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He L, Tiemuerniyazi X, Chen L, Yang Z, Huang S, Nan Y, Song Y, Feng W. Clinical outcomes of on-pump versus off-pump coronary-artery bypass surgery: a meta-analysis. Int J Surg 2024; 110:5063-5070. [PMID: 38626442 PMCID: PMC11325898 DOI: 10.1097/js9.0000000000001481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/31/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND The ongoing debate regarding off-pump coronary artery bypass grafting (CABG) and on-pump CABG has endured for over three decades. Although numerous randomized controlled trials (RCTs) and meta-analyses have been reported, new evidence has emerged. Therefore, an updated and comprehensive meta-analysis to guide clinical practice is essential. MATERIALS AND METHODS A comprehensive search for eligible articles published after 2000, reporting RCTs involving at least 100 patients and comparing off-pump CABG with on-pump CABG, was performed throughout the databases including Embase, Ovid Medline, and Web of Science. The primary interested outcomes included the short-term incidence of stroke and long-term mortality. The primary analysis utilized fixed-effect model with the inverse variance method. The Grade of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the certainty of evidence. RESULTS After thorough screening, 39 articles were included, consisting of 28 RCTs and involving a total of 16 090 patients. Off-pump CABG significantly reduced the incidence of short-term stroke (1.27 vs. 1.78%, OR: 0.74, P =0.03, high certainty). However, it was observed to be associated with increased mid-term coronary reintervention (2.77 vs. 1.85%, RR: 1.49, P <0.01, high certainty) and long-term mortality (21.8 vs. 21.0%, RR: 1.09, P =0.02, moderate certainty). CONCLUSIONS Off-pump CABG significantly reduces the short-term incidence of stroke, but it also increases the incidence of mid-term coronary reintervention. Moreover, it may increase long-term mortality.
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Affiliation(s)
- Liaoming He
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Sandner S, Redfors B, An KR, Harik L, Heise R, Di Franco A, Fremes SE, Hare DL, Kulik A, Lamy A, Peper J, Ruel M, Ten Berg JM, Willemsen LM, Zhao Q, Zhu Y, Wojdyla DM, Bhatt DL, Alexander JH, Gaudino M. Coronary Artery Bypass Graft Failure in Women: Incidence and Clinical Implications. J Am Coll Cardiol 2024; 84:182-191. [PMID: 38960512 DOI: 10.1016/j.jacc.2024.04.046] [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: 02/06/2024] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Women have worse outcomes after coronary artery bypass surgery (CABG) than men. OBJECTIVES This study aimed to determine the incidence of CABG graft failure in women, its association with cardiac events, and whether it contributes to sex-related differences in outcomes. METHODS A pooled analysis of individual patient data from randomized clinical trials with systematic imaging follow-up was performed. Multivariable logistic regression models were used to assess the association of graft failure with myocardial infarction and repeat revascularization between CABG and imaging (primary outcome) and death after imaging (secondary outcome). Mediation analysis was performed to evaluate the effect of graft failure on the association between female sex and risk of death. RESULTS Seven randomized clinical trials (N = 4,413, 777 women) were included. At a median imaging follow-up of 1.03 years, graft failure was significantly more frequent among women than men (37.3% vs 32.9% at the patient-level and 20.5% vs 15.8% at the graft level; P = 0.02 and P < 0.001, respectively). In women, graft failure was associated with an increased risk of myocardial infarction and repeat revascularization (OR: 3.94; 95% CI: 1.79-8.67) and death (OR: 3.18; 95% CI: 1.73-5.85). Female sex was independently associated with the risk of death (direct effect, HR: 1.84; 95% CI: 1.35-2.50) but the association was not mediated by graft failure (indirect effect, HR: 1.04; 95% CI: 0.86-1.26). CONCLUSIONS Graft failure is more frequent in women and is associated with adverse cardiac events. The excess mortality risk associated with female sex among CABG patients is not mediated by graft failure.
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Affiliation(s)
- Sigrid Sandner
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA; Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Björn Redfors
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Gothenburg University, Gothenburg, Sweden
| | - Kevin R An
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Rachel Heise
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Stephen E Fremes
- Schulich Heart Centre Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - David L Hare
- Department of Cardiology, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Alexander Kulik
- Division of Cardiac Surgery, Boca Raton Regional Hospital and Florida Atlantic Hospital, Boca Raton, Florida, USA
| | - Andre Lamy
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Joyce Peper
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jurrien M Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Laura M Willemsen
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Qiang Zhao
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yunpeng Zhu
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine, Mount Sinai, New York, New York, USA
| | - John H Alexander
- Department of Medicine and Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA.
