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Fong KY, Yeo S, Luo H, Kofidis T, Teoh KLK, Kang GS. Stroke prevention strategies for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. ANZ J Surg 2024; 94:522-535. [PMID: 38529814 DOI: 10.1111/ans.18947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 01/15/2023] [Accepted: 03/04/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Stroke is a much-feared complication of cardiac surgery, but existing literature on preventive strategies is fragmented. Hence, a systematic review and meta-analysis of stroke prevention strategies for cardiac surgery was conducted. METHODS An electronic literature search was conducted to retrieve randomized controlled trials (RCTs) investigating perioperative interventions for cardiac surgery, with stroke as an outcome. Random-effects meta-analyses were conducted to generate risk ratios (RRs), 95% confidence intervals (95% CI), and forest plots. Descriptive analysis and synthesis of literature was conducted for interventions not amenable to meta-analysis, focusing on risks of stroke, myocardial infarction and study-defined major adverse cardiovascular events (MACE). RESULTS Fifty-six RCTs (61 894 patients) were retrieved. Many included trials were underpowered to detect differences in stroke risk. Among pharmacological therapies, only preoperative amiodarone was shown to reduce stroke risk in one trial. Concomitant left atrial appendage closure (LAAC) significantly reduced stroke risk (RR = 0.55, 95% CI = 0.36-0.84, P = 0.006) in patients with preoperative atrial fibrillation, and there was no difference in on-pump versus off-pump coronary artery bypass grafting (CABG) (RR = 0.94, 95% CI = 0.64-1.37, P = 0.735). Much controversy exists in literature on the timing of carotid endarterectomy relative to CABG in patients with severe carotid stenosis. The use of preoperative remote ischemic preconditioning was not found to reduce rates of stroke or MACE. CONCLUSION This review presents a comprehensive synthesis of existing interventions for stroke prevention in cardiac surgery, and identifies gaps in research which may benefit from future, large-scale RCTs. LAAC should be considered to reduce stroke incidence in patients with preoperative atrial fibrillation.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Selvie Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Haidong Luo
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Theodoros Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Kristine L K Teoh
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Giap Swee Kang
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
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Ntinopoulos V, Haeussler A, Odavic D, Papadopoulos N, Rings L, Dushaj S, Rodriguez Cetina Biefer H, Dzemali O. Conversion from off-pump to on-pump coronary artery bypass grafting: impact of surgeon and anaesthetist experience. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad205. [PMID: 38123498 PMCID: PMC10751234 DOI: 10.1093/icvts/ivad205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/30/2023] [Accepted: 12/19/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES Intraoperative conversion from off-pump to on-pump coronary artery bypass grafting (CABG) is associated with increased postoperative morbidity and mortality. The aim of this study is to assess the impact of surgeon and anaesthetist experience on the conversion rate. METHODS We performed a retrospective analysis of the data of all patients who underwent planned off-pump CABG in a single centre in 2007-2021, some of whom were non-electively converted to on-pump. Surgeon and anaesthetist experience were assessed by the number of off-pump bypass procedures per year. Multivariable logistic regression analysis was used to assess the impact of surgeon and anaesthetist experience on conversion rate. RESULTS A total of 2742 patients met the inclusion criteria. Ninety-four (3.4%) patients underwent non-elective conversion to on-pump surgery. Converted patients had significantly higher mortality [11 (11.7%) vs 35 (1.3%), P < 0.0001] in comparison to non-converted patients. Anaesthetist experience was found to be a risk factor for conversion (P = 0.011). Surgeon experience did not significantly affect conversion rate (P = 0.51). Other risk factors for conversion were female gender [odds ratio 2.65 (95% confidence interval 1.65-4.26), P = 0.0001] and left ventricular ejection fraction ≤35% [odds ratio 1.91 (95% confidence interval 1.05-3.49), P = 0.040]. CONCLUSIONS Conversion from off-pump to on-pump CABG is associated with worse postoperative outcomes. Limited experience of anaesthetists in off-pump bypass surgery is associated with a higher conversion rate.
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Affiliation(s)
- Vasileios Ntinopoulos
- Department of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, Municipal Hospital of Zurich—Triemli, Zurich, Switzerland
| | - Achim Haeussler
- Department of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, Municipal Hospital of Zurich—Triemli, Zurich, Switzerland
| | - Dragan Odavic
- Department of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, Municipal Hospital of Zurich—Triemli, Zurich, Switzerland
| | - Nestoras Papadopoulos
- Department of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, Municipal Hospital of Zurich—Triemli, Zurich, Switzerland
| | - Laura Rings
- Department of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, Municipal Hospital of Zurich—Triemli, Zurich, Switzerland
| | - Stak Dushaj
- Department of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, Municipal Hospital of Zurich—Triemli, Zurich, Switzerland
| | - Hector Rodriguez Cetina Biefer
- Department of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, Municipal Hospital of Zurich—Triemli, Zurich, Switzerland
- Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Omer Dzemali
- Department of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, Municipal Hospital of Zurich—Triemli, Zurich, Switzerland
- Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
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Rufa MI, Ursulescu A, Aktuerk D, Nagib R, Albert M, Göbel N, Shavahatli T, Franke UF. Minimally invasive strategies of surgical coronary artery revascularization for the aging population. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:534-540. [PMID: 37255493 DOI: 10.23736/s0021-9509.23.12621-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
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.
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Affiliation(s)
- Magdalena I Rufa
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany -
| | - Adrian Ursulescu
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | | | - Ragi Nagib
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Marc Albert
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Nora Göbel
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Tunjay Shavahatli
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Ulrich F Franke
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
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Ogawa S, Mori Y, Batkhishig T, Yamada T, Saito Y, Numata Y, Kamiya S, Asano M, Saito T, Suda H. Propensity score analysis comparing off-pump versus on-pump coronary artery bypass grafting in older adults. Gen Thorac Cardiovasc Surg 2023; 71:498-504. [PMID: 36806757 DOI: 10.1007/s11748-023-01915-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/09/2023] [Indexed: 02/21/2023]
Abstract
OBJECTIVE This study aimed to compare the results of off-pump and on-pump coronary artery bypass grafting in older adults and to examine early and late outcomes. METHODS This study included 226 patients aged ≥ 75 years who underwent isolated coronary artery bypass grafting. Of these, 141 and 85 patients were included in the off-pump and on-pump groups, respectively. Propensity scores were calculated for each case, matched, and compared between the two groups (68 cases in each group), along with mid-term outcomes of survival and major adverse cardiac events. RESULTS Operative time, red blood cell transfusion volume, and postoperative hospital stay duration were significantly higher in the on-pump group (267 vs 370 min, P < 0.001; 4.3 vs 17.2 units, P < 0.001; and 20.8 vs 35.8 days, P = 0.012, respectively). Postoperative occurrence of new atrial fibrillation was significantly higher in the on-pump group (4.4% vs 27.9%, P < 0.001), and Kaplan-Meier survival analysis showed a significantly worse prognosis in the on-pump group than in the off-pump group (3-year survival rate 90.7% vs 71.5%, log rank P = 0.007). However, there was no statistically significant difference in cardiovascular-related deaths (log rank P = 0.07). CONCLUSIONS On-pump coronary artery bypass grafting in an older adult population resulted in increased transfusion volume and postoperative occurrence of atrial fibrillation. The mid-term postoperative outcomes were also poorer with on-pump coronary artery bypass grafting. Off-pump coronary artery bypass grafting reduced future all-cause deaths in older adults.
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Affiliation(s)
- Shinji Ogawa
- Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan.
| | - Yoshiharu Mori
- Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Tumurbaatar Batkhishig
- Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Toshiyuki Yamada
- Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Yuhei Saito
- Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Yukihide Numata
- Department of Cardiovascular Surgery, Nagoya City University East Medical Center, Nagoya, Japan
| | - Shinji Kamiya
- Department of Cardiovascular Surgery, Nagoya City University East Medical Center, Nagoya, Japan
| | - Miki Asano
- Department of Cardiovascular Surgery, Nagoya City University East Medical Center, Nagoya, Japan
| | - Takayuki Saito
- Department of Cardiovascular Surgery, Kariya Toyota General Hospital, Kariya, Japan
| | - Hisao Suda
- Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
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Krasivskyi I, Ivanov B, Gerfer S, Großmann C, Mihaylova M, Eghbalzadeh K, Sabashnikov A, Deppe AC, Rahmanian PB, Mader N, Djordjevic I, Wahlers T. Acute stroke in patients undergoing coronary artery bypass grafting surgery in acute coronary syndrome: Predictors and outcomes. Perfusion 2023:2676591231193636. [PMID: 37504576 DOI: 10.1177/02676591231193636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
OBJECTIVES Coronary artery bypass grafting (CABG) surgery in patients with acute coronary syndrome (ACS) remains a high-risk procedure and is associated with adverse outcomes. The risk factors of acute stroke in the above-mentioned patients stay unclear and some appropriate data is lacking in the literature. Thus, we aimed to investigate the predictors of acute stroke in patients undergoing CABG surgery in ACS. METHODS The retrospective single-centre cohort analysis was conducted. All patients (n = 1344) who suffered from acute coronary syndrome and underwent CABG procedure at the University hospital Cologne from June 2011 until October 2019 were included in our study. In order to find the risk factors of acute stroke after bypass surgery, patients were divided into two groups (non-stroke group (n = 1297) and stroke group (n = 47)). In order to even above-mentioned groups propensity score matching (PSM) analysis was performed (non-stroke group (n = 46) and stroke group (n = 46). RESULTS Duration of cardiopulmonary bypass (p = .015) and cross clamp time (p = .006) were significantly longer in patients who suffered stroke. Perioperative myocardial infarction was significantly higher (p = .030) in the stroke group. Likewise, the duration of intensive care unit stay (p < .001) and in-hospital stay (p < .001) were significantly longer in patients with stroke. However, the mortality rate did not differ significantly (p = .131) between above-mentioned groups. Univariate and multivariate analysis showed cardiogenic shock (p = .003), peripheral vascular disease (PVD, p = .025) and previous stroke (p = .045) as relevant independent predictors for acute stroke after CABG procedure in patients with ACS. CONCLUSION Based on our findings, acute stroke after bypass surgery in patients with ACS is associated with increased mortality and adverse outcomes. Cardiogenic shock, peripheral vascular disease and previous stroke were independent predictors of stroke after CABG procedure. Therefore, preoperative evaluation of potential risk factors may be crucial to improve postoperative results.
