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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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Hajizeinali A, Iri M, Hosseinsabet A. Assessment of the Right and Left Atrial Functions at Midterm After Surgical and Device Atrial Septal Defect Closure: A 2-Dimensional Speckle-Tracking Echocardiographic Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:1979-1993. [PMID: 30570151 DOI: 10.1002/jum.14887] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 11/08/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES The available literature lacks data on the comparison of the functions of the right atrium (RA) and left atrium (LA) between surgical atrial septal defect (ASD) closure and percutaneous device ASD closure at follow-up durations of longer than 1 year. We sought to evaluate the RA and LA functions in patients who underwent surgical or device ASD closure between 1 and 5 years postprocedurally. METHODS The study population included 30 patients who underwent device ASD closure and 30 who underwent surgical ASD closure, who were matched for the procedural time, age, and sex, in addition to 30 control participants. The RA and LA functions were evaluated with 2-dimensional speckle-tracking echocardiography. RESULTS The LA systolic and early diastolic strain and strain rate values and the RA early diastolic strain rate in the device closure group were more likely to be abnormal than in the control group. The RA systolic and late diastolic strain and strain rate values, the RA early diastolic strain rate, and the LA early diastolic strain in the surgical closure group were more likely to be abnormal than in the control group. The RA systolic strain and strain rate in the surgical closure group were more likely to be abnormal than in the device closure group. CONCLUSIONS The LA reservoir and conduit functions and the RA contraction function in the patients who underwent device ASD closure and all of the RA functions and the LA conduit function in the patients who underwent surgical ASD closure were more likely to be abnormal than those in the control participants. The RA reservoir function in the surgical closure group was more likely to be abnormal than that in the device closure group.
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Affiliation(s)
- Alimohammad Hajizeinali
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Iri
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Hosseinsabet
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
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Off-Pump versus Conventional Coronary Artery Bypass Grafting: A Meta-Analysis and Consensus Statement from the 2004 ISMICS Consensus Conference. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019. [DOI: 10.1097/01243895-200500110-00002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background The purpose of this evidence-based consensus statement is to systematically review and meta-analyze the randomized and nonrandomized evidence comparing off-pump (OPCAB) to conventional coronary artery bypass (CCAB) surgery and to provide consensus on the role of OPCAB in low- and high-risk surgical patients. Methods and Results This consensus conference was conducted according to the American College of Cardiology (ACC)/American Heart Association (AHA) standards for development of clinical practice guidelines. The Steering Committee collated all published studies of OPCAB versus CCAB through May 2004 and developed six questions central to controversies surrounding OPCAB surgery in mortality, morbidity, and resource utilization. For mixed-risk patient populations, meta-analysis of 37 randomized clinical trials (3,369 patients, Level A) reported across a total of 53 papers, and two meta-analyses of nonrandomized trials (Level B) comparing OPCAB versus CCAB were identified. For high-risk patient populations, we performed a meta-analysis of 3 randomized and 42 nonrandomized trials (26,349 patients, Level B). Conclusion Meta-analysis of Level A and B evidence provided the basis for the following consensus statements in patients undergoing surgical myocardial revascularization: (1) OPCAB should be considered a safe alternative to CCAB with respect to risk of mortality [Class I, Level A]; (2) With appropriate use of modern stabilizers, heart positioning devices, and adequate surgeon experience, similar completeness of revascularization and graft patency can be achieved [Class IIa, Level A]; (3) OPCAB is recommended to reduce perioperative morbidity [Class I, Level A]; (4) OPCAB may be recommended to minimize midterm cognitive dysfunction [Class IIa, Level A]; (5) OPCAB should be considered as an equivalent alternative to CCAB in regard to quality of life [Class I, Level A]; (6) OPCAB is recommended to reduce the duration of ventilation, ICU and hospital stay, and resource utilization [Class I, Level A]; (7) OPCAB should be considered in high-risk patients to reduce perioperative mortality, morbidity, and resource utilization [Class IIa, Level B].
