Off-pump coronary surgery may reduce stroke, respiratory failure, and mortality in octogenarians

Minimally invasive strategies of surgical coronary artery revascularization for the aging population

BACKGROUND

The increasing prevalence of elderly or frail patients with severe coronary disease, who are not suitable for interventional coronary revascularization, necessitates the exploration of alternative treatment options. A less invasive approach, such as minimally-invasive off-pump coronary-artery-bypass (MICS-CABG) grafting through mini-thoracotomy, which avoids both extracorporeal circulation and sternotomy, may be more appropriate for this patient population. This study, a retrospective, monocentric analysis, aimed to evaluate the long-term outcomes of these patients.

METHODS

The study included 172 patients aged 80 years or older, who underwent MICS-CABG between 2007 and 2018. The patients underwent single, double, or triple-vessel revascularization using the left internal thoracic artery, and in some cases, the radial artery or saphenous vein. Follow-up, mean duration of 50.4±30.8 months, was available for 163 patients (94.7%).

RESULTS

The mean age of the patients was 83.2±3.0 years, 77.3% of them were male. The EuroSCORE I additive was 11.0±12.1. There were no conversions to sternotomy or cardiopulmonary-bypass. The postoperative 30-day mortality rate was 2.9%, with 5 deaths. The in-hospital rate of major adverse cardiac and cerebrovascular events was 4.7% (perioperative myocardial infarction 1.2%, perioperative stroke 2.3%, repeat revascularization 1.2%). Acute renal kidney injury, (stage 3 KDOQI or more), occurred in 5 patients (2.9%) and new-onset atrial fibrillation in 6 patients (3.5%). The 1-, 3-, 5- and 8-year actuarial survival rate of the 30-day survivors was 97%, 82%, 73%, and 42%, respectively.

CONCLUSIONS

MICS-CABG grafting is associated with excellent early and long-term outcomes in eligible octogenarians.

Off-pump versus on-pump coronary artery bypass grafting for octogenarians: A meta-analysis involving 146 372 patients

There is an ongoing debate concerning the optimal surgical option of myocardial revascularization for octogenarians. The current meta‐analysis aimed to compare clinical outcomes following off‐pump coronary artery bypass grafting (OPCABG) or conventional coronary artery bypass grafting (CCABG) in octogenarians. PubMed, Cochrane, Web of Science, and EMBASE databases were searched to identify eligible studies from inception to March 2021. The analysis was performed using STATA 15.1. A literature search yielded 18 retrospective studies involving 146 372 patients (OPCABG = 44 522 vs. CCABG = 101 850). Pooled analysis showed a strong trend toward reducing mortality risk in the OPCABG group (odds ratio: 0.75, 95% confidence interval: 0.56–1.00, p = .05). However, it did not reach statistical significance. The sensitive analysis demonstrated that OPCABG was less likely to cause death than CCABG. There were comparable data in myocardial infarction, renal failure, deep sternal wound infection, and hospital stays between the two groups, although the incidence of stroke, atrial fibrillation, prolonged ventilation, and reoperation for bleeding was significantly lower in the OPCAGB group. OPCABG may be an effective surgical strategy for myocardial revascularization, especially in reducing the incidence of postoperative stroke, atrial fibrillation, prolonged ventilation, and reoperation for bleeding.

Perioperative safety of simultaneous off-pump coronary artery bypass grafting with non-cardiac surgery of moderate-to-severe severity

BACKGROUND

To evaluate the perioperative safety of simultaneous off-pump coronary artery bypass grafting (OPCABG) with non-cardiac surgery.

METHODS

From September 2013 to January 2019, patients who underwent OPCABG surgery in the Department of Cardiology, Peking University First Hospital were included in this retrospective study. A total of 54 patients who underwent simultaneous surgery were defined as simultaneous surgery group. A total of 108 patients who had recently undergone isolated OPCABG surgery, and had similar vascular reconstruction methods were selected for matching, and these patients were defined as the OPCABG group. The general data and laboratory indicators were detected and were used as baseline data, and the EuroSCORE II scoring system was used to evaluate the surgical risk of patients based on these data. During surgery, intraoperative indicators were assessed and evaluated during surgery. In addition, evaluation of postoperative indicators was performed, including mechanical ventilation time, residence time in ICU, and proportion of perioperative myocardial infarction, perioperative stroke, postoperative renal failure, and surgical wound infection.

