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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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Dhurandhar V, Saxena A, Parikh R, Vallely MP, Wilson MK, Butcher JK, Black DA, Tran L, Reid CM, Bannon PG. Comparison of the Safety and Efficacy of On-Pump (ONCAB) versus Off-Pump (OPCAB) Coronary Artery Bypass Graft Surgery in the Elderly: A Review of the ANZSCTS Database. Heart Lung Circ 2015; 24:1225-32. [DOI: 10.1016/j.hlc.2015.04.162] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 03/24/2015] [Accepted: 04/04/2015] [Indexed: 11/29/2022]
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Dhurandhar V, Saxena A, Parikh R, Vallely MP, Wilson MK, Butcher JK, Black DA, Tran L, Reid CM, Bannon PG. Outcomes of On-Pump versus Off-Pump Coronary Artery Bypass Graft Surgery in the High Risk (AusSCORE > 5). Heart Lung Circ 2015; 24:1216-24. [DOI: 10.1016/j.hlc.2015.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 02/10/2015] [Accepted: 02/13/2015] [Indexed: 10/23/2022]
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Edelman JJ, Tatoulis J, Hayward PA, Smith JA, Costa RJ, Vallely MP, Bannon PG. ANZSCTS Response to the Discussion Paper: Proposed Recommendations for Myocardial Revascularisation. Heart Lung Circ 2015; 24:646-8. [PMID: 25637251 DOI: 10.1016/j.hlc.2014.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 11/26/2014] [Indexed: 11/28/2022]
Affiliation(s)
- J J Edelman
- Australian and New Zealand Society of Cardiac and Thoracic Surgeons, Sydney, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital; The Baird Institute; University of Sydney, Sydney, Australia
| | - J Tatoulis
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital; Department of Surgery, University of Melbourne
| | - P A Hayward
- Australian and New Zealand Society of Cardiac and Thoracic Surgeons, Sydney, Australia; Victorian Heart Centre, Epworth Hospital; Department of Cardiac Surgery, Austin Hospital; University of Melbourne, Melbourne, Australia
| | - J A Smith
- Australian and New Zealand Society of Cardiac and Thoracic Surgeons, Sydney, Australia; Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (Monash Medical Centre), Monash University, Clayton, Victoria, Australia
| | - R J Costa
- Australian and New Zealand Society of Cardiac and Thoracic Surgeons, Sydney, Australia; Department of Cardiothoracic Surgery, Westmead Hospital, Sydney, Australia
| | - M P Vallely
- Australian and New Zealand Society of Cardiac and Thoracic Surgeons, Sydney, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital; The Baird Institute; University of Sydney, Sydney, Australia
| | - P G Bannon
- Australian and New Zealand Society of Cardiac and Thoracic Surgeons, Sydney, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital; The Baird Institute; University of Sydney, Sydney, Australia.
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Seco M, Edelman JJB, Forrest P, Ng M, Wilson MK, Fraser J, Bannon PG, Vallely MP. Geriatric cardiac surgery: chronology vs. biology. Heart Lung Circ 2014; 23:794-801. [PMID: 24851829 DOI: 10.1016/j.hlc.2014.04.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 03/14/2014] [Accepted: 04/04/2014] [Indexed: 01/25/2023]
Abstract
Cardiac surgery is increasingly performed in elderly patients, and whilst the incidence of common risk factors associated with poorer outcome increases with age, recent studies suggest that outcomes in this population may be better than is widely appreciated. As such, in this review we have examined the current evidence for common cardiac surgical procedures in patients aged over 70 years. Coronary artery bypass grafting (CABG) in the elderly has similar early safety to percutaneous intervention, though repeat revascularisation is lower. Totally avoiding instrumentation of the ascending aorta with off-pump techniques may also reduce the incidence of neurological injury. Aortic valve replacement (AVR) significantly improves quality of life and provides excellent short- and long-term outcomes. Combined AVR and CABG carries higher risk but late survival is still excellent. Mini-sternotomy AVR in the elderly can provide comparable survival to full-sternotomy AVR. More accurate risk stratification systems are needed to appropriately select patients for transcatheter aortic valve implantation. Mitral valve repair is superior to replacement in the elderly, although choosing the most effective method is important for achieving maximal quality of life. Minimally-invasive mitral valve surgery in the elderly has similar postoperative outcomes to sternotomy-based surgery, but reduces hospital length of stay and return to activity. In operative candidates, surgical repair is superior to percutaneous repair. Current evidence indicates that advanced age alone is not a predictor of mortality or morbidity in cardiac surgery. Thus surgery should not be overlooked or denied to the elderly solely on the basis of their "chronological age", without considering the patient's true "biological age".
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Affiliation(s)
- Michael Seco
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - J James B Edelman
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Paul Forrest
- Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Martin Ng
- Sydney Medical School, The University of Sydney, Sydney, Australia; Cardiology Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael K Wilson
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital, The University of Queensland
| | - Paul G Bannon
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael P Vallely
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia.