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Affiliation(s)
- Ihor Krasivskyi
- Department of Cardiothoracic Surgery, University Hospital Cologne, Kerpener street 62, 50937 Cologne, Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, Helios Hospital Siegburg, Siegburg, Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, University Hospital Cologne, Kerpener street 62, 50937 Cologne, Germany
| | - Clara Großmann
- Department of Cardiothoracic Surgery, University Hospital Cologne, Kerpener street 62, 50937 Cologne, Germany
| | - Mariya Mihaylova
- Department of Cardiothoracic Surgery, University Hospital Cologne, Kerpener street 62, 50937 Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital Cologne, Kerpener street 62, 50937 Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital Cologne, Kerpener street 62, 50937 Cologne, Germany
| | - Antje-Christin Deppe
- Department of Cardiothoracic Surgery, University Hospital Cologne, Kerpener street 62, 50937 Cologne, Germany
| | - Parwis Baradaran Rahmanian
- Department of Cardiothoracic Surgery, University Hospital Cologne, Kerpener street 62, 50937 Cologne, Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, University Hospital Cologne, Kerpener street 62, 50937 Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital Cologne, Kerpener street 62, 50937 Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital Cologne, Kerpener street 62, 50937 Cologne, Germany
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Kroeze VJ, Olsthoorn JR, van Straten AHM, Princee A, Soliman-Hamad MA. Predictors and Outcomes of Stroke After Isolated Coronary Artery Bypass Grafting. A Single-Center Experience in 20,582 Patients. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00246-X. [PMID: 37149473 DOI: 10.1053/j.jvca.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/15/2023] [Accepted: 04/07/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVE Stroke remains a devastating complication after cardiac surgical procedures despite perioperative monitoring and management advances. This study aimed to determine the predictors of stroke in a large, contemporary coronary artery surgery population. DESIGN Patient data were analyzed retrospectively. SETTING This single-center study was performed in the Catharina Hospital (Eindhoven). PARTICIPANTS All patients who underwent isolated coronary artery bypass grafting (CABG) between January 1998 and February 2019 were included. INTERVENTIONS Isolated CABG. MEASUREMENTS AND MAIN RESULTS The primary endpoint was a postoperative stroke, defined according to the international updated definition for stroke. Logistic regression was performed to retrieve variables associated with postoperative stroke. A total of 20,582 patients underwent CABG during the period of the study. Stroke was observed in 142 patients (0.7%), of which 75 (52.8%) occurred during the first 72 hours. The incidence of postoperative stroke declined over the years. A significantly higher 30-day mortality rate was seen in patients with stroke (20.4%) compared with 1.8% in the rest of the population; p < 0.001. Multivariate logistic regression analysis showed age, peripheral arterial disease, reexploration for bleeding, perioperative myocardial infarction, and year of surgery as independent predictors for stroke. Patients with postoperative stroke had worse long-term survival (log-rank p < 0.001). Cox regression analysis revealed postoperative stroke (odds ratio 2.13 [1.73-2.64)) as an independent predictor of late mortality. CONCLUSIONS Stroke after CABG is associated with high early and late mortality. Age, peripheral vascular disease, and the year of surgery were associated with postoperative stroke.
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Affiliation(s)
- Vincent J Kroeze
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jules R Olsthoorn
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Anouk Princee
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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Chang Y, Ragheb SM, Oravec N, Kent D, Nugent K, Cornick A, Hiebert B, Rudolph JL, MacLullich AMJ, Arora RC. Diagnostic accuracy of the "4 A's Test" delirium screening tool for the postoperative cardiac surgery ward. J Thorac Cardiovasc Surg 2023; 165:1151-1160.e8. [PMID: 34243932 DOI: 10.1016/j.jtcvs.2021.05.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 05/12/2021] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Delirium is prevalent and underdetected among cardiac surgery patients on the postoperative ward. This study aimed to validate the 4 A's Test delirium screening tool and evaluate its accuracy both when used by research assistants and when subsequently implemented by nursing staff on the ward. METHODS This single-center, prospective observational study evaluated the performance of the 4 A's Test administered by research assistants (phase 1) and nursing staff (phase 2). Assessments were undertaken during the patients' first 3 postoperative days on the postcardiac surgery ward along with previous routine nurse-led Confusion Assessment Method assessments. These index tests were compared with a reference standard diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Surveys regarding delirium screening were administered to nurses pre- and postimplementation of the 4 A's Test in phase 2 of the study. RESULTS In phase 1, a total of 137 patients were enrolled, of whom 24.8% experienced delirium on the postoperative cardiac ward. The 4 A's Test had a sensitivity of 85% (95% confidence interval, 73-93) and a specificity of 90% (95% confidence interval, 85-93) compared with the reference standard. The nurse-assessed Confusion Assessment Method had a sensitivity of 23% (95% confidence interval, 13-37) and specificity of 100% (95% confidence interval, 99-100). In phase 2, nurses (n = 51) screened 179 patients for delirium using the 4 A's Test. Compared with the reference rater, the 4 A's Test had a sensitivity of 58% (95% confidence interval, 28-85) and specificity of 94% (95% confidence interval, 85-98). Postimplementation, 64% of nurses thought that the 4 A's Test improved their confidence in delirium detection, and 76% of nurses would consider routine 4 A's Test use. CONCLUSIONS The 4 A's Test demonstrated moderate sensitivity and high specificity to detect delirium in a real-world setting after cardiac surgery on the postoperative ward. A modified model of use with less frequent administration, along with increased engagement of the postoperative team, is recommended to improve early delirium detection on the cardiac surgery postoperative ward.
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Affiliation(s)
- Yue Chang
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sandra M Ragheb
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nebojsa Oravec
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Kent
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Kristina Nugent
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Alexandra Cornick
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Brett Hiebert
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - James L Rudolph
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, and Brown University, Providence, RI
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada.
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8
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Coerkamp CF, Hoogewerf M, van Putte BP, Appelman Y, Doevendans PA. Revascularization strategies for patients with established chronic coronary syndrome. Eur J Clin Invest 2022; 52:e13787. [PMID: 35403216 PMCID: PMC9539712 DOI: 10.1111/eci.13787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/03/2022] [Accepted: 04/04/2022] [Indexed: 11/28/2022]
Abstract
Coronary artery disease is the most common type of cardiovascular disease, leading to high mortality rates worldwide. Although the vast majority can be treated effectively and safely by medical therapy, revascularization strategies remain essential for numerous patients. Outcomes of both percutaneous coronary intervention and coronary artery bypass grafting improve in a rapid pace, resulting from technical innovation and ongoing research. Progress has been achieved by technical improvements in coronary stents, optimal coronary target and graft selection, and the availability of minimally invasive surgical strategies. Besides technical progress, evidence-based patient-tailored decision-making by the Heart Team is the basic precondition for optimal outcome. The combination of fast innovation and long-term clinical evaluations creates a dynamic field. Research outcomes should be carefully interpreted according to the techniques used and the trial's design. Therefore, more and more trial outcomes suggest that revascularization strategies should be tailored towards the specific patient. Although the European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines on myocardial revascularization date from 2018 and a large variety of trial outcomes on revascularization strategies in chronic coronary syndrome have been published since, we aim to provide an updated overview within this review.
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Affiliation(s)
- Casper F Coerkamp
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marieke Hoogewerf
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Bart P van Putte
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands
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9
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Rubanenko OA, Rubanenko AO. The Influence of Multivessel Bypass Surgery on the Onset of Atrial Fibrillation in Elderly Patients. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-04-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aim. To study the factors associated with the development of postoperative atrial fibrillation (POAF) with single- or two- or more vascular bypass grafting in elderly patients with coronary heart disease.Methods. The study included 454 patients with coronary artery disease who underwent CABG. Patients were divided into 4 groups: 1 group – with single-vessel bypass, 2 group – with 2-vessels, 3 group – with 3-vessels and 4 group with 4-vessels bypass. During the observation period postoperative atrial fibrillation (POAF) occurred in 7.5% of patients in group 1, 18.4% in group 2, 17.5% in group 3 and 19.2% of patients in group 4. Since there were no significant differences in the incidence of POAF in patients with 2-4-vessels bypass grafting, these groups were combined for further analysis. 2 groups are allocated: Group I comprised patients with single-vessel bypass graft (79 patients, 76.0% of males, the average age of 65.0 [63.0;68.0] years), Group II – with 2-4-vessels bypass grafts (357 patients, 78.4% of males, the median age of 67.5 [64.5;69.0] years).Results. POAF occurred in 7.5% of patients in group I and in 18.4% of patients in group II (p=0.03) on the median 4.9 [1.2;8.7] day after coronary artery bypass graft. The multivariate regression analysis showed that indicators, associated with POAF development in patients undergoing CABG were the following: aortic cross-clamping time >36 min (odds ratio [OR)]1.4; 95% confidence interval (CI) 1.1-2.8; p=0.030), time of ischemia >19 min (OR 1.7; 95% CI 1.2-3.3; p=0.020), age >65 years (OR 1.8; 95% CI 1,1-4,1; p=0.010), left atrium diameter >39 mm (OR 2.9; 95% CI 1.5-5.4; p=0.005), left ventricular ejection fraction <51% (OR 1.9; 95% CI 1.2-3.0; p=0.04).Conclusion. In our study, atrial fibrillation in the early postoperative period was more common in patients undergoing multivessel coronary bypass surgery. Indicators, significantly associated with POAF in patients undergoing Coronary artery bypass graft were aortic cross-clamping time >36 minutes, time of ischemia >19 minutes, age >65 years, left atrium diameter >39 mm and left ventricular ejection fraction <51%.
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Zhang S, Huang S, Tiemuerniyazi X, Song Y, Feng W. A Meta-Analysis of Early, Mid-term and Long-Term Mortality of On-Pump vs. Off-Pump in Redo Coronary Artery Bypass Surgery. Front Cardiovasc Med 2022; 9:869987. [PMID: 35548406 PMCID: PMC9081922 DOI: 10.3389/fcvm.2022.869987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 03/31/2022] [Indexed: 12/15/2022] Open
Abstract
We aimed to compare the early, mid-term, and long-term mortality between on-pump vs. off-pump redo coronary artery bypass grafting (CABG). We conducted a systematic search for studies comparing clinical outcomes of patients who underwent on-pump vs. off-pump redo CABG. We pooled the relevant studies quantitatively to compare the early (perioperative period, whether in hospital or within 30 days after discharge), mid-term (≥1 year and <5 years), and long-term (≥5 year) mortality of on-pump vs. off-pump redo CABG. A random-effect model was applied when there was high heterogeneity (I2 > 50%) between studies. Otherwise, a fixed-effect model was utilized. After systematic literature searching, 22 studies incorporating 5,197 individuals (3,215 in the on-pump group and 1,982 in the off-pump group) were identified. A pooled analysis demonstrated that compared with off-pump redo CABG, on-pump redo CABG was associated with higher early mortality (OR 2.11, 95%CI: 1.54-2.89, P < 0.00001). However, no significant difference was noted in mid-term mortality (OR 1.12, 95%CI: 0.57-2.22, P = 0.74) and long-term mortality (OR 1.12, 95%CI: 0.41-3.02, P = 0.83) between the two groups. In addition, the complete revascularization rate was higher in the on-pump group than the off-pump group (OR 2.61, 95%CI: 1.22-5.60, P = 0.01). In conclusion, the off-pump technique is a safe and efficient alternative to the on-pump technique, with early survival advantage and similar long-term mortality to the on-pump technique in the setting of redo CABG, especially in high-risk patients. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021244721.
