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Shell D. Coronary Artery Bypass Grafting in Dialysis-Dependent Patients - Key Peri-Operative Considerations. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 54:73-80. [PMID: 37183155 DOI: 10.1016/j.carrev.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 04/26/2023] [Accepted: 05/09/2023] [Indexed: 05/16/2023]
Abstract
Cardiovascular disease represents the leading cause of mortality in dialysis-dependent (DD) patients, with the great majority of these patients afflicted by severe coronary artery disease. As rates of end-stage renal disease increase worldwide, DD patients represent a growing proportion of the coronary artery bypass grafting (CABG) cohort. Yet, these patients are complex, with crucial changes in their haemodynamic and physiologic profiles that complicate revascularisation surgery. First, this comprehensive literature review explores the outcomes and prognostic factors for DD patients undergoing CABG. We then summarise the intricacies relating to important peri-operative decisions such as use of cardio-pulmonary bypass and choice of conduit.
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Affiliation(s)
- Daniel Shell
- Department of Cardiothoracic Surgery, St Vincent's Hospital - Melbourne, St Vincent's Health Australia, Melbourne, Australia.
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Li XH, Zhang SY, Xiao F. Clinical outcomes after coronary artery bypass grafting in patients with dialysis-dependent end-stage renal disease and an analysis of the related influencing factors. Heart Vessels 2023:10.1007/s00380-023-02261-w. [PMID: 36941459 DOI: 10.1007/s00380-023-02261-w] [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: 10/19/2022] [Accepted: 03/08/2023] [Indexed: 03/23/2023]
Abstract
Perioperative and short/mid-term survival rates of dialysis-dependent patients with end-stage renal disease (ESRD), who undergo coronary artery bypass grafting (CABG), and the factors influencing mortality are not well evaluated In China. We retrospectively analyzed the perioperative and postoperative 1-, 3-, and 5-year survival rates of 53 dialysis-dependent ESRD patients who underwent CABG, and compared the factors related to perioperative mortality and all-cause mortality during the postoperative follow-up. Survival rates were expressed as Kaplan-Meier survival curves, and factors influencing the follow-up survival rates were analyzed using the log rank (Mantel-Cox) test. There were eight perioperative deaths, resulting in 15.1% mortality. Intraoperative intra-aortic balloon pump use (P = 0.01), advanced age (P = 0.0027), and high EuroSCORE II score (P = 0.047) were associated with increased perioperative mortality. Forty-five discharged patients were followed from 2 months to 10 years (median, 4.2 years) postoperatively. There were 19 all-cause deaths, including 10 cardiac deaths (10/19, 52.6%). Comparisons between groups indicated that the presence of peripheral artery disease (PAD) increased mortality during follow-up (P = 0.025); 1-, 3-, and 5-year survival rates were 93.3, 79.5, and 66.8%, respectively. The results of the long-rank analysis indicated that the presence of PAD was a risk factor for postoperative survival (log rank χ2 = 4.543; P = 0.033). Dialysis-dependent patients with ESRD had high perioperative mortality and unsatisfactory short- and medium-term survival after CABG. PAD was a risk factor affecting patients' postoperative survival. Multidisciplinary teamwork is needed to enhance postoperative management and reduce complications, to improve postoperative survival in these patients.
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Affiliation(s)
- Xi-Hui Li
- Department of Cardiovascular Surgery, Peking University First Hospital, Beijing, 100034, China.