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Puskas J, Cheng D, Knight J, Angelini G, DeCannier D, Diegeler A, Dullum M, Martin J, Ochi M, Patel N, Sim E, Trehan N, Zamvar V. Off-Pump versus Conventional Coronary Artery Bypass Grafting: A Meta-Analysis and Consensus Statement from the 2004 ISMICS Consensus Conference. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019. [DOI: 10.1177/155698450500100102] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- John Puskas
- Division of Cardiothoracic Surgery, Emory University, Atlanta, USA
| | - Davy Cheng
- Department of Anesthesia & Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - John Knight
- Cardiothoracic Surgical Unit, Flinders Medical Center, Bedford Park, Australia
| | | | | | - Anno Diegeler
- Herz-Und Gefasse Klinik Bad Neustadt, University of Leipzig, Bad Neustadt, Germany
| | - Mercedes Dullum
- Department of Cardiothoracic Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Janet Martin
- Department of Anesthesia & Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - Masami Ochi
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Nirav Patel
- Lenox Hill Hospital, New York, New York, USA
| | - Eugene Sim
- Department of Cardiovascular Surgery, National University Hospital, Singapore, Singapore
| | - Naresh Trehan
- Escorts Heart Institute and Research Center, New Delhi, India
| | - Vipin Zamvar
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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Incidence of atrial fibrillation after off-pump versus on-pump coronary artery bypass grafting: A meta-analysis of randomized clinical trials and propensity score matching trials. Curr Med Sci 2017; 37:956-964. [DOI: 10.1007/s11596-017-1834-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 05/23/2017] [Indexed: 12/28/2022]
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Apostolakis E, Papakonstantinou NA, Koniari I. Myocardial revascularization without extracorporeal circulation; Why hasn't it convinced yet? Ann Card Anaesth 2017; 20:219-225. [PMID: 28393784 PMCID: PMC5408529 DOI: 10.4103/aca.aca_39_16] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Extracorporeal circulation has led to a great development in cardiovascular surgery during the last five decades. Its time-proven efficacy and safety have made on-pump coronary artery bypass grafting (CABG) the gold standard method of surgical revascularization. However, coronary revascularization on cardiopulmonary bypass and the accompanying aortic manipulation are related to plenty of deleterious complications. Therefore, off-pump CABG surgery was established to avoid complications. Nevertheless, despite the initial enthusiasm on this technique, only 20% of myocardial revascularization procedures worldwide are performed off-pump. Not only are off-pump cardiac procedures more technically difficult but also they do not provide better results in terms of graft patency, completeness of revascularization, repeat revascularization requirement, cost, and quality of life. Completeness of revascularization and anastomotic quality should not be compromised to avoid cardiopulmonary bypass.
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Affiliation(s)
- Efstratios Apostolakis
- Department of Cardiothoracic Surgery, University Hospital of Ioannina, School of Medicine, 45500 Ioannina, Greece
| | | | - Ioanna Koniari
- Department of Cardiothoracic Surgery, University Hospital of Patras, School of Medicine, Rion 26500, Patras, Greece
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Bainbridge D, Martin J, Cheng D. Off Pump Coronary Artery Bypass Graft Surgery Versus Conventional Coronary Artery Bypass Graft Surgery: A Systematic Review of the Literature. Semin Cardiothorac Vasc Anesth 2016; 9:105-11. [PMID: 15735848 DOI: 10.1177/108925320500900110] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The recent development of off-pump coronary artery bypass (OPCAB) graft surgical techniques has led to numerous observational and several randomized trials that have investigated outcomes compared with the current gold standard of conventional on-pump coronary bypass (CCAB) graft surgery. This systematic review assesses the current randomized trials that compare OPCAB and CCAB. Numerous end points were investigated, including mortality, stroke, myocardial infarction, atrial fibrillation, blood transfusions, wound infections, and renal failure. In addition to these important outcomes, resource utilization markers were also examined such as hospital length of stay, intensive care unit length of stay, and duration of intubation/ventilation. Finally, when level I evidence from randomized trials was unavailable, level II evidence was examined. This was done for subgroup analysis, where currently no randomized trials exist, looking at OPCAB in high-risk patients. Recommendations were made as to who should receive OPCAB and the potential benefits in this patient population.
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Affiliation(s)
- Daniel Bainbridge
- Department of Anesthesia & Perioperative Medicine, The University of Western Ontario, London, Ontario, Canada.