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Affiliation(s)
| | | | | | | | - Wei Feng
- Department of Cardiac Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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11
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Sun L, Zhou M, Ji Y, Wang X, Wang X. Off-pump versus on-pump coronary artery bypass grafting for octogenarians: A meta-analysis involving 146 372 patients. Clin Cardiol 2022; 45:331-341. [PMID: 35266173 PMCID: PMC9019872 DOI: 10.1002/clc.23794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/10/2022] [Accepted: 01/27/2022] [Indexed: 01/10/2023] Open
Abstract
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.
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Affiliation(s)
- Lifu Sun
- Department of Cardiovascular SurgeryThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Meijing Zhou
- Department of EndocrineThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Yumeng Ji
- Department of Cardiovascular SurgeryThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Xufeng Wang
- Department of Cardiovascular SurgeryThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Xiaowei Wang
- Department of Cardiovascular SurgeryThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
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12
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Deo SV, Elgudin Y, Shroyer ALW, Altarabsheh S, Sharma V, Rubelowsky J, Cornwell L, Davierwala P, Chu D, Cmolik B. Off-Pump Coronary Artery Bypass Grafting: Department of Veteran Affairs' Use and Outcomes. J Am Heart Assoc 2022; 11:e023514. [PMID: 35229663 PMCID: PMC9075317 DOI: 10.1161/jaha.121.023514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Coronary artery bypass can be performed off pump (OPCAB) without cardiopulmonary bypass. However, trends over time for OPCAB versus on-pump (ONCAB) use and long-term outcome has not been reported, nor has their long-term outcome been compared. Methods and Results We queried the national Veterans Affairs database (2005-2019) to identify isolated coronary artery bypass procedures. Procedures were classified as OPCAB on ONCAB using the as-treated basis. Trend analyses were performed to evaluate longitudinal changes in the preference for OPCAB. The median follow-up period was 6.6 (3.5-10) years. An inverse probability weighted Cox model was used to compare all-cause mortality between OPCAB and ONCAB. From 47 685 patients, 6759 (age 64±8 years) received OPCAB (14%). OPCAB usage declined from 16% (2005-2009) to 8% (2015-2019). Patients with triple vessel disease who received OPCAB received a lower mean number of grafts (2.8±0.8 versus 3.2±0.8; P<0.01). The ONCAB 5-, 10-, and 15-year survival rates were 82.9% (82.5-83.3), 60.4% (59.8-61.1), and 37.2% (36.1-38.4); correspondingly, OPCAB rates were 80.7% (79.7-81.7), 57.4% (56-58.7), and 34.1% (31.7-36.6) (P<0.01). OPCAB was associated with increased risk-adjusted all-cause mortality (hazard ratio, 1.15 [1.13-1.18]; P<0.01) and myocardial infarction (incident rate ratio, 1.16 [1.05-1.28]; P<0.01). Conclusions Over 15 years, OPCAB use declined considerably in Veterans Affairs medical centers. In Veterans Affairs hospitals, late all-cause mortality and myocardial infarction rates were higher in the OPCAB cohort.
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Affiliation(s)
- Salil V. Deo
- Surgical ServicesLouis Stokes Cleveland VA Medical CenterClevelandOH
- Cleveland Cardiothoracic Research GroupClevelandOH
- Department of SurgeryCase School of Medicine, Case Western Reserve UniversityClevelandOH
| | - Yakov Elgudin
- Surgical ServicesLouis Stokes Cleveland VA Medical CenterClevelandOH
- Cleveland Cardiothoracic Research GroupClevelandOH
| | - A. Laurie W. Shroyer
- Department of SurgeryHealth Sciences CenterStony Brook Renaissance School of MedicineStony BrookNew York
- Research and Development OfficeNorthport VA Medical CenterNorthportNY
| | - Salah Altarabsheh
- Department of Cardiac SurgeryQueen Alia Heart InstituteAmmanJordan
- Division of Cardiovascular SurgeryMayo ClinicRochesterMinnesota
| | - Vikas Sharma
- Surgical ServicesGeorge E Wahlen VA Medical CenterSalt Lake CityUT
- Division of Cardiothoracic SurgeryUniversity of Utah School of MedicineSalt Lake CityUT
| | - Joseph Rubelowsky
- Surgical ServicesLouis Stokes Cleveland VA Medical CenterClevelandOH
- Cleveland Cardiothoracic Research GroupClevelandOH
| | | | | | - Danny Chu
- Division of Cardiac SurgeryDepartment of Cardiothoracic SurgeryUniversity of PittsburghPA
| | - Brian Cmolik
- Surgical ServicesLouis Stokes Cleveland VA Medical CenterClevelandOH
- Cleveland Cardiothoracic Research GroupClevelandOH
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13
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Machado RJ, Saraiva FA, Mancio J, Sousa P, Cerqueira RJ, Barros AS, Lourenço AP, Leite-Moreira AF. A systematic review and meta-analysis of randomized controlled studies comparing off-pump versus on-pump coronary artery bypass grafting in the elderly. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 63:60-68. [PMID: 34792312 DOI: 10.23736/s0021-9509.21.12012-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AIM Comparison of short and mid-term outcomes between off-pump CABG (OPCAB) and on-pump CABG (ONCAB) in patients older than 65 throughout a meta-analysis of randomized clinical trials (RCTs). EVIDENCE ACQUISITION A literature search was conducted using 3 databases. RCTs reporting mortality outcomes of OPCAB versus ONCAB among the elderly were included. Data on myocardial infarction, stroke, re-revascularization, renal failure and composite endpoints after CABG were also collected. Random effects models were used to compute statistical combined measures and 95% confidence intervals (CI). EVIDENCE SYNTHESIS Five RCTs encompassing 6221 patients were included (3105 OPCAB and 3116 ONCAB). There were no significant differences on mid-term mortality (pooled HR: 1.02, 95%CI: 0.89-1.17, p=0.80) and composite endpoint incidence (pooled HR: 0.98, 95%CI: 0.88-1.09, p=0.72) between OPCAB and ONCAB. At 30-day, there were no differences in mortality, myocardial infarction, stroke and renal complications. The need for early re-revascularization was significantly higher in OPCAB (pooled OR: 3.22, 95%CI: 1.28-8.09, p=0.01), with a higher percentage of incomplete revascularization being reported for OPCAB in trials included in this pooled result (34% in OPCAB vs 29% in ONCAB, p<0.01). CONCLUSIONS Data from RCTs in elderly patients showed that OPCAB and ONCAB provide similar mid-term results. OPCAB was associated with a higher risk of early rerevascularization. As CABG on the elderly is still insufficiently explored, further RCTs, specifically designed targeting this population, are needed to establish a better CABG strategy for these patients.
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Affiliation(s)
- Rui J Machado
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Francisca A Saraiva
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Jennifer Mancio
- Intensive Care and Perioperative Medicine Department, Royal Brompton and Harefield & Guys and St. Thomas NHS Foundation Trust, London, UK
| | - Patrícia Sousa
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rui J Cerqueira
- Cardiothoracic Surgery Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - António S Barros
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal
| | - André P Lourenço
- Anaesthesiology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Adelino F Leite-Moreira
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal - .,Cardiothoracic Surgery Department, Centro Hospitalar Universitário São João, Porto, Portugal
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14
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Gao Y, Li D, Dong H, Guo Y, Peng Y, Liu Y, Su P. Risk factors analysis of hyperbilirubinemia after off-pump coronary artery bypass grafting: a retrospective observational study. J Cardiothorac Surg 2021; 16:294. [PMID: 34629102 PMCID: PMC8503987 DOI: 10.1186/s13019-021-01678-6] [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] [Received: 06/28/2021] [Accepted: 09/25/2021] [Indexed: 12/04/2022] Open
Abstract
Background Hyperbilirubinemia is a common complication after off-pump coronary artery bypass grafting (OPCAB), but the incidence and the risk factors are unclear. This study aimed to analyze the incidence and risk factors of postoperative hyperbilirubinemia in patients undergoing OPCAB. Methods From December 2016 to March 2019, a total of 416 consecutive patients undergoing OPCAB were enrolled in this single-center retrospective study. Patients were divided into the normal serum total bilirubin group and the hyperbilirubinemia group based on the serum total bilirubin levels. Perioperative variables between the two groups were compared by univariate logistic regression analysis. Then, multivariate binary logistic regression analysis was used to analyze the independent risk factors of developing hyperbilirubinemia in patients underwent OPCAB. P < 0.05 was considered as statistically significant. Results Thirty two of 416 (7.7%) patients developed postoperative hyperbilirubinemia. Univariate regression analysis showed significant differences in gender (73.96% vs. 93.75%, P = 0.012), preoperative total bilirubin levels (11.92 ± 4.52 vs. 18.28 ± 7.57, P < 0.001), perioperative IABP implantation (22.66% vs. 43.75%, P = 0.008), perioperative blood transfusion (37.50% vs. 56.25%, P = 0.037) between the two groups. Multivariate logistic regression analysis revealed that elevated preoperative serum total bilirubin levels (OR = 1.225, 95% CI 1.145–1.310, P < 0.001), perioperative blood transfusion (OR = 4.488, 95% CI 1.876–10.737, P = 0.001) and perioperative IABP implantation (OR = 4.016, 95% CI 1.709–9.439, P = 0.001) were independent risk factors for hyperbilirubinemia after OPCAB. Conclusions Hyperbilirubinemia is also a common complication after OPCAB. Elevated preoperative serum total bilirubin levels, perioperative blood transfusion, and perioperative IABP implantation were independent risk factors for patients developing hyperbilirubinemia after OPCAB. Further studies need to be conducted to confirm the risk factors of hyperbilirubinemia after OPCAB procedure.