| | - Si-Yu Zhang
- Department of Cardiovascular Surgery, Peking University First Hospital, Beijing, 100034, China
| | - Feng Xiao
- Department of Cardiovascular Surgery, Peking University First Hospital, Beijing, 100034, China
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Hayashi J, Nakajima H, Asakura T, Iguchi A, Tokunaga C, Takazawa A, Chubachi F, Hori Y, Yoshitake A. Validity of Ipsilateral Internal Mammary Coronary Artery Bypass Graft of Arteriovenous Fistula. Heart Lung Circ 2022; 31:1399-1407. [PMID: 35840512 DOI: 10.1016/j.hlc.2022.06.662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 05/28/2022] [Accepted: 06/04/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND In coronary artery bypass grafting (CABG) for haemodialysis patients, arteriovenous fistula can reduce blood flow from the internal mammary artery (IMA) graft. The purpose of this study was to delineate the rationale of ipsilateral IMA grafting to the arteriovenous fistula by assessing graft flow and patency. METHOD The clinical records of 139 haemodialysis patients who underwent off-pump CABG, including IMA grafting to the left anterior descending artery (LAD) between April 2007 and December 2018, were retrospectively reviewed. Clinical outcomes and transit-time flowmetry results of IMA to LAD bypass grafts during off-pump CABG and postoperative angiography were examined. RESULTS An ipsilateral IMA to the arteriovenous fistula (Ipsi-IMA) was used in 89 patients, and a contralateral IMA to the arteriovenous fistula (Contra-IMA) was used in 50 patients and no hospital deaths occurred. The mean graft flow and angiographic patency rate did not differ between the Ipsi-IMA and Contra-IMA groups. In patients with 51 to 90% stenosis of LAD, there was no significant difference in the mean graft flow. In comparison, in the patients with 91 to 100% stenosis of LAD, the mean graft flow in the Ipsi-IMA group was significantly lower than that in the Contra-IMA group (p=0.03). Kaplan-Meier analyses showed a 5-year survival rate of 57.6% for Ipsi-IMA and 64.8% for Contra-IMA (p=0.47). CONCLUSIONS In the revascularisation of the LAD, the graft patency rate of the Ipsi-IMA was not inferior to that of the Contra-IMA. However, when the LAD has 91 to 100% stenosis, a Contra-IMA to arteriovenous fistula may be beneficial in terms of sufficient flow capacity.
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Affiliation(s)
- Jun Hayashi
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan.
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Toshihisa Asakura
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Atsushi Iguchi
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Chiho Tokunaga
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Akitoshi Takazawa
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Fumiya Chubachi
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yuto Hori
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Akihiro Yoshitake
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
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Abstract
PURPOSE Off-pump coronary arterial bypass grafting (OPCAB) has become a common practice for coronary artery bypass grafting (CABG) in Japan, with approximately 65% CABG procedures currently being performed using OPCAB. However, it is unclear whether OPCAB is superior in terms of associated mortality, incidence of complications, graft patency rate, and long-term outcomes compared with conventional CABG (CCABG). METHODS Literature consideration was performed, mainly based on observational studies involving large samples and randomized controlled trials (RCTs). RESULTS Many RCTs indicated that the acute-phase and long-term mortality rates were comparable between CCABG and OPCAB or that OPCAB was inferior to CCABG. In contrast, many observational studies indicated that OPCAB was superior to CCABG. CONCLUSION CABG is a delicate procedure, the outcomes of which vary in accordance with the patient's condition as well as the level of expertise of the associated institution and surgeon. In the future, we hope that reports will emerge with excellent results, including long-term results, from Japanese institutions experienced in performing OPCAB.
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Affiliation(s)
- Go Kuwahara
- Department of Cardiovascular Surgery, Saiseikai Fukuoka General Hospital, Fukuoka, Fukuoka, Japan
| | - Tadashi Tashiro
- Department of Cardiovascular Surgery, Saiseikai Fukuoka General Hospital, Fukuoka, Fukuoka, Japan.,Department of General Medical Research Center, Fukuoka University School of Medicine, Fukuoka, Fukuoka, Japan
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Jha AK, Lata S. Kidney transplantation and cardiomyopathy: Concepts and controversies in clinical decision-making. Clin Transplant 2020; 34:e13795. [PMID: 31991012 DOI: 10.1111/ctr.13795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/21/2019] [Accepted: 01/24/2020] [Indexed: 11/30/2022]
Abstract
Increasing comorbidities and an aging population have led to a tremendous increase in the burden of both kidney and cardiac dysfunction. Concomitant cardiomyopathy exposes the patients with kidney disease to further physiological, hemodynamic, and pathologic alterations. Kidney transplantation imposes lesser anesthetic and surgical complexities compared to another solid organ transplant. The surgical decision-making remains an unsettled issue in these conditions. The surgical choices, techniques, and sequences in kidney transplant and cardiac surgery depend on the pathophysiological perturbations and perioperative outcomes. The absence of randomized controlled trials eludes us from suggesting definite management protocol in patients with end-stage kidney disease with cardiomyopathy. Nevertheless, in this review, we extracted data from published literature to understand the pathophysiologic interactions between end-stage renal diseases with cardiomyopathy and also proposed the management algorithm in this challenging scenario. The proposed management algorithm would ensure consensus across all stakeholders involved in decision-making. Our simplistic evidence-based approach would augur future randomized trials and would further ensure refinement in our management approach after the emergence of more definitive evidence.
