains unclear despite a large body of literature evidence comparing the two approaches. The potential advantages of avoiding cardiopulmonary bypass (CPB), minimizing aortic manipulation and maintaining pulsatile flow may be associated with reduced inflammatory responses and embolic events. Numerous studies compared OPCAB with ONCAB and the cumulative data have been presented in meta-analyses of both randomized and observational studies. Although there is an abundance of data with respect to the operative morbidity and mortality and the short-term outcomes associated with these two strategies, not much is known about how they impact long-term survival and recurrence of myocardial ischaemic events. Recent studies and meta-analyses have focused on long-term survival and major secondary outcomes in OPCAB vs. ONCAB within the general population. Significant limitations in methodology, however, have raised concerns about the strength of several randomized trials with restrictive inclusion criteria that reduced the populations to those at low risk only, thus creating result bias. Here, we present a review of the best available evidence with a focus on long-term outcomes.
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Affiliation(s)
- Pierpaolo Chivasso
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Gustavo A Guida
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Daniel Fudulu
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Vito D Bruno
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Roberto Marsico
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Hristo Sedmakov
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Mustafa Zakkar
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Filippo Rapetto
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Alan J Bryan
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Gianni D Angelini
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
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9
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Kirmani BH, Holmes MV, Muir AD. Long-Term Survival and Freedom From Reintervention After Off-Pump Coronary Artery Bypass Grafting. Circulation 2016; 134:1209-1220. [PMID: 27777290 DOI: 10.1161/circulationaha.116.021933] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 09/13/2016] [Indexed: 01/21/2023]
Abstract
Background:
The long-term outcomes of off-pump coronary artery bypass grafting (CABG) are the subject of speculation. Our institution has >15 years of experience performing CABG both off-pump (OPCAB) and on cardiopulmonary bypass (CPB). Our null hypothesis was that there would be no difference in a long-term composite of death and revascularisation between the 2 methods.
Methods:
We performed a retrospective cohort study of all isolated CABG at our institution from 2001 to 2015. We used an intention-to-treat analysis, performing risk adjustment with adjustment for and matching to propensity score. In total, 13 226 patients had CABG: 5882 had OPCAB and 7344 had CPB, with a median follow-up of 6.2 years.
Results:
Of the 5882 OPCAB, 76 (1.3%) converted to CPB. One-, 5-, and 10-year survivals in each group were similar (OPCAB vs CPB: 96.7%, 87.9%, 72.1% vs 96.2%, 87.4%, 72.8%). No difference was found in long-term survival (adjusted hazards ratio [HR] 1.03; 95% confidence interval [CI]: 0.94–1.11 for OPCAB vs CPB;
P
=0.56) or freedom from death and reintervention (HR 0.98; 95% CI: 0.92–1.06 for OPCAB vs CPB;
P
=0.23). Patients receiving OPCAB had higher EuroSCOREs (median [quartiles]: 2.81 [1.53–5.57] vs 2.73 [1.51–5.22];
P
=0.01), fewer grafts (mean±SD: 3.0±0.9 vs 3.3±0.9;
P
<0.001), but more total arterial grafting (45.9% vs 8.4%;
P
<0.001). OPCAB also had more trainee first operators (15.3% vs 12.5%), lower cardiac enzyme rise, shorter length of stay, and fewer complications (such as myocardial infarction).
Conclusions:
OPCAB is associated with similar long-term outcomes to CABG performed on CPB in our institution. Our low conversion rate to CPB, while training junior surgeons, demonstrates that OPCAB can be taught safely. The number of grafts performed between the 2 approaches is clinically comparable, if statistically different, and appears to provide equal benefits to survival and freedom from reintervention as on-pump CABG.
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Affiliation(s)
- Bilal H Kirmani
- From the Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, United Kingdom (B.H.K., A.D.M.); MRC Population Health Research Unit, Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom (M.V.H.); and Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom (M.V.H.).
| | - Michael V Holmes
- From the Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, United Kingdom (B.H.K., A.D.M.); MRC Population Health Research Unit, Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom (M.V.H.); and Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom (M.V.H.)
| | - Andrew D Muir
- From the Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, United Kingdom (B.H.K., A.D.M.); MRC Population Health Research Unit, Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom (M.V.H.); and Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom (M.V.H.)