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Affiliation(s)
- Yingdi Gao
- Department of Cardiac Surgery, Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gong Ti South Road, Chaoyang District, Beijing, 100020, China
| | - Dongjie Li
- Department of Cardiac Surgery, Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gong Ti South Road, Chaoyang District, Beijing, 100020, China
| | - Honghong Dong
- Department of Thoracic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Yulin Guo
- Department of Cardiac Surgery, Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gong Ti South Road, Chaoyang District, Beijing, 100020, China
| | - Yuanshu Peng
- Department of Cardiac Surgery, Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gong Ti South Road, Chaoyang District, Beijing, 100020, China
| | - Yan Liu
- Department of Cardiac Surgery, Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gong Ti South Road, Chaoyang District, Beijing, 100020, China
| | - Pixiong Su
- Department of Cardiac Surgery, Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gong Ti South Road, Chaoyang District, Beijing, 100020, China.
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15
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Kitamura H, Tamaki M, Kawaguchi Y, Okawa Y. Results of off-pump coronary artery bypass grafting with off-pump first strategy in octogenarian. J Card Surg 2021; 36:4611-4616. [PMID: 34613636 PMCID: PMC9291825 DOI: 10.1111/jocs.16055] [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] [Received: 09/11/2021] [Accepted: 09/13/2021] [Indexed: 11/28/2022]
Abstract
Background and Aim Ischemic heart disease is the leading cause of death around the world. Coronary artery bypass grafting offers efficient surgical revascularization for ischemic disease. Both on‐ or off‐pump coronary artery bypass methods provide promising results to octogenarians, once complete vascularization is achieved. However, off‐pump bypass requires a certain level of experience to achieve sufficient results. We have applied an off‐pump coronary artery bypass‐first strategy to all generations since 2008. This study investigated early and long‐term results of surgical revascularization for octogenarians by a team with an off‐pump‐first strategy. Methods All cases of isolated coronary artery bypass grafting performed since 2008 were identified and divided into a young group (age < 80 years) and an old group (age ≥ 80 years). Peri‐operative results were investigated retrospectively in both groups and long‐term results for the old group were assessed. Results Among the 707 patients, 97% underwent off‐pump bypass, and 94 cases were classified to the old group. Distal anastomoses and ventilator time were identical between groups (young vs. old: 3.3 vs. 3.2; 3.7 h vs. 3.7 h). In‐hospital death rates were 0.5% and 0% in the young and old groups, respectively. With a mean follow‐up of 1318 days, actual 1‐, 3‐, and 5‐year survival rates for octogenarians were 92.1%, 81.2%, and 68.3%, respectively. Nearly half of the patients reached their nineties, which was close to the life expectancy of the national general octogenarian. Conclusions An experienced team with an off‐pump‐first strategy could provide valid therapeutic options for octogenarians.
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Affiliation(s)
- Hideki Kitamura
- Department of Cardiovascular Surgery, Nagoya Heart Center, Nagoya, Aichi, Japan
| | - Mototsugu Tamaki
- Department of Cardiovascular Surgery, Nagoya Heart Center, Nagoya, Aichi, Japan
| | - Yasuhiko Kawaguchi
- Department of Cardiovascular Surgery, Nagoya Heart Center, Nagoya, Aichi, Japan
| | - Yasuhide Okawa
- Department of Cardiovascular Surgery, Nagoya Heart Center, Nagoya, Aichi, Japan
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16
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Mohamed MO, Hirji S, Mohamed W, Percy E, Braidley P, Chung J, Aranki S, Mamas MA. Incidence and predictors of postoperative ischemic stroke after coronary artery bypass grafting. Int J Clin Pract 2021; 75:e14067. [PMID: 33534146 DOI: 10.1111/ijcp.14067] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/26/2021] [Accepted: 01/29/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Data on the incidence and outcomes of ischemic stroke in patients undergoing coronary artery bypass grafting (CABG) in the current era are limited. The goal of this study was to examine contemporary trends, predictors, and outcomes of ischemic stroke following CABG in a large nationally representative database over a 12-year-period. METHODS The National Inpatient Sample was used to identify all adult (≥18 years) patients who underwent CABG between 2004 and 2015. The incidence and predictors of post-CABG ischemic stroke were assessed and in-hospital outcomes of patients with and without post-CABG stroke were compared. RESULTS Out of 2 569 597 CABG operations, ischemic stroke occurred in 47 279 (1.8%) patients, with a rising incidence from 2004 (1.2%) to 2015 (2.3%) (P < .001). Patient risk profiles increased over time in both cohorts, with higher Charlson comorbidity scores observed amongst stroke patients. Stroke was independently associated with higher rates of in-hospital mortality (3-fold), longer lengths of hospital stay (~6 more days), and higher total hospitalisation cost (~$80 000 more). Age ≥60 years and female sex (OR 1.33, 95% CI 1.31-1.36) were the strongest predictors of stroke (both P < .001). Further, on-pump CABG was not an independent predictor of stroke (P = .784). CONCLUSION In this nationally representative study we have shown that the rates of postoperative stroke complications following CABG have increased over time to commensurate with a parallel increase in overall baseline patient risks. Given the adverse impact of stroke on in-hospital morbidity and mortality after CABG, further studies are warranted to systematically delineate factors contributing to this striking trend.
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Affiliation(s)
- Mohamed O Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Newcastle, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Walid Mohamed
- University Hospitals of Leicester NHS Foundation Trust, Leicester, UK
| | - Edward Percy
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Joshua Chung
- Department of Cardiac Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Sary Aranki
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Newcastle, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
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17
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Mauldon H, Dieberg G, Smart N, King N. Effect of Age on Clinical Outcomes Following On-/Off-Pump Coronary Artery Bypass: Meta-Analysis and Meta-Regression. Braz J Cardiovasc Surg 2020; 35:797-814. [PMID: 33118746 PMCID: PMC7598957 DOI: 10.21470/1678-9741-2018-0388] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective There is currently much debate about which patients would benefit more after on- or off-pump coronary artery bypass grafting (CABG). The aim of this meta-analysis and meta-regression is to investigate the effect of age on short-term clinical outcomes after these approaches. Methods To identify potential studies, systematic searches were carried out in the Excerpta Medica dataBASE (EMBASE), PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL). The search strategy included the key concepts of “cardiopulmonary bypass” AND “coronary artery bypass grafting” AND “off pump” OR “on pump”. This was followed by a meta-analysis and meta-regression investigating the effect of age on the incidences of stroke, myocardial infarction (MI), and mortality. Results Thirty-seven studies including 15,324 participants were analysed. Overall, there was a significant odds reduction for patients receiving off-pump CABG suffering a stroke (odds ratio [OR] 0.770, 95% confidence intervals [CI] 0.594, 0.998, P=0.048); however, when patients were subdivided according to different age bands, this difference disappeared. There were also no significant differences in the odds of mortality (OR 0.876, 95% CI 0.703, 1.093, P=0.241) or MI (OR 0.937, 95% CI 0.795, 1.105, P=0.439). Meta-regression analysis revealed no significant relationship between age and stroke (P=0.652), age and mortality (P=548), and age and MI (P=0.464). Conclusion Patients undergoing CABG are becoming older and may suffer from multiple comorbidities increasing their risk profile. However, with respect to short-term clinical outcomes, the patient’s age does not help in determining whether off- or on-pump is superior.
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Affiliation(s)
- Hayley Mauldon
- University of Plymouth Ringgold Standard Institution Plymouth United Kingdom of Great Britain and Northern Ireland University of Plymouth, Ringgold Standard Institution, Plymouth, United Kingdom of Great Britain and Northern Ireland
| | - Gudrun Dieberg
- University of New England Ringgold Standard Institution Armidale Australia University of New England, Ringgold Standard Institution, Armidale, Australia
| | - Neil Smart
- University of New England Ringgold Standard Institution Armidale Australia University of New England, Ringgold Standard Institution, Armidale, Australia
| | - Nicola King
- University of Plymouth Ringgold Standard Institution Plymouth United Kingdom of Great Britain and Northern Ireland University of Plymouth, Ringgold Standard Institution, Plymouth, United Kingdom of Great Britain and Northern Ireland
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18
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Perioperative safety of simultaneous off-pump coronary artery bypass grafting with non-cardiac surgery of moderate-to-severe severity. Coron Artery Dis 2020; 32:411-417. [PMID: 32976242 DOI: 10.1097/mca.0000000000000963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Knapik P, Hirnle G, Kowalczuk-Wieteska A, O.Zembala M, Pawlak S, Hrapkowicz T, Przybyłowski P, Nadziakiewicz P, Cieśla D, Perek B, Kapelak B, Cisowski M, Rogowski J, Pietrzyk E, Tobota Z, Zembala M. Off-pump versus on-pump coronary artery surgery in octogenarians (from the KROK Registry). PLoS One 2020; 15:e0238880. [PMID: 32913359 PMCID: PMC7482977 DOI: 10.1371/journal.pone.0238880] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/25/2020] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Piotr Knapik
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
- * E-mail:
| | - Grzegorz Hirnle
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Anetta Kowalczuk-Wieteska
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Michał O.Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Szymon Pawlak
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Tomasz Hrapkowicz
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Piotr Przybyłowski
- Silesian Centre for Heart Diseases, Zabrze, Poland
- First Chair of General Surgery, Jagiellonian University, Medical College, Cracow, Poland
| | - Paweł Nadziakiewicz
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Daniel Cieśla
- Department of Science and New Technologies, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Bartłomiej Perek
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Bogusław Kapelak
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Marek Cisowski
- First Department of Cardiac Surgery, American Heart of Poland, Bielsko-Biala, Poland
| | - Jan Rogowski
- Department of Cardiac and Vascular Surgery, Medical University of Gdańsk, Gdańsk, Poland
| | - Edward Pietrzyk
- Department of Cardiac Surgery, Świętokrzyskie Centre of Cardiology, Kielce, Poland
| | - Zdzisław Tobota
- Department of Paediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Marian Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
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20
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Xiao QX, Cheng CX, Deng R, Liu Q, Ren YB, He L, Yu FX, Zhang Y. LncRNA-MYL2-2 and miR-124-3p Are Associated with Perioperative Neurocognitive Disorders in Patients after Cardiac Surgery. J INVEST SURG 2020; 34:1297-1303. [PMID: 32727232 DOI: 10.1080/08941939.2020.1797949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Perioperative neurocognitive disorders (PND) resulting from cardiac surgery is a complication with high morbidity and mortality. However, the pathogenesis is unknown. METHODS For the sake of investigating the risk factors and mechanism of PND, we collected the characteristics and neurological scores of patients undergoing cardiac surgery in the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University and Affiliated Hospital of Southwest Medical University from Jan 1, 2016 to Dec 11, 2018. RESULTS We found that age and left atrial thrombus are independent risk factors for PND after cardiac surgery. Furthermore, the serum of 29 patients was collected on the 7th day after cardiac surgery for detecting the expression of lncRNA-MYL2-2 and miR-124-3p. Increased lncRNA-MYL2-2 and decreased miR-124-3p in serum were associated with the decline of patients' cognition. CONCLUSIONS LncRNA-MYL2-2 and miRNA-124-3p may jointly participate in the occurrence and development of PND after cardiac surgery. These important findings are advantaged to further understand the pathogenesis of PND and prevent it, provide new biomarkers for the diagnosis and monitoring of PND.