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Kowalewski M, Pawliszak W, Malvindi PG, Bokszanski MP, Perlinski D, Raffa GM, Kowalkowska ME, Zaborowska K, Navarese EP, Kolodziejczak M, Kowalewski J, Tarelli G, Taggart DP, Anisimowicz L. Off-pump coronary artery bypass grafting improves short-term outcomes in high-risk patients compared with on-pump coronary artery bypass grafting: Meta-analysis. J Thorac Cardiovasc Surg 2015; 151:60-77.e1-58. [PMID: 26433633 DOI: 10.1016/j.jtcvs.2015.08.042] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 07/27/2015] [Accepted: 08/12/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To assess the benefits and risks of off-pump coronary artery bypass (OPCAB) versus coronary artery bypass grafting (CABG) through a meta-analysis of randomized controlled trials (RCTs), and to investigate the relationship between outcomes and patient risk profile. METHODS PubMed, Embase, the Cumulative Index of Nursing and Allied Health Literature, Scopus, Web of Science, Cochrane Library, and major conference proceedings databases were searched for RCTs comparing OPCAB and CABG and reporting short-term (≤ 30 days) outcomes. Endpoints assessed were all-cause mortality, myocardial infarction (MI), and cerebral stroke. RESULTS The meta-analysis included 100 studies, with a total of 19,192 subjects. There was no difference between the 2 techniques with respect to all-cause mortality and MI (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.71-1.09; P = .25; I(2) = 0% and OR, 0.90; 95% CI, 0.77-1.05; P = .19; I(2) = 0%, respectively). OPCAB was associated with a significant 28% reduction in the odds of cerebral stroke (OR, 0.72; 95% CI, 0.56-0.92; P = .009; I(2) = 0%). A significant relationship between patient risk profile and benefits from OPCAB was found in terms of all-cause mortality (P < .01), MI (P < .01), and cerebral stroke (P < .01). CONCLUSIONS OPCAB is associated with a significant reduction in the odds of cerebral stroke compared with conventional CABG. In addition, benefits of OPCAB in terms of death, MI, and cerebral stroke are significantly related to patient risk profile, suggesting that OPCAB should be strongly considered in high-risk patients.
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Affiliation(s)
- Mariusz Kowalewski
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland; Faculty of Health Sciences, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland; Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Düsseldorf, Germany.
| | - Wojciech Pawliszak
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Pietro Giorgio Malvindi
- University Hospital Southampton NHS Foundation Trust, Wessex Cardiothoracic Centre, Southampton, United Kingdom
| | - Marek Pawel Bokszanski
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Damian Perlinski
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS - ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Magdalena Ewa Kowalkowska
- Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Düsseldorf, Germany; Department and Clinic of Obstetrics, Gynecology, and Oncological Gynecology, Collegium Medicum, Bydgoszcz, Poland
| | - Katarzyna Zaborowska
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Eliano Pio Navarese
- Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Düsseldorf, Germany; Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Michalina Kolodziejczak
- Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Düsseldorf, Germany; Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
| | - Janusz Kowalewski
- Lung Cancer and Thoracic Surgery Department, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
| | - Giuseppe Tarelli
- Department of Cardiac Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - David Paul Taggart
- Department of Cardiac Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | - Lech Anisimowicz
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
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Puskas JD, Martin J, Cheng DCH, Benussi S, Bonatti JO, Diegeler A, Ferdinand FD, Kieser TM, Lamy A, Mack MJ, Patel NC, Ruel M, Sabik JF, Yanagawa B, Zamvar V. ISMICS Consensus Conference and Statements of Randomized Controlled Trials of Off-Pump versus Conventional Coronary Artery Bypass Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015. [DOI: 10.1177/155698451501000401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- John D. Puskas
- Department of Cardiovascular Surgery, Icahn School of Medicine, Mount Sinai, New York, NY USA
| | - Janet Martin
- Centre for Medical Evidence, Decision Integrity, Clinical Impact (MEDICI), Department of Anesthesia & Perioperative Medicine, and Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - Davy C. H. Cheng
- Centre for Medical Evidence, Decision Integrity, Clinical Impact (MEDICI), Department of Anesthesia & Perioperative Medicine, and Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - Stefano Benussi
- Division of Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Johannes O. Bonatti
- Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Anno Diegeler
- Herz-Und Gefasse Klinik Bad Neustadt, University of Leipzig, Bad Neustadt, Germany
| | - Francis D. Ferdinand
- Division of Cardiovascular and Thoracic Surgery, Lankenau Medical Center, Wynnewood, PA USA