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10
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Yuan SM, Li Y, Ben YH, Cheng XF, Li DZ, Li DM, Jing H. Graft pathology at the time of harvest: impact on long-term survival. Braz J Cardiovasc Surg 2015; 29:543-51. [PMID: 25714207 PMCID: PMC4408816 DOI: 10.5935/1678-9741.20140118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 10/12/2014] [Indexed: 12/02/2022] Open
Abstract
Objective This study aims to present the graft pathology at the time of harvest and its
impact on long-term survival. Methods The remnants of the bypass grafts from 66 consecutive patients with coronary
artery disease receiving a coronary artery bypass grafting were investigated
pathologically, and pertinent predictive risk factors and survival were
analyzed. Results Medial degenerative changes with or without intimal proliferation were present in
36.8%, 37.8% and 35.6% of left internal mammary artery (IMA), radial artery and
saphenous vein grafts. There were 2 (3.0%) hospital deaths and 9 (14.1%) late
deaths. Multinomial logistic regression revealed left IMA pathological changes,
dyslipidemia, history of percutaneous transluminal coronary angioplasty/stent
deployment and Y-graft were significant predictive risk factors negatively
influencing the patients’ long-term survival. Kaplan-Meier survival analysis
revealed that the long-term survival of patients with left IMA pathological
changes were significantly reduced compared with those without (74.1% vs. 91.4%,
P=0.002); whereas no differences were noted in long-term
survivals between patients with and without pathological changes of the radial
arterial or saphenous vein grafts. Conclusion Pathological changes may be seen in the bypass graft at the time of harvest. The
subtle ultrastructural modifications and the expressions of vascular tone
regulators might be responsible for late graft patency. The pathological changes
of the left IMA at the time of harvest rather than those of the radial artery or
saphenous vein graft affect significantly longterm survival. Non-traumatic
maneuver of left IMA harvest, well-controlled dyslipidemia and avoidance of using
composite grafts can be helpful in maintaining the architecture of the grafts.
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Affiliation(s)
- Shi-Min Yuan
- The First Hospital of Putian, Teaching Hospital, Fujian Medical University, Putian, People's Republic of China
| | - Yun Li
- Department of Thoracic Surgery, Provincial Hospital Affiliated, Shandong University, Ji'nan, Shandong Province, People's Republic of China
| | - Yan Hong Ben
- Jinling Hospital, School of Clinical Medicine, Nanjing University, Jiangsu Province, People's Republic of China
| | - Xiao Feng Cheng
- Jinling Hospital, School of Clinical Medicine, Nanjing University, Jiangsu Province, People's Republic of China
| | - Da Zhu Li
- First Department of Surgery, Fourth People's Hospital of Lu'an, Lu'an, Anhui Province, People's Republic of China
| | - De Min Li
- Jinling Hospital, School of Clinical Medicine, Nanjing University, Jiangsu Province, People's Republic of China
| | - Hua Jing
- Jinling Hospital, School of Clinical Medicine, Nanjing University, Jiangsu Province, People's Republic of China
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11
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Long Term Changes in Echocardiography Findings After On-Pump and Off-Pump Coronary Artery Bypass Grafting; A Historical Cohort Study. RAZAVI INTERNATIONAL JOURNAL OF MEDICINE 2015. [DOI: 10.5812/rijm.25054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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12
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Cohn WE, Frazier OH, Mallidi HR, Cooley DA. Surgical Treatment of Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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13