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Affiliation(s)
- Qiu-Xia Xiao
- Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan, China
| | - Chun-Xia Cheng
- Department of Ultrasound, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan, China
| | - Rui Deng
- Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan, China
| | - Qing Liu
- Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan, China
| | - Ying-Bo Ren
- Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan, China
| | - Li He
- Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan, China
| | - Feng-Xu Yu
- Department of Cardiothoracic Surgery, Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Ying Zhang
- Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan, China
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21
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Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2020; 40:87-165. [PMID: 30165437 DOI: 10.1093/eurheartj/ehy394] [Citation(s) in RCA: 3948] [Impact Index Per Article: 987.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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22
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Lorusso R, Moscarelli M, Di Franco A, Grazioli V, Nicolini F, Gherli T, De Bonis M, Taramasso M, Villa E, Troise G, Scrofani R, Antona C, Mariscalco G, Beghi C, Miceli A, Glauber M, Ranucci M, De Vincentiis C, Gaudino M. Association Between Coronary Artery Bypass Surgical Techniques and Postoperative Stroke. J Am Heart Assoc 2019; 8:e013650. [PMID: 31830873 PMCID: PMC6951073 DOI: 10.1161/jaha.119.013650] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The impact of the coronary artery bypass grafting (CABG) technique (on- versus off-pump, single versus multiple aortic clamping) on postoperative neurological outcome remains a matter of controversy. The aim of this study was to assess the association between the incidence of postoperative stroke and the degree of aortic manipulation in one of the largest contemporary CABG series. Methods and Results A retrospective, multicenter, international study was conducted in 25 388 patients undergoing isolated CABG procedures with on-pump CABG (ONCAB) or off-pump CABG (OPCAB) technique including single or multiple aortic clamping. Postoperative stroke was defined as a postoperative neurological deficit lasting more than 24 hours and associated with evidence of a brain lesion on computed tomography. The degree of aortic manipulation was assumed to be higher for on-pump versus off-pump surgery and for multiple versus single or no aortic clamping. Logistic regression and propensity matching were used. ONCAB procedures were performed in 17 231 cases and OPCAB in 8157. The incidence of postoperative stroke was significantly lower in the OPCAB group even after propensity matching (0.4% OPCAB versus 1.2% ONCAB, P=0.02). In the ONCAB group (but not in the OPCAB arm) the use of single aortic clamping was associated with significantly reduced postoperative stroke rate (odds ratio, 0.05; 95% CI, 0.008 to 0.07 [P<0.001]). Conclusions OPCAB and the use of single aortic clamping in the ONCAB arm were associated with a reduced incidence of postoperative stroke. Our data confirm a strong association between aortic manipulation and neurological outcome after CABG surgery.
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Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Unit, Heart and Vascular Centre Maastricht University Medical Centre (MUMC) Cardiovascular Research Institute Maastricht (CARIM) Maastricht The Netherlands.,Cardiac Surgery Unit Community Hospital Brescia Italy
| | - Marco Moscarelli
- Cardiothoracic and Vascular Department Maria Cecilia Hospital GVM Care & Research Cotignola (RA) Italy
| | - Antonino Di Franco
- Department of Cardio-Thoracic Surgery Weill Cornell Medicine New York NY
| | | | | | - Tiziano Gherli
- Cardiac Surgery Unit Ospedale Maggiore University of Parma Italy
| | - Michele De Bonis
- Cardiac Surgery Unit San Raffaele Hospital University of Milan Italy
| | | | - Emmanuel Villa
- Cardiac Surgery Unit Poliambulanza Hospital Fondazione Poliambulanza Brescia Italy
| | - Giovanni Troise
- Cardiac Surgery Unit Poliambulanza Hospital Fondazione Poliambulanza Brescia Italy
| | | | - Carlo Antona
- Cardiac Surgery Unit Ospedale Sacco University of Milan Italy
| | | | - Cesare Beghi
- Cardiac Surgery Unit Ospedale di Circolo University of Varese Italy
| | | | | | - Marco Ranucci
- Cardiac Surgery and Intensive Care Units S. Donato Hospital IRCCS University of Milan Italy
| | - Carlo De Vincentiis
- Cardiac Surgery and Intensive Care Units S. Donato Hospital IRCCS University of Milan Italy
| | - Mario Gaudino
- Department of Cardio-Thoracic Surgery Weill Cornell Medicine New York NY
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23
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Kitahara H, McCrorey M, Patel B, Nisivaco S, Balkhy HH. Benefit of Robotic Beating-Heart Totally Endoscopic Coronary Artery Bypass in Octogenarians. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 14:531-536. [PMID: 31533515 DOI: 10.1177/1556984519876901] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE An important advantage of robotic beating-heart totally endoscopic coronary artery bypass (TECAB) is early functional recovery, in which fragile patients like octogenarians (age >80 years) benefit most. The aim of this study was to investigate the safety and feasibility of TECAB in octogenarians. METHODS We retrospectively reviewed patients undergoing TECAB from July 2013 to September 2017 at our institution. Perioperative outcomes of octogenarian patients and that of younger patients were compared. RESULTS Of 308 patients who underwent TECAB, 28 patients (9.1%) were octogenarians (mean age 83.8 ± 3.0 years). Octogenarians had a higher rate of hypertension and atrial fibrillation compared to younger patients. TECAB was successfully performed without conversion to any larger incisions in octogenarians. Mean operative time (299 ± 83 minutes vs 281 ± 89 minutes, P = 0.309) and the rate of multivessel bypass (60.7% vs 58.2%, P = 0.798) were similar between octogenarians and younger patients. New atrial fibrillation was observed more frequently in octogenarians compared to younger patients (35.7% vs 18.6%, P = 0.031). Mean length of hospital stay was similar between the 2 groups (octogenarians: 3.9 ± 1.8 days vs younger patients: 3.5 ± 3.0 days, P = 0.475). Twenty-two octogenarians (78.6%) were discharged directly to home. In-hospital mortality was zero in octogenarians. CONCLUSIONS Robotic beating-heart TECAB had favorable results in octogenarians with acceptable morbidity and mortality and excellent short length of stay similar to younger patients.
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Affiliation(s)
- Hiroto Kitahara
- Department of Surgery, University of Chicago Medicine, IL, USA
| | | | - Brooke Patel
- Department of Surgery, University of Chicago Medicine, IL, USA
| | - Sarah Nisivaco
- Department of Surgery, University of Chicago Medicine, IL, USA
| | - Husam H Balkhy
- Department of Surgery, University of Chicago Medicine, IL, USA
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24
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Lee SO, Lee H, Cho YH, Jeong DS, Lee YT, Kim WS. Comparison of Off-Pump Coronary Artery Bypass between Octogenarians and Septuagenarians: A Propensity Score Analysis. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 52:155-161. [PMID: 31236375 PMCID: PMC6559184 DOI: 10.5090/kjtcs.2019.52.3.155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 11/19/2018] [Accepted: 11/21/2018] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Sang On Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Heemoon Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Seop Jeong
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Tak Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wook Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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25
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Matkovic M, Tutus V, Bilbija I, Milin Lazovic J, Savic M, Cubrilo M, Aleksic N, Atanasijevic I, Andrijasevic V, Putnik S. Long Term Outcomes of The Off-Pump and On-Pump Coronary Artery Bypass Grafting In A High-Volume Center. Sci Rep 2019; 9:8567. [PMID: 31189989 PMCID: PMC6561934 DOI: 10.1038/s41598-019-45093-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/29/2019] [Indexed: 12/25/2022] Open
Abstract
Coronary artery bypass grafting (CABG) remains the most frequent surgery in the practice of an adult cardiac surgeon and the most frequently performed cardiac surgical procedure worldwide. Despite the ongoing debates regarding the superiority or inferiority of off-pump coronary artery bypass grafting, it still comprises 15-30% of all CABG cases varying in different national registries. We performed a propensity matched study of 302 consecutive CABG patients,143 off -pump cases performed by the four experienced off-pump surgeons and the on-pump CABG cases performed by those surgeons and four other experienced coronary surgeons. The five year follow up was performed and data collected comprised of mortality, rehospitalization due to cardiac origin, repeated revascularization, myocardial infarction and cerebrovascular accident. Overall, the off-pump group of patients had a higher risk profile than the patients in the on-pump group. After matching, fewer differences were found between the groups. Propensity score matching analysis showed no difference in long-term survival as well as MACCE and repeated revascularization. The higher risk profile of the patients subjected to OPCAB and the comparable survival to lower risk CPB patients in this series indicate that in experienced hands, OPCAB is a valuable option in this important subgroup of patients.
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Affiliation(s)
- Milos Matkovic
- Department for Cardiac surgery, Clinical Center of Serbia, Koste Todorovica 8, 11000, Belgrade, Serbia.