RESULTS

All the combined non-cardiac surgeries were assessed to be of moderate-to-severe grade by operative severity scoring system. The analysis of intraoperative indicators showed that there were no significant differences in proportion of emergency or urgent surgery, cases of arterial and venous anastomosis, and proportion of intraoperative blood transfusion between two groups (P > 0.05). Meanwhile, the values of operation time and intraoperative blood loss of patients in simultaneous surgery group were significantly higher than that in OPCABG group (P < 0.05). No perioperative death events occurred in this study. In terms of postoperative indicators, the values of operation duration and intraoperative blood loss of patients in simultaneous surgery group were significantly higher than that in OPCABG group (P < 0.05).

CONCLUSIONS

Simultaneous OPCABG surgery with non-cardiac surgeries of moderate-to-severe severity may not be associated with increased postoperative risks when compared with isolated OPCABG.

Off-pump versus on-pump coronary artery surgery in octogenarians (from the KROK Registry)

Background

According to the medical literature, both on-pump and off-pump coronary artery surgery is safe and effective in octogenarians.

Objectives

The aim of our study was to examine the epidemiology, in-hospital outcomes and long-term follow-up results in octogenarians undergoing off-pump and on-pump coronary artery surgery utilizing nationwide registry data.

Methods

All octogenarians (≥ 80 years) enrolled in the Polish National Registry of Cardiac Surgical Procedures (KROK Registry), who underwent isolated coronary surgery between January 2006 and September 2017 were identified. Preoperative data, perioperative complications, hospital mortality and long-term mortality were analyzed. Unadjusted and propensity-matched comparisons were performed between octogenarians undergoing off-pump and on-pump coronary artery bypass surgery.

Results

Octogenarians accounted for 4.1% of the total population undergoing coronary artery surgery in Poland during the analyzed period (n = 152,631) and this percentage is increasing. Among 6,006 analyzed patients, 2,744 (45.7%) were operated on-pump and 3,262 (54.3%) were operated off-pump. Propensity-matched analysis revealed that patients operated on-pump were more often reoperated due to postoperative bleeding and their in-hospital mortality was higher (6.6% vs 4.5%, p = 0.006 and 8.7% vs 5.8%, p = 0.001, respectively). Long-term all-cause mortality was lower among patients operated off-pump (p = 0.013).

Conclusion

On the basis of our findings we suggest that off pump technique should be considered as perfectly acceptable in octogenarians.

Postoperative complications associated with coronary artery bypass graft surgery and their therapeutic interventions

Coronary artery disease is one of the commonest surgery demanding cardiovascular diseases. Coronary artery bypass graft surgery is practiced all over the world for the treatment of coronary artery disease. Systemic trauma during the surgery is associated with a wide range of complications, some of which are fatal. Preoperative risk factors such as age, previous illness and obesity are common predictors of these adverse events. Advances in therapeutic medicine have allowed timely treatment of these adverse events and co-morbidities. This review summarizes some of the most occurring complications associated with coronary artery bypass graft and corresponding treatment options.

Prediction of complications and death in octogenarians with left main coronary artery disease after coronary artery bypass implantation - off-pump, on-pump and minimally invasive techniques comparison

Introduction

Off-pump coronary artery bypass grafting is considered potentially more effective than on-pump surgery in elderly patients.

Aim

To compare the early and long-term results of these techniques in patients ≥ 80 years of age with left main coronary artery disease.

Material and methods

All patients ≥ 80 years of age (N = 3648) who were reported to the Polish National Registry of Cardiac Surgery Procedures between 2006 and 2016 and underwent primary, isolated coronary artery bypass surgery were included in the study. The patients were divided into 2 groups: group A – without significant left main stenosis (LMS) (n = 2094) and B group – with LMS ≥ 50% (n = 1524). The groups were compared according to the type of surgery: on-pump (A = 1107 vs. B = 891), off-pump (A = 908 vs. B = 616) and MIDCAB (A = 79 vs. B = 17).