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Men JL, Ren J, Ma R, Wang ZX. High Level of von Willebrand Factor in Non-ST Segment Elevation Myocardial Infarction Patients Predicted Cardiovascular Ischemic Events After Off-Pump Coronary Artery Bypass Surgery. Int Heart J 2015; 56:298-302. [DOI: 10.1536/ihj.14-138] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Jian-Long Men
- Medical Laboratory, Tianjin Medical University General Hospital
| | - Jing Ren
- Medical Laboratory, Tianjin Medical University General Hospital
| | - Rui Ma
- Medical Laboratory, Tianjin Medical University General Hospital
| | - Zan-Xin Wang
- Department of Cardiovascular Surgery, Tianjin Medical University General Hospital
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14
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Takagi H, Umemoto T. Worse long-term survival after off-pump than on-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg 2014; 148:1820-9. [DOI: 10.1016/j.jtcvs.2014.05.034] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/06/2014] [Accepted: 05/16/2014] [Indexed: 11/16/2022]
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Parissis H, Ramesh BC, Al-Alao B. Off-pump coronary surgery: current justifications. Gen Thorac Cardiovasc Surg 2014; 62:660-70. [PMID: 25208659 DOI: 10.1007/s11748-014-0470-2] [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] [Received: 02/16/2014] [Accepted: 09/01/2014] [Indexed: 11/25/2022]
Abstract
Although the literature has failed to project an overall superiority of off-pump vs. on-pump surgery, nevertheless, small randomized control trials and large meta-analysis studies have concluded that the incidence of a stroke is less than 1 % when anaortic off-pump techniques are advocated in patients with diseased ascending aorta. Furthermore, off-pump techniques or their combination with hybrid procedures may lead to a reduction of adverse outcome in the aged high-risk population with concomitant poor left ventricular function and co-morbidities. However, despite this, controversy still exists among the cardiac surgery community in terms of the benefit of this technique and its safety; hence, off-pump is becoming out of fashion. In this review paper, by looking at a "marginal group of patients" (elderly, high risks, atherosclerotic aortas) we attempt to re-establish and justify this technique and re-invent its usage.
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Affiliation(s)
- Haralabos Parissis
- Cardiothoracic Department, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK,
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16
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Off-Pump Versus On-Pump Coronary Revascularization: Meta-Analysis of Mid- and Long-Term Outcomes. Ann Thorac Surg 2014; 98:563-72. [DOI: 10.1016/j.athoracsur.2014.05.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 05/01/2014] [Accepted: 05/05/2014] [Indexed: 02/08/2023]
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17
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Nardi P, Pellegrino A, Bassano C, Mani R, Chiariello GA, Zeitani J, Chiariello L. The fate at mid-term follow-up of the on-pump vs. off-pump coronary artery bypass grafting surgery. J Cardiovasc Med (Hagerstown) 2014; 16:125-33. [PMID: 25022926 DOI: 10.2459/jcm.0000000000000041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS To evaluate the fate of on-pump coronary artery bypass grafting (ON-pump CABG) vs. off-pump coronary artery bypass grafting (OP-CABG) surgery at mid-term follow-up. METHODS From January 2008 to December 2010, 369 patients underwent surgical myocardial revascularization by means of OP-CABG techniques (n = 166) or with ON-pump CABG (n = 203). Data of the two groups of patients were retrospectively analyzed. RESULTS As compared with OP-CABG, in the ON-pump CABG patients, mean value of Logistic EuroSCORE (8.1 ± 7.8% vs. 