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Ikeda M, Niinami H, Morita K, Saito S, Yoshitake A. Long-term results following off-pump coronary-artery bypass grafting in left ventricular dysfunction. Heart Vessels 2024; 39:571-581. [PMID: 38461187 PMCID: PMC11189952 DOI: 10.1007/s00380-024-02383-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 02/28/2024] [Indexed: 03/11/2024]
Abstract
Severe left ventricular (LV) dysfunction is an independent risk factor for early and long-term mortality after coronary-artery bypass grafting (CABG). Off-pump CABG (OPCAB) significantly reduces the early incidence of major complications in high-risk patients. Moreover, bilateral internal thoracic artery (BITA) grafting after CABG is associated with improved long-term outcomes. We aimed to evaluate the impact of multivessel OPCAB with BITA grafting for complete revascularization on postoperative and long-term outcomes in patients with low LV ejection fraction (EF). We included 121 patients with EF ≤ 30.0% who underwent isolated multivessel OPCAB (average LVEF, 24.8%) between April 2007 and December 2019. Sixty-six patients received BITA grafts, while 55 had single internal thoracic artery (SITA) grafts. We conducted multivariate analyses to examine the correlation between perioperative data and late mortality rate. The early mortality rate was 1.65%. After excluding in-hospital mortality cases, we performed long-term follow-up of 119 patients. Early postoperative echocardiography showed significant LVEF improvement in 89 (75.2%) patients. However, LVEF remained ≤ 30.0% in 30 (24.8%) patients. We recorded 15 and 30 cases of cardiac death and cardiac events, respectively, during the long-term follow-up period. Postoperative LVEF ≤ 30.0% (P < 0.01) and no use of BITA grafting (P = 0.03) were significant predictors of cardiac death and events; moreover, hemodialysis was a significant predictor of all-cause mortality rather than cardiac death. Multivessel OPCAB in patients with severe LV dysfunction was associated with acceptable in-hospital mortality and early postoperative improvement in LV function. Additionally, OPCAB with BITA grafting may provide long-term benefits with respect to cardiac death and events. However, the long-term benefits were significantly limited in patients without early postoperative improvement in LV function and patients with chronic hemodialysis.Clinical registration number: 5590 (14/5/2020 Tokyo Women's Medical University).
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Affiliation(s)
- Masahiro Ikeda
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan.
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
| | - Kozo Morita
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
| | - Satoshi Saito
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
| | - Akihiro Yoshitake
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
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Outcomes of isolated CABG from “OPCAB favor institution” for patients with left ventricular dysfunction. Gen Thorac Cardiovasc Surg 2022:10.1007/s11748-022-01894-4. [DOI: 10.1007/s11748-022-01894-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 11/22/2022] [Indexed: 12/04/2022]
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Letsou GV, Musfee FI, Zhang Q, Loor G, Lee AD. Stroke and mortality rates after off-pump vs. pump-assisted/no-clamp coronary artery bypass grafting. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:742-748. [PMID: 36168952 DOI: 10.23736/s0021-9509.22.12337-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Ascending aorta manipulation during on-pump coronary artery bypass grafting (CABG) surgery can release embolic matter and may cause stroke. Strategies for lowering the stroke rate associated with coronary artery bypass grafting surgery include off-pump surgery without cardiopulmonary bypass and pump-assisted surgery with minimal aortic manipulation (i.e., without aortic cross-clamping). We examined whether one approach is superior to the other in reducing stroke and perioperative mortality rates. METHODS We reviewed consecutive elective, urgent, and emergency off-pump/no-bypass and pump-assisted/no-clamp coronary artery bypass grafting procedures performed by a single surgeon at our institution from June 2011 through October 2017. RESULTS Of 570 patients analyzed, 395 (69.3%) underwent off-pump/no-bypass surgery, 43 (7.5%) underwent pump-assisted/no-clamp surgery, and 132 (23.2%) transitioned mid-procedure from off-pump/no-bypass to pump-assisted/no-clamp surgery. Patients who were >70 years old, were female, or had diabetes, cardiomegaly, or a history of myocardial infarction or congestive heart failure were more likely to undergo pump-assisted/no-clamp surgery or the combined technique. None of the pump-assisted/no-clamp patients had a stroke, versus 0.3% of the off-pump/no-bypass patients and 0.8% of the combination patients. Stroke and in-hospital mortality rates did not differ by technique. CONCLUSIONS A hybrid strategy incorporating off-pump, pump-assisted, and combined off-pump/pump-assisted techniques achieved very low stroke rates in patients undergoing coronary revascularization. Perioperative mortality was similar for all three techniques. Avoiding aortic clamping may be crucial for decreasing CABG-related stroke rates. Off-pump/no-bypass surgery had no significant advantage over the pump-assisted/no-clamp or combined techniques in reducing the stroke rate after coronary artery bypass grafting surgery.