Results

There were significant differences in preoperative status between the groups in the whole cohort, which were not observable after propensity score matching. The in-hospital mortality was significantly higher in the LMS group operated on-pump (10.5% vs. 7.0%; p = 0.01) and non-significant in the off-pump group (5.1% vs. 5.7%; p = 0.78), as well as in the MIDCAB subgroup (5.9% vs. 5.1%; p = 0.64). 10-year survival in all subgroups was comparable and remained at a level of 50–60%. The mean entire cohort follow-up was 3.4 ±2.7 vs. 3.7 ±2.8 years (p = 0.2).

Conclusions

Off-pump coronary bypass grafting may optimize the outcomes in elderly patients with significant left main stenosis. Octogenarians surgically treated for coronary artery disease, despite increased post-operative risks, present encouraging long-term survival.

Comparison of Off-Pump Coronary Artery Bypass between Octogenarians and Septuagenarians: A Propensity Score Analysis

Background

Coronary artery bypass grafting (CABG) is being offered increasingly frequently to octogenarians. However, old age is known to be an independent risk factor in CABG. The aim of this study was to compare the outcomes of off-pump coronary artery bypass (OPCAB) between octogenarians and septuagenarians.

Methods

We retrospectively reviewed the data of 1,289 consecutive patients aged ≥70 years who underwent OPCAB at a single institution between 2001 and 2016. We compared the outcomes of 115 octogenarians and 1,174 septuagenarians. Using propensity score matching, based on preoperative clinical characteristics, 114 octogenarians were matched with 338 septuagenarians.

Results

Propensity score analysis revealed that the incidence of acute kidney injury (14.9% vs. 7.9%, p=0.028) and respiratory complications (8.8% vs. 4.2%, p=0.040) was significantly higher in octogenarians. The early mortality rate (2.6% vs. 1.0%, p=0.240) and 1-year survival rate (89.5% vs. 94.4%, p=0.097) were not statistically significant between the groups. However, the 5-year survival rate (67.3% vs. 79.9%, p<0.001) was significantly lower in octogenarians. Previous myocardial infarction and a left ventricular ejection fraction ≤35% were associated with a poor 1-year survival rate.

Conclusion

Early and 1-year outcomes of OPCAB in octogenarians were tolerable when compared with those in septuagenarians. OPCAB could be a suitable option for octogenarians.

Off- vs. on-pump coronary artery bypass graft surgery on hospital outcomes in 134,117 octogenarians

Background

In octogenarian patients there is a potential for more tangible clinical benefits from off-pump coronary artery bypass (OPCAB) compared to conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) (COCAB). We aimed to investigate whether, compared to COCAB, OPCAB is associated with better operative outcomes in octogenarians by analyzing the Nationwide Inpatient Sample (NIS) databases 2003-2011.

Methods

Of the 134,117 discharge records from 797 hospitals analyzed of patients aged ≥80 years undergoing first time isolated CABG from 2003 to 2011, 70.9% (n=95,057) had COCAB and the remaining 29.1% (n=39,060) received OPCAB. Hospital and patient-level covariates were used to adjust the effect of OPCAB on operative outcomes.

Results

COCAB and OPCAB were comparable in terms of operative mortality (5.5% vs. 5.2% respectively, P=0.30). However, rate of stroke was significantly lower in the OPCAB (2.4% vs. 1.8% respectively, P=0.004) and this result was confirmed after full adjustment (OR 0.72; 95% CI: 0.58-0.91; P=0.005). OPCAB was associated with lower risk of wound infection (OR 0.61; 95% CI: 0.47-0.78; P=0.0001) and atrial fibrillation (OR 0.88; 95% CI: 0.82-0.94; P=0.0004). No differences were observed in terms of bleeding, sepsis, need for tracheostomy and haemodialysis. OPCAB was associated with a marginal trend towards lower costs but did not reduce hospital-stay length.