6.2 ± 5.9%, P = 0.04), more extended coronary disease (2.7 ± 0.5 vs. 2.5 ± 0.7 diseased vessels/patient, P < 0.001) consequently requiring greater number of grafts/patient (2.9 ± 0.9 vs. 2.3 ± 0.9, P < 0.0001), and emergency surgery (12 vs. 6%, P = 0.03) were more frequently observed. Operative mortality was 1.9% in ON-pump CABG vs. 1.2% in OP-CABG (P = 0.6) and incidence of stroke 2.46 vs. 1.81% (P = 0.7). The incidence of stroke was reduced at 1.2% when OP-CABG PAS-Port 'clamp-less' technique was used.Intraoperatively, costs per patient were higher for OP-CABG vs. ON-pump CABG (1.930,00 +1.050,00 €, if PAS-port system was included, vs. 1.060,00 € for ON-pump surgery). ICU stay (1.9 ± 1.0 days vs. 1.4 ± 0.7 days) and total postoperative in-hospital stay (5.3 ± 3.3 days vs. 5.5 ± 3.5 days) were similar in both groups.At 4 years, survival (91 ± 13% in the ON-pump CABG vs. 84 ± 19% in the OP-CABG), freedom from major adverse cardiac events (composite end-point of all-cause death, myocardial infarction, and repeat coronary revascularization of the target lesion) (82 ± 9% vs. 76 ± 14%), and major adverse cardiac and cerebrovascular events (80 ± 11% vs. 72 ± 16%) were not significantly different. Freedom from late cardiac death was slightly significant higher after ON-pump CABG (98 ± 4% vs. 90 ± 10%, P = 0.05). CONCLUSION Mid-term freedom from composite end-points is similar after ON-pump CABG and OP-CABG. Freedom from cardiac death appears to be better after ON-pump CABG. OP-CABG needs for more expensive surgical technique. OP-CABG performed by an experienced surgical team using 'clamp-less' techniques can be an effective strategy in reducing postoperative stroke.
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Affiliation(s)
- Paolo Nardi
- Cardiac Surgery Unit, Policlinico Tor Vergata, Tor Vergata University of Rome, Rome, Italy
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18
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Kim JB, Yun SC, Lim JW, Hwang SK, Jung SH, Song H, Chung CH, Lee JW, Choo SJ. Long-Term Survival Following Coronary Artery Bypass Grafting. J Am Coll Cardiol 2014; 63:2280-8. [DOI: 10.1016/j.jacc.2014.02.584] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 02/25/2014] [Indexed: 10/25/2022]
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Head SJ, Börgermann J, Osnabrugge RLJ, Kieser TM, Falk V, Taggart DP, Puskas JD, Gummert JF, Kappetein AP. Coronary artery bypass grafting: Part 2--optimizing outcomes and future prospects. Eur Heart J 2014; 34:2873-86. [PMID: 24086086 DOI: 10.1093/eurheartj/eht284] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Since first introduced in the mid-1960s, coronary artery bypass grafting (CABG) has become the standard of care for patients with coronary artery disease. Surprisingly, the fundamental surgical technique itself did not change much over time. Nevertheless, outcomes after CABG have dramatically improved over the first 50 years. Randomized trials comparing percutaneous coronary intervention (PCI) to CABG have shown converging outcomes for select patient populations, providing more evidence for wider use of PCI. It is increasingly important to focus on the optimization of the short- and long-term outcomes of CABG and to reduce the level of invasiveness of this procedure. This review provides an overview on how new techniques and widespread consideration of evolving strategies have the potential to optimize outcomes after CABG. Such developments include off-pump CABG, clampless/anaortic CABG, minimally invasive CABG with or without extending to hybrid procedures, arterial revascularization, endoscopic vein harvesting, intraprocedural epiaortic scanning, graft flow assessment, and improved secondary prevention measures. In addition, this review represents a framework for future studies by summarizing the areas that need more rigorous clinical (randomized) evaluation.