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Affiliation(s)
- Ajay Kumar Jha
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Suman Lata
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Tsubota H, Sakaguchi G, Marui A. Open and endovascular thoracic aortic repair in patients with end-stage renal disease. Interact Cardiovasc Thorac Surg 2019; 29:761-765. [DOI: 10.1093/icvts/ivz163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 06/05/2019] [Accepted: 06/10/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
The number of end-stage renal disease (ESRD) patients has increased, but there have been few reports of thoracic aortic surgery in patients with ESRD. The purpose of this study was to evaluate the early and late outcomes of open and endovascular thoracic aortic repairs in patients with ESRD.
METHODS
A total of 36 patients with ESRD who needed chronic haemodialysis undergoing open surgery (n = 21) or thoracic endovascular aortic repair (TEVAR) (n = 15) of the thoracic aorta from 2007 to 2017 in our hospital were identified. Primary end points were in-hospital mortality and late survival; secondary end points were perioperative complications and late aortic events.
RESULTS
Fourteen patients (39%) had aortic dissection, and 16 (44%) had aortic aneurysms. Emergency surgery was performed in 12 patients (33%). There were 3 hospital deaths (8%) (open surgery, n = 1, 5%; TEVAR, n = 2, 13%). The TEVAR group had fewer transfusions than the open surgery group and shorter intensive care unit and hospital stays. The 1-, 3- and 5-year survival rates were 79%, 58% and 40%, respectively, for patients overall. Freedom from aortic events at 1 and 3 years was 97% and 92%, respectively.
CONCLUSIONS
The early outcome of thoracic aorta surgery in patients with ESRD was acceptable. However, the long-term mortality in patients with ESRD was still poor. Therefore, whether to perform surgery needs to be considered carefully.
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Affiliation(s)
- Hideki Tsubota
- Department of Cardiovascular Surgery, Kokura Memorial Hospital, Kitakyusyu, Fukuoka, Japan
| | - Genichi Sakaguchi
- Department of Cardiovascular Surgery, Kokura Memorial Hospital, Kitakyusyu, Fukuoka, Japan
| | - Akira Marui
- Department of Cardiovascular Surgery, Kokura Memorial Hospital, Kitakyusyu, Fukuoka, Japan
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Farina P, Gaudino M, Angelini GD. Off-pump coronary artery bypass surgery: The long and winding road. Int J Cardiol 2019; 279:51-55. [DOI: 10.1016/j.ijcard.2018.09.101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/23/2018] [Accepted: 09/25/2018] [Indexed: 11/27/2022]
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Gaudino M, Angelini GD, Antoniades C, Bakaeen F, Benedetto U, Calafiore AM, Di Franco A, Di Mauro M, Fremes SE, Girardi LN, Glineur D, Grau J, He G, Patrono C, Puskas JD, Ruel M, Schwann TA, Tam DY, Tatoulis J, Tranbaugh R, Vallely M, Zenati MA, Mack M, Taggart DP. Off-Pump Coronary Artery Bypass Grafting: 30 Years of Debate. J Am Heart Assoc 2018; 7:e009934. [PMID: 30369328 PMCID: PMC6201399 DOI: 10.1161/jaha.118.009934] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Mario Gaudino
- Department of Cardio‐Thoracic SurgeryWeill Cornell MedicineNew York CityNY
| | | | | | | | | | | | - Antonino Di Franco
- Department of Cardio‐Thoracic SurgeryWeill Cornell MedicineNew York CityNY
| | | | - Stephen E. Fremes
- Schulich Heart CentreSunnybrook Health ScienceUniversity of TorontoCanada
| | - Leonard N. Girardi
- Department of Cardio‐Thoracic SurgeryWeill Cornell MedicineNew York CityNY
| | - David Glineur
- Division of Cardiac SurgeryOttawa Heart InstituteOttawaCanada
| | - Juan Grau