Conclusions

In the NIS 2003-2011, compared to COCAB, OPCAB was associated with lower risk of stroke and atrial fibrillation in octogenarians. OPCAB might represent a valid option to reduce procedure-specific morbidity in this high-risk subgroup, in particular in subjects at higher risk of cerebrovascular events.

Use of cardiopulmonary pump support during coronary artery bypass grafting in the high-risk: a meta-analysis

BACKGROUND

Data from randomized trials evaluating the efficacy of on- versus off-pump coronary artery bypass grafting remain inconclusive, particularly in high-risk populations.

AIMS

The aim of this study is to compare the outcomes associated with on- versus off-pump coronary artery bypass grafting among high-risk patients.

METHODS

We performed a meta-analysis of randomized control trials comparing on- versus off-pump coronary artery bypass grafting, focusing on high-risk populations. Studies focusing on "high-risk" features: European System of Cardiac Operative Risk Evaluation (EuroSCORE) ≥ 5, age > 70 years, preexisting renal insufficiency, history of stroke(s), and the presence of left ventricular dysfunction were included. MEDLINE, Scopus, and Embase were searched for all publications between January 1, 2000 and August 1, 2016, using the following terms: on-pump, off-pump, coronary artery bypass, high-risk, left ventricular dysfunction, elderly, aged, and renal insufficiency. Endpoints included cardiovascular and all-cause mortality, non-fatal myocardial infarction, stroke, need for revascularization, renal failure, and length of hospital stay.

RESULTS

Nine studies incorporating 11,374 patients with a mean age of 70 years were selected. There was no statistical difference in cardiovascular mortality, all-cause mortality, non-fatal myocardial infarction, and renal failure between the two groups. There was a decrease in further revascularization at 1 year with on-pump (OR 0.67 (0.50-0.89)). However, there was an increase in length of hospital stay by 2.24 days (p = 0.03) among the on-pump group with no difference in stroke (OR 1.34 (1.00-1.80)).

CONCLUSIONS

On-pump is associated with a decreased risk of additional revascularization by 1 year. However, this appears to be a cost of longer hospitalization.

Off-pump grafting does not reduce postoperative pulmonary dysfunction

Objectives Pulmonary dysfunction is a recognized postoperative complication that may be linked to use of cardiopulmonary bypass. The off-pump technique of coronary artery bypass aims to avoid some of the complications that may be related to cardiopulmonary bypass. In this study, we compared the influence of on-pump or off-pump coronary artery bypass on pulmonary gas exchange following routine surgery. Methods Fifty patients (mean age 60.4 ± 8.4 years) with no preexisting lung disease and good left ventricular function undergoing primary coronary artery bypass grafting were prospectively randomized to undergo surgery with or without cardiopulmonary bypass. Alveolar/arterial oxygen pressure gradients were calculated prior to induction of anesthesia while the patients were breathing room air, and repeated postoperatively during mechanical ventilation and after extubation while inspiring 3 specific fractions of oxygen. Results Baseline preoperative arterial blood gases and alveolar/arterial oxygen pressure gradients were similar in both groups. At both postoperative stages, the partial pressure of arterial oxygen and alveolar/arterial oxygen pressure gradients increased with increasing fraction of inspired oxygen, but there were no statistically significant differences between patients who underwent surgery with or without cardiopulmonary bypass, either during ventilation or after extubation. Conclusions Off-pump surgery is not associated with superior pulmonary gas exchange in the early postoperative period following routine coronary artery bypass grafting in patients with good left ventricular function and no preexisting lung disease.

Insurance statements from French anaesthesiologists and intensivists: A database analysis

BACKGROUND

From its origins, anaesthesia is a leading medical specialty for improving patient safety. However, perioperative adverse events remain frequent and may be preventable in 50% of cases. We conducted a collaborative retrospective study analysis of the insurance-database of the MACSF-Sou Medical insurance company to assess the perioperative risk.

MATERIAL AND METHODS

Retrospective study, including all the statements declared by anaesthesiologists to the MACSF-Sou Medical insurance company. A description of risk in perioperative medicine was performed by the assessment of these statements by three experts member of the SFAR. All the statements concerning regional anaesthesia and dental injuries were excluded.