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Affiliation(s)
- Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, PO Box 2040, 3000 CA Rotterdam, The Netherlands
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20
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Chaudhry UAR, Rao C, Harling L, Athanasiou T. Does off-pump coronary artery bypass graft surgery have a beneficial effect on long-term mortality and morbidity compared with on-pump coronary artery bypass graft surgery? Interact Cardiovasc Thorac Surg 2014; 19:149-59. [PMID: 24659552 DOI: 10.1093/icvts/ivu075] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether off-pump coronary artery bypass grafting (CABG) surgery offered superior long-term outcomes compared with on-pump CABG surgery. Best evidence papers were considered to be those that had a follow-up period of ≥5 years, had >50 patients in either cohort, did not utilize concomitant interventions nor comprised low-risk, high-risk or sub-population groups. Where potential duplicate data sets from the same institution were likely, the more credible and recently published study was included. Two hundred and fifty-six papers were found as a result of the reported search, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The 16 studies comprised 4 prospective randomized controlled trials (RCTs), with the remaining 12 retrospective, of which 8 were propensity-score matched. All 4 RCTs contained fewer than 450 participants. Two studies concluded with a survival advantage towards on-pump CABG: one, a large registry-based study, the Veterans Affairs, with >25 000 patients, and another, a propensity-matched retrospective study involving almost 8000 patients. The remaining 14 studies all provided evidence to suggest comparable long-term survival. In addition, all other long-term outcomes mentioned within these studies including angina recurrence, myocardial infarction heart failure, need for revascularization, stroke, graft patency, cognitive and quality of life showed similar results between the two groups. We conclude that off-pump CABG surgery may have similar or slightly reduced long-term survival compared with on-pump CABG surgery. Other long-term indicators such as cardiovascular or cerebrovascular events or neuro-psychological outcomes were similar between the two groups. Despite these conclusions, the evidence is limited by substantial variability in patient selection and study methods. The CORONARY (coronary artery bypass surgery off- or on-pump revascularization study) trial recently presented results, which showed no significant differences in composite outcomes at 1 year; it will be interesting to observe whether these comparable outcomes are maintained for a much longer time frame.
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Affiliation(s)
- Umar A R Chaudhry
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
| | - Christopher Rao
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
| | - Leanne Harling
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
| | - Thanos Athanasiou
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
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21
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Navia D, Vrancic M, Piccinini F, Camporrotondo M, Thierer J, Gil C, Benzadon M. Is the second internal thoracic artery better than the radial artery in total arterial off-pump coronary artery bypass grafting? A propensity score–matched follow-up study. J Thorac Cardiovasc Surg 2014; 147:632-8. [DOI: 10.1016/j.jtcvs.2013.02.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 11/14/2012] [Accepted: 02/12/2013] [Indexed: 01/21/2023]
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Invited commentary. Ann Thorac Surg 2013; 96:2060. [PMID: 24296180 DOI: 10.1016/j.athoracsur.2013.08.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 08/15/2013] [Accepted: 08/19/2013] [Indexed: 11/20/2022]
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23
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Dalén M, Ivert T, Holzmann MJ, Sartipy U. Long-Term Survival After Off-Pump Coronary Artery Bypass Surgery: A Swedish Nationwide Cohort Study. Ann Thorac Surg 2013; 96:2054-60. [DOI: 10.1016/j.athoracsur.2013.07.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 07/02/2013] [Accepted: 07/02/2013] [Indexed: 11/28/2022]
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Affiliation(s)
- Harold L. Lazar
- From the Department of Cardiothoracic Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA
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25
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Bakaeen FG, Chu D, Kelly RF, Ward HB, Jessen ME, Chen GJ, Petersen NJ, Holman WL. Performing coronary artery bypass grafting off-pump may compromise long-term survival in a veteran population. Ann Thorac Surg 2013; 95:1952-8; discussion 1959-60. [PMID: 23647861 DOI: 10.1016/j.athoracsur.2013.02.064] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 02/02/2013] [Accepted: 02/12/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are ample data regarding the short-term outcomes of on-pump and off-pump coronary artery bypass grafting (CABG), but little is known about the long-term survival associated with these approaches. METHODS Using the Veterans Affairs (VA) Continuous Improvement in Cardiac Surgery Program, we identified all VA patients (n = 65,097) who underwent primary isolated CABG from October 1997 to April 2011. The primary outcome measure was all-cause mortality. Age, 17 preoperative risk factors, and year of operation were used to calculate propensity scores for each patient. A greedy-match algorithm using the propensity scores matched 8,911 off-pump with 26,733 on-pump patients. Survival functions were estimated by the Kaplan-Meier method and compared by using the log-rank test. RESULTS In the complete cohort, off-pump was used in 11,629 of 65,097 (17.9%) operations. For the matched cohort, the median follow-up was 6.7 years (interquartile range, 3.72 to 9.35 years). Risk-adjusted mortality did not differ significantly between the off-pump and on-pump groups at 1 year (4.67% vs 4.78%; risk ratio [RR], 0.98; 95% confidence interval [CI], 0.88 to 1.09) or 3 years (9.21% vs 8.89%; RR, 1.04; 95% CI, 0.96 to 1.12). However, risk-adjusted mortality was higher in the off-pump group at 5 years (14.47% vs 13.45%; RR, 1.08; 95% CI 1.02 to 1.15) and 10 years (25.18% vs 23.57%; RR, 1.07; 95% CI, 1.03 to 1.12). Overall, the hazard ratio for off-pump vs on-pump was 1.06 (95% CI, 1.00 to 1.13; p = 0.04). CONCLUSIONS Off-pump CABG may be associated with decreased long-term survival. Further studies are needed to identify the reasons behind this finding.