- Division of Cardiac SurgeryOttawa Heart InstituteOttawaCanada
| | - Guo‐Wei He
- TEDA International Cardiovascular HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeTianjinChina
| | - Carlo Patrono
- Department of PharmacologyCatholic University School of MedicineRomeItaly
| | - John D. Puskas
- Department of Cardiovascular SurgeryIcahn School of Medicine at Mount SinaiNew York CityNY
| | - Marc Ruel
- University of Ottawa Heart InstituteOttawaCanada
| | | | - Derrick Y. Tam
- Schulich Heart CentreSunnybrook Health ScienceUniversity of TorontoCanada
| | - James Tatoulis
- Department of SurgeryUniversity of MelbourneParkvilleAustralia
| | - Robert Tranbaugh
- Department of Cardio‐Thoracic SurgeryWeill Cornell MedicineNew York CityNY
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Kundu A, Yadava OP, Taggart D. Off-pump versus on-pump coronary artery bypass grafting-a surreal controversy? Indian J Thorac Cardiovasc Surg 2018; 34:266-271. [PMID: 33060948 DOI: 10.1007/s12055-018-0668-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 02/28/2018] [Accepted: 03/06/2018] [Indexed: 11/26/2022] Open
Abstract
As per the findings of the SYNTAX Trial, it has been established that coronary artery bypass grafting (CABG) affords the best long-term results in patients with multivessel disease. However, it is still a point of contention whether 'off-pump' CABG (OPCAB) (on cardiopulmonary bypass) is better. Many studies appear to establish the superiority of one or the other. But there is still no well-planned multi-centre randomised controlled trial looking into all aspects of the issue that can, once and for all, put the controversy to rest. But as long as one is able to give the patient a good result, does it really matter whether the procedure is done off or on pump? This article looks at the available evidence with regard to various parameters comparing OPCAB and conventional CABG in an attempt to answer the question, if at all, it is a question!
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Affiliation(s)
- Anirban Kundu
- National Heart Institute, 49 Community Centre, New Delhi, Delhi 110065 India
| | - Om Prakash Yadava
- National Heart Institute, 49 Community Centre, New Delhi, Delhi 110065 India
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Wang Y, Zhu S, Gao P, Zhou J, Zhang Q. Off-pump versus on-pump coronary surgery in patients with chronic kidney disease: a meta-analysis. Clin Exp Nephrol 2017. [DOI: 10.1007/s10157-017-1432-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
Cardiovascular disease is a major concern for patients with end-stage renal disease (ESRD), especially those on hemodialysis. ESRD patients with coronary artery disease often do not have symptoms or present with atypical symptoms. Coronary lesions in ESRD patients are characterized by increased media thickness, infiltration and activation of macrophages, and marked calcification. Several studies showed worsened clinical outcomes after coronary revascularization, which were dependent on the severity of renal dysfunction. ESRD patients on hemodialysis have the most severe renal dysfunction; thus, the clinical outcomes are worse in these patients than in those with other types of renal dysfunction. Medications for primary or secondary cardiovascular prevention are also insufficient in ESRD patients. Efficacy of drug-eluting stents is inferior in ESRD patients, compared to the excellent outcomes observed in patients with normal renal function. Unsatisfactory outcomes with trials targeting cardiovascular disease in patients with ESRD emphasize a large potential to improve outcomes. Thus, optimal strategies for diagnosis, prevention, and management of cardiovascular disease should be modified in ESRD patients.