RESULTS

Eight hundred and seventy statements were analyzed. The patients involved were predominantly women (sex-ratio: 0.86), with a mean age of 56 years (±18). Three hundred and fifteen cardiac arrests, 157 severe systemic complications, 340 moderate complications and 106 conflicts were analyzed. Most of the events were revealed postoperatively (79.3%) and almost half of them after the discharge of the postanesthetic care unit. The medical consequences were considered as serious. Death followed 35.9% of the events declared. Relative or true hypovolaemia and stroke were responsible for a large part of postoperative mortality and morbidity.

CONCLUSION

Collaborating with insurance companies allows a relevant approach of the perioperative risk. The study highlighted the importance of the delayed complications and is a plea for a more intense implication of anaesthesia in the postoperative care with the aim of improving patient safety.

[Epidemiology of cerebral perioperative vascular accidents]

OBJECTIVES

Stroke is a well-described postoperative complication, after carotid and cardiac surgery. On the contrary, few studies are available concerning postoperative stroke in general non-cardiac non-carotid surgery. The high morbid-mortality of stroke justifies an extended analysis of recent literature.

ARTICLE TYPE

Systematic review.

DATA SOURCES

Firstly, Medline and Ovid databases using combination of stroke, cardiac surgery, carotid surgery, general non-cardiac non-carotid surgery as keywords; secondly, national and European epidemiologic databases; thirdly, expert and French health agency recommendations; lastly, reference book chapters.

RESULTS

In cardiac surgery, with an incidence varying from 1.2 to 10% according to procedure complexity, stroke occurs peroperatively in 50% of cases and during the first 48 postoperative hours for the others. The incidence of stroke after carotid surgery is 1 to 20% according to the technique used as well as operator skills. Postoperative stroke is a rare (0.15% as mean, extremes around 0.02 to 1%) complication in general surgery, it occurs generally after the 24-48th postoperative hours, exceptional peroperatively, and 40% of them occurring in the first postoperative week. It concerned mainly aged patient in high-risk surgeries (hip fracture, vascular surgery). Postoperative stroke was associated to an increase in perioperative mortality in comparison to non-postoperative stroke operated patients.

CONCLUSION

Postoperative stroke is a quality marker of the surgical teams' skill and has specific onset time and induces an increase of postoperative mortality.

Off-pump versus on-pump revascularization in females: a meta-analysis of observational studies

BACKGROUND

Coronary revascularization in female patients presents several challenges, including smaller target vessels and smaller conduits. Furthermore, late presentation and more co-morbidities than males may increase complication rates. The aim of this study was to assess whether off-pump coronary artery bypass (OPCAB) improves outcomes when compared to on-pump coronary artery bypass (ONCAB) in the female population.

METHODS

A systematic literature review identified six observational studies, incorporating 23313 patients (n=9596 OPCAB, 13717 ONCAB). These were meta-analyzed using random effects modeling. Heterogeneity, subgroup analysis, quality scoring and publication bias were assessed. The primary endpoints were 30-day mortality and major cardiac, respiratory and renal complications. Secondary endpoints were the number of grafts per patient.

RESULTS

No statistically significant difference was observed in 30-day mortality between the OPCAB and ONCAB groups (4.8% vs. 0.7%; OR 0.96; 95% CI [0.41, 2.24], p=0.92). Significant inter-study heterogeneity was also present (I2=94%) and was not explained by study size or quality. Peri-operative myocardial infarction (OR 0.65; 95% CI [0.51, 0.84], p=0.0009) was significantly lower with OPCAB without significant heterogeneity; however, OPCAB did not significantly alter other morbidity outcomes. OPCAB was associated with a trend towards fewer grafts per patient than ONCAB.

CONCLUSIONS

OPCAB is a safe alternative to ONCAB in the surgical revascularisation of female patients and may reduce post-operative myocardial infarction (MI). However, this does not translate into a reduction in 30-day mortality and OPCAB does not significantly improve other cardiovascular, renal or neurological outcomes. Late outcome data remains lacking and a well-structured, randomized trial is required to answer vital questions regarding the effect of OPCAB on women in the long-term.