| | - Vladimir Tutus
- Department for Anesthesiology and Intensive care, Clinical Center of Serbia, Koste Todorovica 8, 11000, Belgrade, Serbia
| | - Ilija Bilbija
- Department for Cardiac surgery, Clinical Center of Serbia, Koste Todorovica 8, 11000, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Doktora Subotica 15, 11000, Belgrade, Serbia
| | - Jelena Milin Lazovic
- Department for Biostatistics, Faculty of Medicine, University of Belgrade, Doktora Subotica 15, 11000, Belgrade, Serbia
| | - Marko Savic
- Department for Biostatistics, Faculty of Medicine, University of Belgrade, Doktora Subotica 15, 11000, Belgrade, Serbia
| | - Marko Cubrilo
- Department for Cardiac surgery, Clinical Center of Serbia, Koste Todorovica 8, 11000, Belgrade, Serbia
| | - Nemanja Aleksic
- Department for Cardiac surgery, Clinical Center of Serbia, Koste Todorovica 8, 11000, Belgrade, Serbia
| | - Igor Atanasijevic
- Institute for Cardiovascular diseases Dedinje, Heroja Milana Tepica 1, 11000, Belgrade, Serbia
| | - Vuk Andrijasevic
- Department for Cardiac surgery, Clinical Center of Serbia, Koste Todorovica 8, 11000, Belgrade, Serbia
| | - Svetozar Putnik
- Department for Cardiac surgery, Clinical Center of Serbia, Koste Todorovica 8, 11000, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Doktora Subotica 15, 11000, Belgrade, Serbia
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26
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Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferović PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. EUROINTERVENTION 2019; 14:1435-1534. [PMID: 30667361 DOI: 10.4244/eijy19m01_01] [Citation(s) in RCA: 310] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Franz-Josef Neumann
- Department of Cardiology & Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
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27
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Sousa-Uva M, Neumann FJ, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur J Cardiothorac Surg 2018; 55:4-90. [PMID: 30165632 DOI: 10.1093/ejcts/ezy289] [Citation(s) in RCA: 347] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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28
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Yuksel A, Yolgosteren A, Kan II, Cayir MC, Velioglu Y, Yalcin M, Tok M, Bicer M, Signak IS. A comparison of early clinical outcomes of off-pump and on-pump coronary artery bypass grafting surgery in elderly patients. Acta Chir Belg 2018; 118:99-104. [PMID: 28946812 DOI: 10.1080/00015458.2017.1383087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The reply of question of "which coronary artery bypass grafting (CABG) technique is superior in elderly patients, off-pump or on-pump CABG surgery?" is controversial. We aimed to compare the early clinical outcomes in elderly patients undergoing off-pump and on-pump CABG. METHODS From January 2009 to January 2015, 344 elderly patients (aged 70 or older) underwent off-pump (n = 137) or on-pump (n = 207) CABG. Patients' medical records were retrospectively reviewed, and their baseline preoperative characteristics, operative data and postoperative outcomes were analyzed, thereby a comparison of early outcomes between off-pump and on-pump patients was performed. RESULTS Mean age of patients was 74.4 ± 3.8 years. Both groups were statistically similar in terms of baseline preoperative characteristics. Number of distal bypass was significantly lower in off-pump group than in on-pump group. Postoperative length of intensive care unit and hospital stay were similar between two groups. Amounts of transfused blood products were significantly lower in off-pump CABG group. There were no significant differences in terms of postoperative complications and mortality between two groups. CONCLUSIONS Our results did not reveal a significant benefit of either surgical technique with respect to early-term clinical outcomes in elderly CABG patients. Further investigations are needed to determine whether off-pump CABG is superior than on-pump CABG in elderly patients.
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Affiliation(s)
- Ahmet Yuksel
- Department of Cardiovascular Surgery, Bursa State Hospital, Bursa, Turkey
| | - Atif Yolgosteren
- Department of Cardiovascular Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Iris Irem Kan
- Department of Cardiovascular Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
| | | | - Yusuf Velioglu
- Department of Cardiovascular Surgery, Abant Izzet Baysal University Faculty of Medicine, Bolu, Turkey
| | - Mustafa Yalcin
- Department of Cardiovascular Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Mustafa Tok
- Department of Cardiovascular Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Murat Bicer
- Department of Cardiovascular Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Isik Senkaya Signak
- Department of Cardiovascular Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
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29
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Benedetto U, Angelini GD, Caputo M, Feldman DN, Kim LK, Lau C, Di Franco A, Girardi LN, Gaudino M. Off- vs. on-pump coronary artery bypass graft surgery on hospital outcomes in 134,117 octogenarians. J Thorac Dis 2017; 9:5085-5092. [PMID: 29312714 DOI: 10.21037/jtd.2017.11.10] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Umberto Benedetto
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, UK
| | - Gianni D Angelini
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, UK
| | - Massimo Caputo
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, UK
| | - Dmitriy N Feldman
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Luke K Kim
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
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El-Essawi A, Breitenbach I, Haupt B, Brouwer R, Baraki H, Harringer W. Impact of minimally invasive extracorporeal circuits on octogenarians undergoing coronary artery bypass grafting. Have we been looking in the wrong direction? Eur J Cardiothorac Surg 2017; 52:1175-1181. [PMID: 28582490 DOI: 10.1093/ejcts/ezx156] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 04/23/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Minimally invasive extracorporeal circuits (MiECCs) aim at the preservation of physiologic reserves, the impact of which is expected to be most evident in patients in whom these are depleted. In this context, octogenarians present a subpopulation of specific interest. METHODS Based on the type of the utilized ECC, we performed a retrospective comparison between all octogenarians (n = 324) who received a primary coronary artery bypass in our institution from 2003 until 2010. RESULTS An MiECC was used in 52% of patients. Preoperative variables showed that the MiECC patients were older (83 ± 2 vs 82 ± 2 years; P = 0.001), had higher incidence of renal dysfunction (8% vs 3%; P = 0.04), moderately reduced left ventricular function (43 vs 33%; P = 0.07) and lower incidence of unstable angina (20% vs 28%; P = 0.06). To overcome these differences, a propensity score matching was performed and yielded 126 matched pairs of patients. The overall transfusion of packed red blood cells (2.3 ± 2.3 vs 3.4 ± 3.2 units per patint; P = <0.001), the rate of low cardiac output (0% vs 6%; P = 0.01) and the 30-day postoperative mortality (2.4% vs 9.5%; P = 0.02) were all in favour of the MiECC group in the matched patient population. CONCLUSIONS The MiECC concept has shown its benefits regarding both morbidity and mortality in this high-risk patient population. We believe that this beneficial effect finds its reason in a better preservation of physiologic reserves that are essential for a positive outcome in this patient group.
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Affiliation(s)
- Aschraf El-Essawi
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Germany
| | - Ingo Breitenbach
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Germany
| | - Benjamin Haupt
- Academy of Perfusion, German Heart Centre Berlin, Berlin, Germany
| | - Rene Brouwer
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Germany
| | - Hassina Baraki
- Department of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Wolfgang Harringer
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Germany
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Nicolini F, Vezzani A, Romano G, Carino D, Ricci M, Chicco MVD, Gherli T. Coronary Artery Bypass Grafting with Arterial Conduits in the Elderly. Int Heart J 2017; 58:647-653. [PMID: 28966319 DOI: 10.1536/ihj.16-468] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Although improved long-term outcomes obtained with the use of arterial grafts for coronary revascularization in comparison with the traditional association of a single arterial and saphenous vein grafts have been demonstrated in the overall population, the efficacy of this newer technique in the elderly is difficult to prove because their shorter life expectancy due to advanced heart disease, associated with severe comorbidities. Moreover, more widespread use of this technique is limited by the concerns on the potential morbidity, particularly the longer time required to perform the operation and the possibility of deep sternal wound infection in case of bilateral internal thoracic artery harvesting due to the decreased blood supply to the sternum and surrounding tissues.The review of the recent literature indicates that the use of bilateral internal thoracic arteries in very elderly patients should not be considered routinely. It seems reasonable to avoid it in octogenarians in the presence of well-known predictors of sternal complications such as diabetes, morbid obesity, and severe chronic lung disease.There is also still controversy about the superiority of the radial artery over the saphenous vein graft as a second or third conduit for surgical myocardial revascularization, although the majority of recent studies seem to support more liberal use of the radial artery as second arterial conduit in the elderly. Although a clinical benefit of arterial graft revascularization cannot be formally excluded for elderly patients, the increased complexity of this technique suggests that careful clinical judgment is necessary to select grafts for individual patients.
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Affiliation(s)
- Francesco Nicolini
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
| | | | - Giorgio Romano
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
| | - Davide Carino
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
| | - Matteo Ricci
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
| | | | - Tiziano Gherli
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
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Can we settle the on-pump or off-pump debate with more than a million patients? J Thorac Cardiovasc Surg 2017; 155:180-181. [PMID: 28942980 DOI: 10.1016/j.jtcvs.2017.08.106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 08/30/2017] [Indexed: 12/13/2022]
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Khan H, Uzzaman M, Benedetto U, Butt S, Raja SG. On- or off-pump coronary artery bypass grafting for octogenarians: A meta-analysis of comparative studies involving 27,623 patients. Int J Surg 2017; 47:42-51. [PMID: 28951288 DOI: 10.1016/j.ijsu.2017.09.054] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 09/13/2017] [Accepted: 09/16/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Coronary artery bypass grafting (CABG) is being increasingly offered to octogenarians. Both on- and off-pump CABG are reported as effective surgical revascularization strategies for octogenarians by single institution studies. However, the issue of superiority of one strategy over the other for octogenarians remains unresolved due to limited sample size of these studies. A meta-analysis of studies comparing outcomes of on- and off-pump CABG in octogenarians was undertaken to address the issue. METHODS A literature search was conducted from 1966 through September 2016 using MEDLINE, EMBASE, Scopus and Web of Science to identify relevant articles. Primary outcomes of interest included in-hospital mortality and stroke. Secondary outcomes of interest were atrial fibrillation, acute renal failure, reoperation for bleeding, deep sternal wound infection, myocardial infarction, intensive therapy unit (ITU) stay and hospital stay. The random effects model was used to calculate the outcomes of both binary and continuous data to control any heterogeneity between the studies. Heterogeneity amongst the trials was determined by means of the Cochran Q value and quantified using the I2 inconsistency test. All p-values were 2-sided and a 5% level was considered significant. RESULTS Sixteen retrospective studies (18,685 on-pump patients and 8938 off-pump patients) were included in the systematic review. In-hospital mortality (pooled OR = 0.64, 95% CI = 0.44 to 0.93; p = 0.02), stroke rate (pooled OR = 0.61, 95% CI = 0.48 to 0.76; p < 0.001) and length of hospital stay (pooled WMD = +0.29, 95% CI = +0.02 to +0.56; p = 0.04) were significantly lower in the off-pump patients. Atrial fibrillation (p = 0.36), acute renal failure (p = 0.47), reoperation for bleeding (p = 0.99), deep sternal wound infection (p = 0.59), myocardial infarction (p = 0.93), and length of ITU stay (p = 0.27) were comparable. CONCLUSION Off-pump compared to on-pump CABG offers surgical myocardial revascularization to octogenarians with lower in-hospital mortality, stroke rate and length of hospital stay with similar incidence of other adverse outcomes. Preferentially offering off-pump CABG to octogenarians could translate into reduced economic burden on the healthcare providers.