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Affiliation(s)
- George V Letsou
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Cardiothoracic Transplantation and Circulatory Support, Texas Heart Institute, Houston, TX, USA
| | - Fadi I Musfee
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UT Health School of Public Health, Houston, TX, USA
| | - Qianzi Zhang
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Gabriel Loor
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Cardiothoracic Transplantation and Circulatory Support, Texas Heart Institute, Houston, TX, USA
| | - Andrew D Lee
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA
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On-pump beating heart versus off-pump myocardial revascularization-a propensity-matched comparison. Indian J Thorac Cardiovasc Surg 2021; 37:639-646. [PMID: 34776662 DOI: 10.1007/s12055-021-01209-x] [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] [Received: 02/15/2021] [Revised: 04/29/2021] [Accepted: 05/02/2021] [Indexed: 10/20/2022] Open
Abstract
Objective On-pump beating heart (OP-BH) coronary artery bypass grafting (CABG) is often undertaken as an alternative between off-pump coronary artery bypass (OPCAB) and conventional on-pump coronary artery bypass grafting (On-pump CABG), especially in India. However, outcome data following OP-BH surgery is sparse. The aim of this study was to compare the outcomes of OP-BH CABG with OPCAB. Methods From our institutional database, all patients undergoing OP-BH CABG (n = 531) were identified. A propensity-matched cohort undergoing OPCAB (n = 531) was identified from the database. Nearest neighbor matching technique was used and the groups were matched for variables including age, gender, body mass index, EuroSCORE, history of recent myocardial infarction or unstable angina, hypertension, peripheral vascular disease, chronic obstructive airway disease, diabetes, pre-op renal impairment, pre-op neurological events, and left ventricular function. Results The propensity-matched groups were well matched in terms of baseline characteristics. The mean EuroSCORE was 3.17 and 3.20 in the OP-BH and the OPCAB groups. The unadjusted 30-day mortality in the propensity-matched OPCAB group was 2.07% (11/531) while mortality in the on-pump beating heart group was significantly higher at 6.9% (37/531). Multivariate analysis showed that OP-BH CABG was an independent risk factor for 30-day mortality as well as major adverse post-operative outcomes including renal, neurological, and respiratory outcomes and post-operative atrial fibrillation. Conclusions OP-BH CABG is associated with worse clinical outcomes compared to patients undergoing OPCAB.