Postoperative stroke related to cardiac surgery in octogenarians

OBJECTIVES

Demographics of cardiac surgery patients are changing, with an increase in aged patients. We aim to identify risk factors, mortality, morbidity and increasing postoperative costs due to postoperative stroke in octogenarians following cardiopulmonary bypass (CPB).

METHODS

A total of 418 consecutive patients older than 80 years (Group A) who underwent cardiac surgery with CPB between 2000 and 2012 were matched according to gender, surgical procedure and comorbidities with 426 younger patients (Group B). Risk factors for postoperative stroke were retrospectively evaluated.

RESULTS

We identified postoperative stroke in 4.1% of patients in Group A and in 3.5% in Group B (P = 0.65). Early stroke was diagnosed in 13 patients in Group A (76.5%) and 10 patients in Group B (66.7%) (P = 0.53). In multivariate analysis, preoperative anaemia (P = 0.033; odds ratio [OR]: 3.84; 95% CI: 1.11-13.28) was the only risk factor associated with postoperative stroke in Group A. In Group B, preoperative peripheral vascular disease (P = 0.0003; OR: 7.30; 95% CI: 2.47-21.55) and postoperative atrial fibrillation (P = 0.0134; OR: 4.05; 95% CI: 1.33-12.31) were identified as risk factors.

CONCLUSIONS

Incidence of postoperative stroke after CPB was not significantly higher in our octogenarian population. Although in younger patients peripheral vascular disease and cardiac rhythm disturbances were significant risk factors, it seems that factors related to intraoperative brain oxygenation (secondary to preoperative anaemia) are the most critical determinant of stroke in the elderly.

Evaluation of remifentanil anesthesia for off-pump coronary artery bypass grafting surgery using heart rate variability

Heart rate variability (HRV) was used in the present study to evaluate a target-controlled approach compared with a constant-rate infusion for remifentanil anesthesia during off-pump coronary artery bypass grafting (OP-CABG) surgery. A total of 65 patients with American Society of Anesthesiologists (ASA) physical status II or III, who were aged 60–85 years and scheduled for OP-CABG, were selected for the study. All patients were administered an intramuscular premedication of 10 mg morphine and 0.3 mg scopolamine. In group I, remifentanil was infused using a target-controlled approach at 1.5–5.0 ng/ml, and in group II, remifentanil was infused at a constant-rate of 0.05–1.0 μg/kg/min and at additional single increments of 1 μg/kg when appropriate. The heart rate and other hemodynamic monitoring indices of the patients, including the mean arterial pressure, central venous pressure, pulmonary artery pressure and pulmonary capillary wedge pressure, were monitored at various time points, including prior to induction (T₀), at extubation (performed intraoperatively; T₇) and at 24 h post-surgery. The HRV indices, including total power (TP), low frequency (LF) and the LF/high frequency (HF) ratio of power (LF/HF), were reduced following induction at T₀ and remained low at 24 h post-surgery. At T₅ (right coronary or left circumflex artery anastomosis) and T₇ (tracheal extubation), all the HRV indices, with the exception of the HF power, were significantly increased (P<0.05). Additionally, the TP, LF and LF/HF values in group II were higher at T₅ compared with those in group I (P<0.05). Remifentanil target-controlled infusion is superior to constant-rate infusion in suppressing the stress response during OP-CABG, maintaining the balance of the cardiac autonomic nervous system and promoting the recovery of the autonomic function following surgery.

Anaortic, total-arterial, off-pump coronary artery bypass surgery: why bother?

Coronary artery bypass grafting (CABG) remains the standard of care for multi-vessel coronary disease. However, the increased rate of peri-operative stroke reported after surgery compared to percutaneous coronary intervention (PCI) remains of concern. Anaortic, total-arterial, off-pump coronary artery bypass (OPCAB) grafting is a technique that offers the main advantages of surgical revascularisation with a rate of stroke that is equivalent to that of PCI. Some recent trials comparing conventional on-pump CABG with OPCAB have questioned the efficacy of the off-pump technique - these are most often performed with manipulation of the ascending aorta. We review the potential benefits of the anaortic, total-arterial OPCAB technique to explain why it is being employed by an increasing number of surgeons.