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Affiliation(s)
- Faisal G Bakaeen
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.
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26
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García Fuster R, Paredes F, García Peláez A, Martín E, Cánovas S, Gil O, Hornero F, Martínez-León J. Impact of increasing degrees of renal impairment on outcomes of coronary artery bypass grafting: the off-pump advantage. Eur J Cardiothorac Surg 2013; 44:732-42. [PMID: 23425679 DOI: 10.1093/ejcts/ezt053] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Increasing degrees of renal impairment are associated with higher rates of morbimortality after coronary artery bypass grafting (CABG). This incremental risk has not been well studied in off-pump procedures (OPCAB). We assessed its impact on OPCAB and on-pump CABG (ONCAB). METHODS A total of 1769 patients undergoing primary CABG (January 1995 through June 2011) had complete data on glomerular filtration rate (eGFR). 930 patients had Stage 2 renal insufficiency, 330 Stage 3, 27 Stage 4 and 465 normal renal function (Stage 1). Seventeen patients with end-stage disease (Stage 5) were excluded. The OPCAB technique was selectively used in 350 high-risk patients. Preoperative variables and postoperative outcomes were compared among eGFR subgroups and between matched and unmatched OPCAB vs ONCAB groups. RESULTS Stages 3-4 patients were older (P < 0.0001), with higher prevalence of diabetes (36.8, 35.0, 39.7 and 74.1%, P < 0.01, 1-4 eGFR groups) peripheral arteriopathy (6.0, 9.0, 15.8 and 29.6%, P < 0.0001) and lower left ventricular ejection fraction (LVEF) (GFR-LVEF correlation: Pearson: 0.12, P < 0.0001). On-pump GFR groups had increasingly higher in-hospital mortality (1.0, 1.2, 3.5 and 15.4%, P < 0.0001), but no differences were observed in OPCAB (5.5, 4.8, 5.4 and 7.1%, P = 0.97). Similar trends on in-hospital morbidity were observed in ONCAB vs OPCAB groups: low cardiac output (P < 0.01), pneumonia (P < 0.01) and stroke (P < 0.05). GFR only predicted mortality in ONCAB patients (odds ratio (OR): 0.96, 95% CI: 0.94-0.98; P < 0.01). Patients with higher eGFR stages had statistically more reduced long-term survival, and this pattern was similar in the three treatment groups, also including the OPCAB group, who had the lowest survival in patients with eGFR stage 4. CONCLUSIONS Patients with low GFR (Stages 3-4) undergoing ONCAB were at increased risk of early morbimortality. In contrast, there were no significant differences in operative morbimortality among eGFR groups in OPCAB patients. This 'off-pump advantage' on early outcomes was not observed at the long-term follow-up.