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Jiang R, Wang Y, Pang L, Sun X, Chu X, Wang F, Huang J. Feasibility of off-pump coronary artery grafting for patients with impaired left ventricular ejection fraction: A retrospective cohort study from a single institutional database. J Card Surg 2021; 36:1935-1942. [PMID: 33665893 DOI: 10.1111/jocs.15462] [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] [Received: 12/20/2020] [Revised: 02/05/2021] [Accepted: 02/14/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Despite substantial advances in surgical practice, the management of patients with impaired left ventricular ejection fraction (LVEF) remains challenging. Furthermore, evidence on the outcomes of off-pump coronary artery bypass (OPCAB) surgery in this population is inconsistent. We conducted the present study to compare the short- and long-term outcomes of OPCAB in patients with different ejection fractions. METHODS This retrospective cohort study used data from the Hua-Shan Cardiac Surgery and included consecutive patients aged ≥ 18 years who underwent OPCAB procedures during 2016-2019. The patients included in the study were followed up until death or the end of data collection. Patients with different ejection fractions were matched 1:2 using propensity score matching. Factors associated with short-term outcomes were determined using logistic regression, and Kaplan-Meier survival analyses for the differences in all-cause death were generated. RESULTS The two propensity score matched groups consisted of 40 left ventricular dysfunction (LVD) and 80 normal left ventricular function (NLVF) patients. No significant intergroup differences were observed in the postoperative outcomes for the occurrence of left heart failure (22.5% in LVD vs. 5.0% in NLVF, p = .009). Age (odds ratio = 1.11, 95% confidence interval = 1.04-1.18) but not the preoperative LVEF was shown to be a strong predictor of short-term events in logistic regression analyses. Kaplan-Meier curves displayed similar freedom from all-cause death (p = .119) or cardio-death (p = .092) between groups. CONCLUSION The immediate postoperative outcomes and long-term outcomes were similar between the groups, indicating that OPCAB is a safe and effective choice for patients with LVD.
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Affiliation(s)
- Rongrong Jiang
- Department of Cardiothoracic Surgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Yiqing Wang
- Department of Cardiothoracic Surgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Liewen Pang
- Department of Cardiothoracic Surgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Xiaotian Sun
- Department of Cardiothoracic Surgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Xianglin Chu
- Department of Cardiothoracic Surgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Fangrui Wang
- Department of Cardiothoracic Surgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Jiechun Huang
- Department of Cardiothoracic Surgery, Huashan Hospital, Fudan University, Shanghai, PR China
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Spetsotaki K, Zayat R, Donuru S, Autschbach R, Schnoering H, Hatam N. Evaluation of Left Ventricular Myocardial Work Performance in Patients Undergoing On-Pump and Off-Pump Coronary Artery Bypass Surgery. Ann Thorac Cardiovasc Surg 2020; 26:276-285. [PMID: 32893224 PMCID: PMC7641886 DOI: 10.5761/atcs.oa.20-00066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: Benefits of off-pump coronary bypass (OPCAB) over on-pump (ONCAB) remain controversial. We aimed to evaluate the early impacts of OPCAB vs ONCAB for varying left ventricular (LV) function baselines by applying the non-invasive myocardial work (MW) analysis, which enables further insights in cardiac mechanics, contractility, and efficacy. Methods: We retrospectively analyzed 98 patients (55 ONCAB vs 43 OPCAB). Transthoracic echocardiography (TTE) and concurrent arterial blood pressure measurements taken at rest, prior to, and early after surgery were performed. Global myocardial work index (GMWI), global constructive work (GCW), and global work efficiency (GWE), inter alia, were quantified. Results: Preoperatively, OPCAB patients had significantly lower values than ONCAB patients in terms of GMWI (1404.33 ± 585.41 mmHg% vs 1619.07 ± 535.42 mmHg%, p = 0.039), GWE (90% (60%, 96%) vs 93% (74%, 98%), p = 0.028). After surgery, GMWI was reduced in both groups. However, a more significant GMWI impairment occurred early after ONCAB than after OPCAB (−343.14 ± 35.20 mmHg%, p <0.001 vs −224.04 ± 120.91 mmHg%, p = 0.042). Conclusion: Despite lower preoperative LV function in OPCAB patients, GMWIs after OPCAB were superior to ONCAB, indicating better preservation of systolic LV function early after OPCAB by means of contractility compared to ONCAB. Further studies should investigate the long-term course of MW response and their clinical impact.