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Affiliation(s)
- Habib Khan
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom.
| | - Mohsin Uzzaman
- Department of Cardiac Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Umberto Benedetto
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
| | - Salman Butt
- Department of Cardiac Surgery, Kings College Hospital, London, United Kingdom
| | - Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom
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Arora RC, Manji RA, Singal RK, Hiebert B, Menkis AH. Outcomes of octogenarians discharged from the hospital after prolonged intensive care unit length of stay after cardiac surgery. J Thorac Cardiovasc Surg 2017; 154:1668-1678.e2. [PMID: 28688711 DOI: 10.1016/j.jtcvs.2017.04.083] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 04/13/2017] [Accepted: 04/26/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Octogenarians offered complex cardiac surgery frequently experience a prolonged intensive care unit length of stay; however, minimal data exist on the outcomes of these patients. We sought to determine the rates and predictors of 1-year noninstitutionalized survival ("functional survival") and rehospitalization for octogenarian patients with prolonged intensive care unit length of stay after cardiac surgery and who were discharged from hospital. METHODS The outcomes of discharged patients aged 80 years or more who underwent cardiac surgery with prolonged intensive care unit length of stay (≥5 consecutive days) from January 1, 2000, to December 31, 2011, were examined retrospectively from linked clinical and administrative provincial databases. Regression analysis was used to determine predictors of 1-year functional survival and rehospitalization after discharge from the hospital. RESULTS A total of 80 of 683 (11.7%) discharged octogenarian patients had prolonged intensive care unit length of stay. Functional survival at 1 year was 92% and 81% for those with nonprolonged and prolonged intensive care unit lengths of stay, respectively (P < .01). Lack of outpatient physician visits within 30 days of discharge (hazard ratio, 5.18; P < .01) was a significant predictor of poor 1-year functional survival. The 1-year rehospitalization rates were 38% and 48% for those with nonprolonged and prolonged intensive care unit lengths of stay, respectively, with 41% of all rehospitalizations occurring within 30 days of initial discharge. A rural residence (hazard ratio, 1.82; P < .01) and nosocomial pneumonia during patients' operative admissions (hazard ratio, 2.74; P < .01) were associated with rehospitalization within 30 days of discharge. CONCLUSIONS Octogenarians with prolonged intensive care unit length of stay have acceptable functional survival at 1 year but have high rates of early rehospitalization. Access to health services may influence functional survival and early rehospitalizations. These data suggest that close follow-up of these vulnerable patients after hospital discharge is warranted.
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Affiliation(s)
- Rakesh C Arora
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Rizwan A Manji
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rohit K Singal
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brett Hiebert
- Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alan H Menkis
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
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Calafiore AM, Prapas S, Osman A, Di Mauro M. Coronary artery bypass grafting off-pump or on-pump: another brick in the wall. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:168. [PMID: 28480204 DOI: 10.21037/atm.2017.03.52] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Sotirios Prapas
- Department of Cardiac Surgery, Henry Dunant Hospital, Athens, Greece
| | - Ahmed Osman
- Department of Critical Care, Cairo University, Giza, Egypt
| | - Michele Di Mauro
- Department of Cardiac Surgery, University G. D'Annunzio, Chieti, Italy
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Zhu ZG, Xiong W, Ding JL, Chen J, Li Y, Zhou JL, Xu JJ. Comparison of outcomes between off-pump versus on-pump coronary artery bypass surgery in elderly patients: a meta-analysis. Braz J Med Biol Res 2017; 50:e5711. [PMID: 28273208 PMCID: PMC5378450 DOI: 10.1590/1414-431x20165711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 12/13/2016] [Indexed: 11/29/2022] Open
Abstract
The aim of this study was to analyze if off-pump coronary artery bypass surgery (CABG) is associated with better treatment outcomes in elderly patients (>70 years of age) than on-pump CABG, using meta-analysis. Medline, PubMed, Cochrane and Google Scholar databases were searched until September 13, 2016. Sensitivity and quality assessment were performed. Twenty-two studies, three randomized control trials (RCTs) and 20 non-RCTs were included with 24,127 patients. The risk of death associated with on-pump or off-pump CABG in the RCTs were similar (pooled OR=0.945, 95%CI=0.652 to 1.371, P=0.766). However, in the non-RCTs, mortality risk was lower in patients treated with off-pump CABG than on-pump CABG (pooled OR=0.631, 95%CI=0.587 to 0.944, P=0.003). No differences were observed between the two treatment groups in terms of the occurrence of 30-day post-operative stroke or myocardial infarction (P≥0.147). In the non-RCTs, off-pump CABG treatment was associated with a shorter length of hospital stay (pooled standardized difference in means=-0.401, 95%CI=-0.621 to -0.181, P≤0.001). The meta-analysis with pooled data from non-RCTs, but not RCTs, found that mortality was lower with off-pump compared with on-pump CABG, and suggested that there may be some benefit of off-pump CABG compared with on-pump CABG in the risk of mortality and length of hospital stay.
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Affiliation(s)
- Z G Zhu
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - W Xiong
- Guangxi University of Chinese Medicine, Nanning, China
| | - J L Ding
- Department of Gastroenterology, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - J Chen
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Y Li
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - J L Zhou
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - J J Xu
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital of Nanchang University, Nanchang, China
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Wang J, Yu W, Zhao D, Liu N, Yu Y. In-Hospital and Long-Term Mortality in 35,173 Chinese Patients Undergoing Coronary Artery Bypass Grafting in Beijing: Impact of Sex, Age, Myocardial Infarction, and Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2017; 31:26-31. [DOI: 10.1053/j.jvca.2016.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Indexed: 11/11/2022]
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Neupane I, Arora RC, Rudolph JL. Cardiac surgery as a stressor and the response of the vulnerable older adult. Exp Gerontol 2017; 87:168-174. [PMID: 27125757 PMCID: PMC5081280 DOI: 10.1016/j.exger.2016.04.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 03/30/2016] [Accepted: 04/21/2016] [Indexed: 12/21/2022]
Abstract
In an aging population, recovery and restoration of function are critical to maintaining independence. Over the past 50years, there have been dramatic improvements made in cardiac surgery processes and outcomes that allow for procedures to be performed on an increasingly older population with the goal of improving function. Although improved function is possible, major surgical procedures are associated with substantial stress, which can severely impact outcomes. Past literature has identified that frail patients, who are vulnerable to the stress of surgery, are more likely to have postoperative major adverse cardiac and cerebrovascular events (OR 4.9, 95% confidence interval 1.6, 14.6). The objective of this manuscript is to examine preoperative frailty in biological, psychological, and social domains using cardiac surgery to induce stress. We systematically searched PubMed for keywords including "cardiac surgery, frailty, and aged" in addition to the biological, psychological, and social keywords. In the biological domain, we examine the association of physiological and physical vulnerabilities, as well as, the impact of comorbidities and inflammation on negative surgical outcomes. In the psychological domain, the impact of cognitive impairment, depression, and anxiety as vulnerabilities were examined. In the social domain, social structure, coping, disparities, and addiction as vulnerabilities are described. Importantly, there is substantial overlap in the domains of vulnerability. While frailty research has largely focused on discrete physical vulnerability criteria, a broader definition of frailty demonstrates that vulnerabilities in biological, psychological, and social domains can limit recovery after the stress of cardiac surgery. Identification of vulnerability in these domains can allow better understanding of the risks of cardiac surgery and tailoring of interventions to improve outcomes.
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Affiliation(s)
- Iva Neupane
- Center of Innovation in Long Term Services and Support, Providence VA Medical Center, Providence, RI, United States; Warren Alpert School of Medicine at Brown University, Providence, RI, United States
| | - Rakesh C Arora
- University of Manitoba, College of Medicine, Department of Surgery, Winnipeg, Manitoba, Canada
| | - James L Rudolph
- Center of Innovation in Long Term Services and Support, Providence VA Medical Center, Providence, RI, United States; Warren Alpert School of Medicine at Brown University, Providence, RI, United States.
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Davierwala PM. Current outcomes of off-pump coronary artery bypass grafting: evidence from real world practice. J Thorac Dis 2016; 8:S772-S786. [PMID: 27942395 DOI: 10.21037/jtd.2016.10.102] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Coronary artery bypass grafting (CABG) can be performed conventionally using cardiopulmonary bypass (CPB) and aortic clamping or on a beating heart (BH) without the use of CPB, the so-called off-pump CABG. Some surgeons, who are proponents of off-pump CABG, preferentially use this technique for the majority of operations, whereas others use it only in certain situations which warrant avoidance of CPB. Ever since the conception of off-pump CABG, the never-ending debate about which technique of CABG is safe and efficacious continues to date. Several randomized controlled trials (RCTs) have been conducted that have either favored on-pump CABG or have failed to show a significant difference in outcomes between the two techniques. However, these RCTs have been fraught with claims that they do not represent the majority of patients undergoing CABG in real world practice. Therefore, assessment of the benefits and drawbacks of each technique through observational and registry studies would be more representative of patients encountered in daily practice. The present review examines various retrospective studies and meta-analyses of observational studies that compare the early and long-term outcomes of off- and on-pump CABG, which assesses their safety and efficacy. Additionally, their outcomes in older patients, females, and those with diabetes mellitus, renal dysfunction, presence of ascending aortic disease, and/or acute coronary syndrome (ACS) have also been discussed separately. The general consensus is that early results of off-pump CABG are comparable to or in some cases better than on-pump CABG. However, on-pump CABG provides a survival benefit in the long term according to a majority of publications in literature.
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Affiliation(s)
- Piroze M Davierwala
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
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40
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Raja SG. Off-pump coronary artery bypass grafting in octogenarians. J Thorac Dis 2016; 8:S799-S807. [PMID: 27942398 PMCID: PMC5124585 DOI: 10.21037/jtd.2016.10.106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 08/29/2016] [Indexed: 11/06/2022]
Abstract
Enhanced life expectancy has confronted cardiac surgery with a rapidly growing population of octogenarians needing coronary artery bypass grafting (CABG). Octogenarians are deemed a high-risk patient population with increased postoperative morbidity and mortality following conventional CABG using cardiopulmonary bypass (CPB). In such patients reducing the invasiveness of the surgical procedure by avoiding CPB may be tried in an attempt to improve outcomes. The increasing performance of off-pump coronary artery bypass (OPCAB) grafting within certain centers reflects surgeon preference to avoid the inherent risks of CPB and cardioplegic arrest including hemodilution, nonpulsatile arterial flow, global myocardial ischemia, atherosclerotic embolization from aortic manipulation, and systemic inflammatory response. Although OPCAB grafting is a well-established surgical myocardial revascularization strategy, its actual benefits in terms of morbidity and mortality remain questionable in the general population. In the higher risk octogenarian patients, however, there is a potential for more tangible clinical benefits when CPB is avoided. This review article provides an overview of the impact of OPCAB grafting on postoperative mortality and morbidity in octogenarians.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, London, UK
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Arora RC, Djaiani G, Rudolph JL. Detection, Prevention, and Management of Delirium in the Critically Ill Cardiac Patient and Patients Who Undergo Cardiac Procedures. Can J Cardiol 2016; 33:80-87. [PMID: 28024558 DOI: 10.1016/j.cjca.2016.08.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 08/06/2016] [Accepted: 08/25/2016] [Indexed: 02/08/2023] Open
Abstract
Delirium is an acute change in cognitive functioning, characterized by inattention and associated with alterations in awareness and fluctuation in arousal, disorganized thinking, or altered level that preferentially affects older adult patients. In the acutely ill cardiac patient, the incidence of delirium has been reported as high as 73%, depending on the type and sensitivity of delirium assessment. Cardiac patients with delirium experience higher rates of in-hospital and longer-term mortality and are at risk for progressive cognitive impairment, loss of functional independence, and increased hospitalization costs. As such, delirium represents an undesirable outcome in cardiac patients. Care improvements such as identifying risk of delirium at time of admission or in the preoperative setting; training cardiologist, surgeons, anaesthesiologists and nurses to screen for delirium; implementing delirium prevention programs; and developing standardized delirium treatment protocols might reduce the incidence of delirium and its associated morbidity.