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Lenihan CR, Montez-Rath ME, Mora Mangano CT, Chertow GM, Winkelmayer WC. Trends in acute kidney injury, associated use of dialysis, and mortality after cardiac surgery, 1999 to 2008. Ann Thorac Surg 2012; 95:20-8. [PMID: 23272825 DOI: 10.1016/j.athoracsur.2012.05.131] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 04/27/2012] [Accepted: 05/02/2012] [Indexed: 01/04/2023]
Abstract
BACKGROUND The development of acute kidney injury (AKI) after cardiac surgery is associated with significant mortality, morbidity, and cost. The last decade has seen major changes in the complexity of cardiac surgical candidates and in the number and type of cardiac surgical procedures being performed. METHODS Using data from the Nationwide Inpatient Sample, we determined the annual rates of AKI, AKI requiring dialysis (AKI-D), and inpatient mortality after cardiac surgery in the United States in the years 1999 through 2008. RESULTS Inpatient mortality with AKI and AKI-D decreased from 27.9% and 45.9%, respectively, in 1999 to 12.8% and 35.3%, respectively, in 2008. Compared with 1999, the odds of AKI and AKI-D in 2008, adjusted for demographic and clinical factors, were 3.30 (95% confidence interval [CI]: 2.89 to 3.77) and 2.23 (95% CI: 1.78 to 2.80), respectively. Corresponding adjusted odds of death associated with AKI and AKI-D were 0.31 (95% CI: 0.26 to 0.36) and 0.47 (95% CI: 0.34 to 0.65.) Taken together, the attributable risks for death after cardiac surgery associated with AKI and AKI-D increased from 30% and 5%, respectively, in 1999 to 47% and 14%, respectively, in 2008. CONCLUSIONS In sum, despite improvements in individual patient outcomes over the decade 1999 to 2008, the population contribution of AKI and AKI-D to inpatient mortality after surgery increased over the same period.
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Affiliation(s)
- Colin R Lenihan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA.
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28
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Emmert MY, Salzberg SP, Seifert B, Scherman J, Plass A, Starck CT, Theusinger O, Hoerstrup SP, Grünenfelder J, Jacobs S, Falk V. Clampless off-pump surgery reduces stroke in patients with left main disease. Int J Cardiol 2012; 167:2097-101. [PMID: 22726394 DOI: 10.1016/j.ijcard.2012.05.116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 05/03/2012] [Accepted: 05/27/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Surgical revascularization is the most appropriate therapy for patients with significant left main coronary-artery disease (LMD). An incidence of perioperative stroke remains an issue when compared to the early outcomes to percutaneous coronary intervention (PCI). This study evaluates the safety and impact of standardized "clampless" OPCAB techniques, composed of either complete in situ grafting or "clampless" device enabled techniques for stroke reduction in patients undergoing surgical revascularization for LMD. METHODS Between 1999 and 2009, 1031 patients with LMD underwent myocardial-revascularization at our institution. Of these, 507 patients underwent "clampless" OPCAB and 524 patients underwent conventional on-pump CABG (ONCABG). Data-collection was performed prospectively and a propensity-adjusted regression-analysis was applied to balance patient characteristics. LMD was defined as a stenosis >50% and endpoints were mortality, stroke, a cardiac-composite (including death, stroke and myocardial-infarction); a non-cardiac composite and complete-revascularization. RESULTS In OPCAB patients, the cardiac composite (3.0% vs. 7.8%; propensity-adjusted (PA)OR=0.27; CI95% 0.12-0.65; p=0.003) as well as the occurrence of stroke (0.4% vs. 2.9%; PAOR=0.04; CI95% 0.003-0.48; p=0.012) were significantly lower while the mortality-rate was well comparable between groups (1.8% vs. 2.5%; PAOR=0.44; CI95% 0.11-1.71; p=0.24). The non-cardiac composite was also significantly decreased after OPCAB (8.9% vs. 19.7%; PAOR=0.55; CI95% 0.34-0.89; p=0.014) and complete revascularization was achieved for similar proportions in both groups (95.1% vs. 93.7%; p=0.35). CONCLUSIONS This study shows the superiority of OPCAB for patients with LMD with regards to risk-adjusted outcomes other than mortality. A "clampless OPCAB strategy", effectively reduces stroke yielding similar early outcomes as PCI.