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Lin Y, Wang YF, Lin DQ, Chen JW, Li JZ, Lan TH, Ou AH, Ruan XM. Efficacy and Safety of Huxin Formula in Patients after CABG: A Multicenter, Double-Blind, Randomized Clinical Trial. ACTA ACUST UNITED AC 2014; 21:351-9. [DOI: 10.1159/000370010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Anaortic Off-Pump Coronary Artery Bypass Grafting in the Elderly and Very Elderly. Heart Lung Circ 2013; 22:989-95. [DOI: 10.1016/j.hlc.2013.05.650] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 05/13/2013] [Accepted: 05/30/2013] [Indexed: 11/19/2022]
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Off-pump coronary artery bypass surgery induces prolonged alterations to host neutrophil physiology. Shock 2013; 39:149-54. [PMID: 23324884 DOI: 10.1097/shk.0b013e31827c2aba] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Persistent alteration to host polymorphonuclear cell (PMN) physiology has been demonstrated after cardiac surgery performed with cardiopulmonary bypass (CPB). However, to date, PMN physiology and function beyond the first 24 h have not been investigated after cardiac surgery performed without CPB (off-pump coronary artery bypass grafting [OPCAB]). Blood samples of 15 patients were collected preoperatively and on days 1, 3, and 5 after OPCAB. Expression of CD11b, CD18, CBRM1/5, and CD62L were assessed by flow cytometry under resting conditions and after stimulation with formyl methionyl-leucyl-phenylalanine (fMLF), and respiratory burst activity was also measured. Under resting conditions, PMN CD11b, CBRM1/5, and CD62L expressions were minimally altered by surgery. Compared with the response of preoperative PMNs, PMNs assayed on days 3 and 5 after OPCAB demonstrated a significantly blunted increase in the expression of CD11b and CBRM1/5 after fMLF, significantly diminished shedding of CD62L in response to platelet-activating factor and fMLF, and diminished superoxide production after stimulation on day 3. The alteration of PMN function after OPCAB implies that cardiac surgical trauma without CPB directly modulates host PMN physiology.
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Shi P, Li Z, Young N, Ji F, Wang Y, Moore P, Liu H. The effects of preoperative renin-angiotensin system inhibitors on outcomes in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2013; 27:703-9. [PMID: 23731712 DOI: 10.1053/j.jvca.2013.01.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The effects of preoperative (pre-op) renin-angiotensin system (RAS) inhibitors on outcomes in patients undergoing cardiac surgery remain uncertain. The aim of this study was to evaluate whether the use of pre-op RAS inhibitors affected major outcomes of cardiac surgery. DESIGN A retrospective cohort study. SETTING A university teaching hospital. PARTICIPANTS Patients undergoing cardiac surgery between January 1, 2001 and December 31, 2011. INTERVENTIONS One thousand two hundred thirty-nine patients who received pre-op RAS inhibitors were compared with those who did not (control group, n = 1,083). MEASUREMENTS AND MAIN RESULTS Acute kidney injury (AKI) was defined using Acute Kidney Injury Network classification. Patients in the RAS inhibitors group presented with higher comorbidities. Pre-op RAS inhibitors therapy was associated with the reduction in the incidence of AKI (27.2% v 34.0%, p<0.001), septicemia (1.9% v 3.5%, p = 0.019), and operative mortality (2.99% v 4.62%, p = 0.039). After adjusted propensity scores and multivariate logistic regression, the pre-op RAS inhibitors were found to have protective effects against AKI (odds ratio [OR]: 0.764, 95% confidence interval [CI]: 0.670-0.873, p<0.001), septicemia (OR: 0.515, 95% CI: 0.348-0.761, p>0.001), and operative mortality (OR: 0.539, 95% CI: 0.348-0.758, p<0.001). CONCLUSION The results suggested that pre-op RAS inhibitor therapy was associated with significant reductions in the risk of AKI, operative mortality, and septicemia.
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Affiliation(s)
- Pengcai Shi
- Department of Anesthesiology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China
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Vallely MP, Edelman JJB. Anaortic, off-pump coronary artery surgery: should it be the standard-of-care? Interv Cardiol 2013. [DOI: 10.2217/ica.13.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Anaortic, total-arterial, off-pump coronary artery bypass surgery: why bother? Heart Lung Circ 2012; 22:161-70. [PMID: 23102694 DOI: 10.1016/j.hlc.2012.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 09/14/2012] [Accepted: 09/17/2012] [Indexed: 11/20/2022]
Abstract
Coronary artery bypass grafting (CABG) remains the standard of care for multi-vessel coronary disease. However, the increased rate of peri-operative stroke reported after surgery compared to percutaneous coronary intervention (PCI) remains of concern. Anaortic, total-arterial, off-pump coronary artery bypass (OPCAB) grafting is a technique that offers the main advantages of surgical revascularisation with a rate of stroke that is equivalent to that of PCI. Some recent trials comparing conventional on-pump CABG with OPCAB have questioned the efficacy of the off-pump technique - these are most often performed with manipulation of the ascending aorta. We review the potential benefits of the anaortic, total-arterial OPCAB technique to explain why it is being employed by an increasing number of surgeons.
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