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Uimonen M, Liukkonen R, Ponkilainen V, Vaajala M, Tarkiainen J, Pakarinen O, Haapanen M, Kuitunen I. Preventive medication efficacy after 1-year follow-up for graft failure in coronary artery bypass surgery patients: Bayesian network meta-analysis. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae052. [PMID: 38974873 PMCID: PMC11227230 DOI: 10.1093/ehjopen/oeae052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 06/03/2024] [Accepted: 06/21/2024] [Indexed: 07/09/2024]
Abstract
To compare preventive medications against graft failures in coronary artery bypass graft surgery (CABG) patients after a 1-year follow-up. Systematic review with Bayesian network meta-analysis and meta-regression analysis. We searched PubMed, Scopus, and Web of Science databases in February 2023 for randomized controlled trials, comparing preventive medications against graft failure in CABG patients. We included studies that reported outcomes at 1 year after surgery. Our primary outcome was graft failure After screening 11,898 studies, a total of 18 randomized trials were included. Acetylsalicylic acid (ASA) [odds ratios (OR) 0.51, 95% credibility interval (CrI) 0.28-0.95, meta-regression OR 0.54, 95% CrI 0.26-1.00], Clopidogrel + ASA (OR 0.27, 95% CrI 0.09-0.76, meta-regression OR 0.28, 95% CrI 0.09-0.85), dipyridamole + ASA (OR 0.50, 95% CrI 0.30-0.83, meta-regression OR 0.49, 95% CrI 0.26-0.90), ticagrelor (OR 0.40, 95% CrI 0.16-1.00, meta-regression OR 0.43, 95% CrI 0.15-1.2), and ticagrelor + ASA (OR 0.26, 95% CrI 0.10-0.62, meta-regression OR 0.28, 95% CrI 0.10-0.68) were superior to placebo in preventing graft failure. Rank probabilities suggested the highest likelihood to be the most efficacious for ticagrelor + ASA [surface under the cumulative ranking (SUCRA) 0.859] and clopidogrel + ASA (SUCRA 0.819). The 95% CrIs of ORs for mortality, bleeding, and major adverse cardio- and cerebrovascular events (MACE) were wide. A trend towards increased bleeding risk and decreased MACE risk was observed when any of the medication regimens were used when compared to placebo. Sensitivity analysis excluding studies with a high risk of bias yielded equivalent results. Of the reviewed medication regimens, dual antiplatelet therapy combining ASA with ticagrelor or clopidogrel was found to result in the lowest rate of graft failures.
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Affiliation(s)
- Mikko Uimonen
- Tampere University Hospital, Heart Hospital, Elämänaukio 1, 33520 Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520 Tampere, Finland
| | - Rasmus Liukkonen
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520 Tampere, Finland
| | - Ville Ponkilainen
- Department of Surgery, Central Finland Hospital Nova, Jyväskylä, Finland
| | - Matias Vaajala
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520 Tampere, Finland
| | - Jeremias Tarkiainen
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520 Tampere, Finland
| | - Oskari Pakarinen
- Department of Surgery, Päijät-Häme Central Hospital, Lahti, Finland
| | - Marjut Haapanen
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ilari Kuitunen
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
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Calafiore AM, Torregrossa G, Salerno TA, Prapas S, Benetti F, Angelini GD, Lima RDC, Di Mauro M, Taggart D, Gaudino M, Puskas JD. Controversy. On pump or off pump: what will I do when I grow up? A narrative systematic review. Eur J Cardiothorac Surg 2024; 66:ezae256. [PMID: 38941506 DOI: 10.1093/ejcts/ezae256] [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: 04/04/2024] [Revised: 05/31/2024] [Accepted: 06/27/2024] [Indexed: 06/30/2024] Open
Abstract
The transition from the second to the third millennium happened to be a turning point in the history of myocardial revascularization on a beating heart, which moved from technical development to critical evaluation. This article describes how the initial acceptance and spread of off-pump coronary artery bypass grafting (OPCABG) was followed by the general perception that the technique could not fulfill the expectations placed in it and provides some insight on what should we do with the know-how of OPCABG in the present and the future of coronary surgical revascularization.
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Affiliation(s)
| | - Gianluca Torregrossa
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, PA, USA
| | - Tomas A Salerno
- Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Sotirios Prapas
- 1st Department of Cardiac Surgery, Henry Dunant Hospital, Athens, Greece
| | | | - Gianni D Angelini
- Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Ricardo De Carvalho Lima
- Department of Cardiovascular Surgery, Faculty of Medical Science, University of Pernambuco, Recife, Brazil
| | - Michele Di Mauro
- Department of Cardiothoracic Surgery, Cardio-Thoracic Surgery Unit, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Cardiology, Pierangeli Hospital, Pescara, Italy
| | - David Taggart
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Dimagli A, Soletti G, Harik L, Perezgrovas Olaria R, Cancelli G, An KR, Alzghari T, Mack C, Gaudino M. Angiographic Outcomes for Arterial and Venous Conduits Used in CABG. J Clin Med 2023; 12:2022. [PMID: 36902809 PMCID: PMC10004690 DOI: 10.3390/jcm12052022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/25/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Coronary artery bypass grafting is the most commonly performed cardiac surgical procedure. Conduit selection is crucial to achieving early optimal outcomes, with graft patency being likely the main driver to long-term survival. We present a review of current evidence on the patency of arterial and venous bypass conduits and of differences in angiographic outcomes.
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Affiliation(s)
- Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | | | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Kevin R. An
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Talal Alzghari
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Charles Mack
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA
- Department of Cardiothoracic Surgery, New York Presbyterian Queens Hospital, Queens, New York, NY 11355, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA
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Tempe DK, Gandhi DA. Time for Judicious Application of Off-Pump CABG. J Cardiothorac Vasc Anesth 2023; 37:6-7. [PMID: 36319563 DOI: 10.1053/j.jvca.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 10/03/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Deepak K Tempe
- Visiting Professor, Institute of Liver and Biliary Sciences, New Delhi, India; Professor of Excellence and Former Dean, Maulana Azad Medical College, New Delhi, India.
| | - Dr Ashish Gandhi
- Consultant, Department of Cardiothoracic Anesthesia, The Essex Cardiothoracic Centre, United Kingdom
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