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Affiliation(s)
- Maximilian Y Emmert
- Dept of Cardiac and Vascular Surgery, University Hospital Zurich, Switzerland.
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29
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Lazar HL. The Year in Review: Surgical Revascularization of Coronary Artery Disease-2011. J Card Surg 2012; 27:347-59. [DOI: 10.1111/j.1540-8191.2012.01451.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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30
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Emmert MY, Salzberg SP, Cetina Biefer HR, Sundermann SH, Seifert B, Grunenfelder J, Jacobs S, Falk V. Total arterial off-pump surgery provides excellent outcomes and does not compromise complete revascularization. Eur J Cardiothorac Surg 2012; 41:e25-31. [DOI: 10.1093/ejcts/ezr225] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Wu C, Camacho FT, Culliford AT, Gold JP, Wechsler AS, Higgins RSD, Lahey SJ, Smith CR, Jordan D, Hannan EL. A comparison of long-term mortality for off-pump and on-pump coronary artery bypass graft surgery. Circ Cardiovasc Qual Outcomes 2012; 5:76-84. [PMID: 22235063 PMCID: PMC3277259 DOI: 10.1161/circoutcomes.111.963124] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 11/28/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND The survival difference between off-pump and on-pump coronary artery bypass graft surgery for follow-up longer than 5 years is not well-understood. The objective of this study is to examine the difference in 7-year mortality after these 2 procedures. METHODS AND RESULTS The state of New York's Cardiac Surgery Reporting System was used to identify the 2640 off-pump and 5940 on-pump patients discharged from July through December 2000. The National Death Index was used to ascertain patients' vital statuses through 2007. A logistic regression model was fit to predict the probability of receiving an off-pump procedure using baseline patient characteristics. Off-pump and on-pump patients were matched with a 1:1 ratio based on the probability of receiving an off-pump procedure. Kaplan-Meier survival curves for the 2 procedures were compared using the propensity-matched data, and the hazard ratio for death for off-pump in comparison with on-pump procedures was obtained. In subgroup analyses, the significance of interactions between type of surgery and baseline risk factors was tested. In this study, 2631 pairs of off-pump and on-pump patients were propensity matched. The 7-year Kaplan-Meier survival rates were 71.2% and 73.4% (P=0.07) for off-pump and on-pump surgery, respectively. The hazard ratio for death (off-pump versus on-pump) was 1.10 (95% confidence interval: 0.99 to 1.21, P=0.07). No statistical significance was detected for the interaction terms between the type of surgery and a number of different baseline risk factors. CONCLUSIONS The difference in long-term mortality between on-pump and off-pump coronary artery bypass graft surgery is not statistically significant.
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Affiliation(s)
- Chuntao Wu
- Department of Public Health Sciences, Penn State Hershey College of Medicine, Hershey, PA 17033, USA.
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Guerra M, Mota JC. Impact of incomplete surgical revascularization on survival. Interact Cardiovasc Thorac Surg 2011; 14:176-82. [PMID: 22159258 DOI: 10.1093/icvts/ivr080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Complete revascularization is considered superior to incomplete revascularization (IR), with better long-term survival and a lower rate of reintervention. However, it has yet to be established whether this difference is due directly to IR as a surgical strategy or whether this approach is merely a marker of more severe coronary disease and more rapid progression. We believe that IR is a prognostic marker for a more complex coronary pathology, and adverse effects are probably due to the preoperative condition of the patient. In fact, although IR may negatively affect long-term outcomes, it may be, when wisely chosen, the ideal treatment strategy in selected high-risk patients. IR can derive from a surgical strategy of target vessel revascularization, where the impact of surgery is minimized to reduce perioperative mortality and morbidity, aiming to achieve the best feasible safe revascularization.
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Affiliation(s)
- Miguel Guerra
- Department of Thoracic Surgery, Centro Hospitalar de Vila Nova de Gaia, Portugal.
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