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Affiliation(s)
- Rakesh C Arora
- Department of Surgery, College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada.
| | - George Djaiani
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - James L Rudolph
- Center of Innovation in Long Term Services and Supports, Providence VA Medical Center; Center for Gerontology, Brown School of Public Health; and Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Pinho-Gomes AC, Taggart DP. Coronary artery bypass grafting for left main disease and the risk of stroke: Incidence, aetiology and prevention. Surgeon 2016; 15:155-160. [PMID: 27720167 DOI: 10.1016/j.surge.2016.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 09/04/2016] [Accepted: 09/10/2016] [Indexed: 10/20/2022]
Abstract
This review explores the association between left main disease and the increased risk of perioperative stroke following coronary artery bypass grafting, specifically addressing the potential underlying mechanisms and its potential prevention. In particular, this correlation appears stronger for patients with left main disease when compared to patients with isolated triple vessel disease. Even though evidence on this topic is limited and of modest quality, there appears to be a significant association between ascending aorta atherosclerosis and coronary artery disease. Furthermore, there seems to be a relationship between the severity and extent of carotid artery stenosis and coronary artery disease. Carotid artery disease is itself associated with atherosclerosis of the ascending aorta, a well-recognised risk factor for postoperative atheroembolic stroke. The association between left main disease, ascending aorta atherosclerosis and carotid artery stenosis may reflect an increased systemic atherosclerotic burden and hence explain, at least partially, the higher risk of perioperative cerebrovascular events. Potential pre-, intra- and post-operative strategies for stroke prevention are discussed.
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Affiliation(s)
| | - David P Taggart
- Department of Cardiac Surgery, Oxford University Hospitals Trust, Oxford, United Kingdom
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O'Neill DE, Knudtson ML, Kieser TM, Graham MM. Considerations in Cardiac Revascularization for the Elderly Patient: Age Isn't Everything. Can J Cardiol 2016; 32:1132-9. [DOI: 10.1016/j.cjca.2016.05.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/04/2016] [Accepted: 05/04/2016] [Indexed: 02/04/2023] Open
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Abstract
PURPOSE OF REVIEW This review will examine the current role of off-pump coronary artery bypass (OPCAB) surgery compared with on-pump coronary artery bypass (ONCAB) surgery for the revascularization of ischemic myocardium. RECENT FINDINGS Recent studies have confirmed earlier findings that OPCAB is associated with less grafts per patient and less complete revascularization, and increased incidence of recurrent angina and need for repeat revascularization procedures, and more frequent rehospitalization for cardiac-related issues. OPCAB does not prevent postoperative renal dysfunction and is associated with worse long-term outcomes. Hospital costs are not reduced and are increased in those OPCAB patients who require intraoperative conversion to ONCAB procedures; however, when multiple arterial grafts are used and a complete revascularization is performed, OPCAB outcomes are equivalent to those of ONCAB procedures. SUMMARY OPCAB should only be performed by surgeons experienced in this technique in patients in whom a complete revascularization can be achieved; preferably with multiple arterial grafts.
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Abstract
For the year 2015, almost 19,000 published references can be found in PubMed when entering the search term "cardiac surgery". The last year has been again characterized by lively discussions in the fields where classic cardiac surgery and modern interventional techniques overlap. Lacking evidence in the field of coronary revascularization with either percutaneous coronary intervention or bypass surgery has been added. As in the years before, CABG remains the gold standard for the revascularization of complex stable triple-vessel disease. Plenty of new information has been presented comparing the conventional to transcatheter aortic valve implantation (TAVI) demonstrating similar short- and mid-term outcomes at high and low risk, but even a survival advantage with transfemoral TAVI at intermediate risk. In addition, there were many relevant and interesting other contributions from the purely operative arena. This review article will summarize the most pertinent publications in the fields of coronary revascularization, surgical treatment of valve disease, heart failure (i.e., transplantation and ventricular assist devices), and aortic surgery. While the article does not have the expectation of being complete and cannot be free of individual interpretation, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery.
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Coronary Artery Bypass Graft Should Be Considered in Octogenarians With Multivessel Coronary Disease. Can J Cardiol 2016; 32:1045.e1-3. [PMID: 27020583 DOI: 10.1016/j.cjca.2016.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 01/28/2016] [Accepted: 01/28/2016] [Indexed: 12/16/2022] Open
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Arora RC, Singal RK. Severe hyperlactatemia after cardiac surgery: Sorting out the badness. J Thorac Cardiovasc Surg 2015; 151:830-831. [PMID: 26707725 DOI: 10.1016/j.jtcvs.2015.11.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 11/20/2015] [Indexed: 01/01/2023]
Affiliation(s)
- Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada.
| | - Rohit K Singal
- Section of Cardiac Surgery, Department of Surgery, College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada
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Parissis H, Mbarushimana S, Ramesh BC, Parissis M, Lampridis S, Mhandu P, Al-Alao B. The impact of off-pump surgery in end-organ function: practical end-points. J Cardiothorac Surg 2015; 10:159. [PMID: 26555853 PMCID: PMC4640374 DOI: 10.1186/s13019-015-0362-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 10/28/2015] [Indexed: 01/16/2023] Open
Abstract
Most surgeons perform coronary bypass surgery with the aid of cardiopulmonary bypass, which inflicts a massive systemic inflammatory response to the body leading to adverse clinical outcome. In an attempt to make CABG less invasive, interest have been diverted to the off pump technique. The current review attempts to bring an insight onto the last ten years knowledge on the off-pump impact in end organ function, with an aim to draw some clear conclusions in order to allow practitioners to reflect on the subject.
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Affiliation(s)
- Haralabos Parissis
- Cardiothoracic Department, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | - Simon Mbarushimana
- Cardiothoracic Department, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | | | - Mondrian Parissis
- Cardiothoracic Department, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | - Savvas Lampridis
- Cardiothoracic Department, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | - Peter Mhandu
- Cardiothoracic Department, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | - Bassel Al-Alao
- Thoracic Department, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Bassano C, Bovio E, Uva F, Iacobelli S, Iasevoli N, Farinaccio A, Ruvolo G. Partially anaortic clampless off-pump coronary artery bypass prevents neurologic injury compared to on-pump coronary surgery: a propensity score-matched study on 286 patients. Heart Vessels 2015; 31:1412-7. [PMID: 26498755 PMCID: PMC5010601 DOI: 10.1007/s00380-015-0748-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 09/09/2015] [Indexed: 11/26/2022]
Abstract
Anaortic coronary artery bypass proved to prevent early neurologic injury compared to on-pump CABG. The Cardica PAS-Port(®) is a fully automated device that might be able to perform proximal aorto-venous anastomoses without an increased embolic risk. We evaluated early post-operative neurologic outcome in a matched population following clampless OPCAB (CCAB: either "all-arterial" or with automatically anastomosed venous grafts) or on-pump CABG. 366 consecutive patients were submitted to isolated coronary bypass by a single surgeon experienced in both off and on-pump procedures between January 2009 and December 2013. Of these patients, 223 underwent a clampless off-pump revascularization. After propensity score matching, 143 pairs were selected, who received either off-pump or on-pump surgery. In the off-pump group, CCAB was performed with an all-arterial approach (n = 33) or with automated proximal anastomosis of the venous graft(s) by means of the Cardica PAS-Port(®) connector (n = 110). Neurologic injury was defined as non-reversible (NRNI: lethal coma or stroke) or reversible (RNI: TIA or delirium). Operative mortality was 2.4 % (CCAB 1.4 %; CABG 3.5 %; p = 0.14). The global rate of early neurologic injury was 5.6 % (CCAB 2.1 vs. CABG 9.1 %; p = 0.006). Incidence was 1.4 % for NRNI (CCAB 0 vs. CABG 2.8 %; p = 0.04) and 4.2 % for RNI (CCAB 2.1 vs. CABG 6.3 %; p = 0.06). No differences were found among other major perioperative outcomes. CCAB prevents both early post-operative RNI and NRNI. This result can be achieved with a totally anaortic strategy and also with the aid of a fully automated device for proximal aorto-venous anastomoses.
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Affiliation(s)
- Carlo Bassano
- Operative Units of Cardiac Surgery, Tor Vergata University, Rome, Italy.
| | - Emanuele Bovio
- Operative Units of Cardiac Surgery, Tor Vergata University, Rome, Italy
| | - Floriano Uva
- Operative Units of Cardiac Surgery, Tor Vergata University, Rome, Italy
| | - Simona Iacobelli
- Interdepartmental Center of Biostatistics and Bioinformatics, Tor Vergata University, Rome, Italy
| | - Nicola Iasevoli
- Operative Units of Anesthesiology, Tor Vergata University, Rome, Italy
| | - Andrea Farinaccio
- Operative Units of Anesthesiology, Tor Vergata University, Rome, Italy
| | - Giovanni Ruvolo
- Operative Units of Cardiac Surgery, Tor Vergata University, Rome, Italy
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Coronary artery bypass grafting in octogenarians: only when percutaneous coronary intervention is not feasible? Curr Opin Cardiol 2015; 30:636-42. [PMID: 26352246 DOI: 10.1097/hco.0000000000000222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to review recent literature reporting the results of coronary revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients older than 80 years. RECENT FINDINGS The review of recent studies on octogenarians demonstrates a surgical CABG advantage in the case of patients with increasing baseline coronary risk, such as severe multivessel disease, chronic total occlusions, and left ventricular dysfunction. PCI seems to be more appropriate for less severe degree and distribution of coronary lesions, and for subgroups of patients with higher surgical risk, such as acute coronary syndromes, reoperations, malignancy, dementia, poor mobility, frailty, and serious comorbidities contraindicating extracorporeal circulation. SUMMARY It is not the case that CABG is indicated only when there are contraindications to PCI. CABG confers more benefit than PCI in patients with increasing baseline cardiac risk, in the absence of serious systemic diseases that can reasonably reduce their life expectancy.CABG and PCI, with proper selection, should be considered complementary rather than competitive procedures in the therapy of octogenarians affected by coronary artery disease.
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