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Affiliation(s)
- Konstantina Spetsotaki
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Rashad Zayat
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Srinath Donuru
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Ruediger Autschbach
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Heike Schnoering
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Nima Hatam
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
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Sepehripour AH, Chaudhry UA, Suliman A, Kidher E, Sayani N, Ashrafian H, Harling L, Athanasiou T. How revascularization on the beating heart with cardiopulmonary bypass compares to off-pump? A meta-analysis of observational studies. Interact Cardiovasc Thorac Surg 2015; 22:63-71. [DOI: 10.1093/icvts/ivv291] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 08/18/2015] [Indexed: 11/12/2022] Open
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Sepehripour AH, Chaudhry UA, Harling L, Athanasiou T. Off-pump or on-pump beating heart: which technique offers better outcomes following coronary revascularization?: Table 1:. Interact Cardiovasc Thorac Surg 2015; 20:546-9. [DOI: 10.1093/icvts/ivu451] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Parissis H, Ramesh BC, Al-Alao B. Off-pump coronary surgery: current justifications. Gen Thorac Cardiovasc Surg 2014; 62:660-70. [PMID: 25208659 DOI: 10.1007/s11748-014-0470-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 09/01/2014] [Indexed: 11/25/2022]
Abstract
Although the literature has failed to project an overall superiority of off-pump vs. on-pump surgery, nevertheless, small randomized control trials and large meta-analysis studies have concluded that the incidence of a stroke is less than 1 % when anaortic off-pump techniques are advocated in patients with diseased ascending aorta. Furthermore, off-pump techniques or their combination with hybrid procedures may lead to a reduction of adverse outcome in the aged high-risk population with concomitant poor left ventricular function and co-morbidities. However, despite this, controversy still exists among the cardiac surgery community in terms of the benefit of this technique and its safety; hence, off-pump is becoming out of fashion. In this review paper, by looking at a "marginal group of patients" (elderly, high risks, atherosclerotic aortas) we attempt to re-establish and justify this technique and re-invent its usage.
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Affiliation(s)
- Haralabos Parissis
- Cardiothoracic Department, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK,
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Raja SG, Husain M, Salhiyyah K, Navaratnarajah M, Chudasama D, Walker CP, Amin F, Amrani M. Concomitant off-pump coronary artery bypass grafting results in improved in-hospital outcomes for patients with ischemic mitral regurgitation undergoing surgery. Heart Surg Forum 2013; 16:E15-20. [PMID: 23439351 DOI: 10.1532/hsf98.20121039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Surgical management of ischemic mitral regurgitation (IMR) has primarily consisted of revascularization with or without the addition of mitral valve repair or replacement. We hypothesize that performing off-pump coronary artery bypass (OPCAB) grafting before fixing MR improves in-hospital outcomes for patients with IMR undergoing surgery. METHODS From January 2000 through December 2010, a total of 96 consecutive patients with moderate or severe IMR, as determined by preoperative echocardiography, underwent on-pump coronary artery bypass grafting (CABG) (n = 66) or OPCAB (n = 30) revascularization with concomitant mitral valve repair or replacement. A retrospective analysis of a prospectively collected cardiac surgery database (PATS; Dendrite Clinical Systems, Oxford, UK) was performed. In addition, medical notes and charts were reviewed for all study patients. RESULTS The 2 groups had similar preoperative demographic and EuroSCORE risk-stratification characteristics. The operative mortality rate for the entire cohort was 9.4%. Patients who underwent OPCAB grafting had a lower operative mortality than those who underwent CABG (3.3% versus 12.1%; P = .006). The mean ±SD cardiopulmonary bypass time (82.7 ± 34.7 minutes versus 160.7 ± 45.2 minutes; P < .001) and cross-clamp time (49.0 ± 22.4 minutes versus 103.4 ± 39.5 minutes; P < .001) were significantly shorter in the off-pump group than in the on-pump group. The OPCAB group also had significantly less in-hospital morbidity and shorter stays in the intensive care unit and the hospital. CONCLUSION Our analysis shows that OPCAB grafting (compared with conventional CABG) before repairing MR is associated with favorable in-hospital outcomes for patients undergoing surgery for IMR.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, London, UK.
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