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Affiliation(s)
- Jiro Aoki
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Yuji Ikari
- Department of Cardiovascular Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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Chen JJ, Lin LY, Yang YH, Hwang JJ, Chen PC, Lin JL, Chi NH. On pump versus off pump coronary artery bypass grafting in patients with end-stage renal disease and coronary artery disease - A nation-wide, propensity score matched database analyses. Int J Cardiol 2016; 227:529-534. [PMID: 27836299 DOI: 10.1016/j.ijcard.2016.10.108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 10/30/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The usage of on or off cardiopulmonary bypass in patients with coronary artery disease receiving coronary artery bypass grafting (CABG) surgery had been debated and had not yet been investigated thoroughly in patients with end-stage renal disease (ESRD). We aimed to study cardiovascular outcomes and total mortality in these patients by using our National Health Insurance (NHI) database. METHOD By using our NHI ESRD claim database, we searched ESRD patients aged more than 18years, who received CABG and divided them into on pump and off pump groups. Baseline characteristics and underlying comorbidities were identified from the database. Propensity score (PS) method was used to match all the potential confounders between patients. Outcomes including mortality, myocardial infarction, stroke and repeat revascularization within 30days, 1year and whole follow-up period were also obtained. RESULT A total of 134,410 ESRD patients were identified in the database. We included 341 patients and 543 patients who received off pump and on pump CABG respectively. The hazard ratios of different outcomes at 30days, 1year and a median of 745days after CABG did not show significant different between on, or off pump groups before and after PS match. CONCLUSION ESRD patients with CAD undergoing either on pump or off pump CABG surgery showed similar outcomes in 30days, 1year and whole follow-up period.
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Affiliation(s)
- Jien-Jiun Chen
- Cardiovascular Center, National Taiwan University Hospital Yun-Lin Branch, Douliou, Taiwan
| | - Lian-Yu Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Hsu Yang
- Department for Traditional Chinese Medicine, Chang Gung Memorial Hospital Chia-Yi, Taiwan; Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Juey-Jen Hwang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Pau-Chung Chen
- Department for Traditional Chinese Medicine, Chang Gung Memorial Hospital Chia-Yi, Taiwan
| | - Jiunn-Lee Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Nai-Hsin Chi
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.
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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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Hibino M, Oshima H, Narita Y, Abe T, Mutsuga M, Fujimoto KL, Tokuda Y, Terazawa S, Ito H, Usui A. Early and Late Outcomes of Thoracic Aortic Surgery in Hemodialysis Patients. Ann Thorac Surg 2016; 102:1282-8. [DOI: 10.1016/j.athoracsur.2016.03.073] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 03/18/2016] [Accepted: 03/22/2016] [Indexed: 11/16/2022]
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Shroff GR, Herzog CA. Coronary Revascularization in Patients with CKD Stage 5D: Pragmatic Considerations. J Am Soc Nephrol 2016; 27:3521-3529. [PMID: 27493258 DOI: 10.1681/asn.2016030345] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Coronary revascularization decisions for patients with CKD stage 5D present a dilemma for clinicians because of high baseline risks of mortality and future cardiovascular events. This population differs from the general population regarding characteristics of coronary plaque composition and behavior, accuracy of noninvasive testing, and response to surgical and percutaneous revascularization, such that findings from the general population cannot be automatically extrapolated. However, this high-risk population has been excluded from all randomized trials evaluating outcomes of revascularization. Observational studies have attempted to address long-term outcomes after surgical versus percutaneous revascularization strategies, but inherent selection bias may limit accuracy. Compared with percutaneous strategies, surgical revascularization seems to have long-term survival benefit on the basis of observational data but associates with substantially higher short-term mortality rates. Percutaneous revascularization with drug-eluting and bare metal stents associates with a high risk of in-stent restenosis and need for future revascularization, perhaps contributing to the higher long-term mortality hazard. Off-pump coronary bypass surgery and the newest generation of drug-eluting stent platforms offer no definitive benefits. In this review, we address the nuances, complexities, and tradeoffs that clinicians face in determining the optimal method of coronary revascularization for this high-risk population.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota; and
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota; and .,Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
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Denniss AR, Gregory AT. Countdown to a Silver Jubilee for Heart, Lung and Circulation Journal in 2016 – Looking Back in Order to Move Forward. Heart Lung Circ 2015; 24:1137-40. [DOI: 10.1016/s1443-9506(15)01460-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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