| | - Teresa M. Kieser
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB Canada
| | - André Lamy
- Division of Cardiac Surgery and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Michael J. Mack
- Baylor Health System, Heart Hospital Baylor Plano, Dallas, TX USA
| | - Nirav C. Patel
- Department of Cardiothoracic Surgery, Lenox Hill, New York, NY USA
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Joseph F. Sabik
- Heart Vascular Institute, Cleveland Clinic, Cleveland, OH USA
| | - Bobby Yanagawa
- Department of Cardiovascular Surgery, Icahn School of Medicine, Mount Sinai, New York, NY USA
| | - Vipin Zamvar
- Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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ISMICS Consensus Conference and Statements of Randomized Controlled Trials of Off-Pump versus Conventional Coronary Artery Bypass Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015; 10:219-29. [DOI: 10.1097/imi.0000000000000184] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective At this consensus conference, we developed evidence-informed consensus statements and recommendations on the practice of off-pump coronary artery bypass graft (OPCAB) by systematically reviewing and performing meta-analysis of the randomized controlled trials (RCTs) comparing OPCAB and conventional coronary artery bypass (CCAB). Methods All RCTs of OPCAB versus CCAB through April 2013 were screened, and 102 relevant RCTs (19,101 patients) were included in a systematic review and meta-analysis (15 RCTs of 9551 high-risk patients; and 87 RCTs of 9550 low-risk patients) in accordance with the Cochrane Collaboration and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Consensus statements for the risks and benefits of OPCAB surgery in mortality, morbidity, and resource use were developed based on best available evidence. Results Compared to CCAB, it is reasonable to perform OPCAB to reduce risks of stroke [class IIa, level of evidence (LOE) A], renal dysfunction/failure (class IIa, LOE A), blood transfusion (class I, LOE A), respiratory failure (class I, LOE A), atrial fibrillation (class I, LOE A), wound infection (class I, LOE A), ventilation time, and ICU and hospital length of stay (class I, LOE A). However, OPCAB may be associated with a reduced number of grafts performed (class I, LOE A) and with diminished graft patency (class IIa, LOE A, with increased coronary reintervention at 1 year and beyond (class IIa, LOE A), as well as increased mortality at a median follow-up of 5 years (class IIb, LOE A). Conclusions OPCAB compared with CCAB may improve outcomes in the short-term (stroke, renal dysfunction, blood transfusion, respiratory failure, atrial fibrillation, wound infection, ventilation time, and length of stay). However, over the longer-term, OPCAB may be associated with reduced graft patency, and increased risk of cardiac re-intervention and death.
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Kolat P, Ried M, Haneya A, Philipp A, Kobuch R, Hirt S, Hilker M, Schmid C, Diez C. Impact of age on early outcome after coronary bypass graft surgery using minimized versus conventional extracorporeal circulation. J Cardiothorac Surg 2014; 9:143. [PMID: 25185963 PMCID: PMC4243947 DOI: 10.1186/s13019-014-0143-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 08/04/2014] [Indexed: 02/04/2023] Open
Abstract
Background Objective of this study was to evaluate the impact of age on comparative early outcomes after coronary artery bypass graft surgery (CABG) with minimized (MECC) and conventional extracorporeal circulation (CECC). Methods A retrospective age-, gender- and operation-matched cohort analysis between January 2005 and December 2010 with a total of 2274 patients undergoing CABG with MECC (n = 1137; 50%) or CECC was performed. Patients were stratified into 4 groups according to age: <59 years, 60–69 years, 70–79 years, and 80 years of age or older. Outcomes were compared within each age group. Patients with preoperative dialysis were excluded from analysis. Primary endpoint was 30-day mortality. Results Patients treated with CECC had a significantly higher mean logistic EuroSCORE (6.3% vs. 5.0%; p < 0.001), a slightly lower rate of preoperative myocardial infarction (46% vs. 51%; p = 0.01) and a higher rate of impaired renal function (eGFR < 60 mL/min/1.73 m2: 24% vs. 20%; p = 0.01) compared to MECC-patients. Left internal mammary artery was significantly used more often in MECC patients (93% vs. 86%; p < 0.001). Cardiopulmonary bypass and aortic-cross clamping time were significantly lower in the MECC group (p < 0.001). Overall 30-day mortality was significantly higher in patients treated with CECC (4.4% vs. 2.2%; p = 0.002). Within the different age groups mortality rates were not significantly different except for patients aged 60–69 years (4.5% vs. 1.8%; p = 0.03). Postoperative requirement of renal replacement therapy (4% vs. 2.2%; p = 0.01), respiratory insufficiency (9.9% vs. 6.6%; P = 0.004) and incidence of low cardiac output syndrome (3% vs. 1.2%; p = 0.003) were significantly increased in patients with CECC. Multivariate analysis identified age (p = 0.005; 95% CI 1.01 to 1.08; OR 1.05) among other parameters as an independent risk factor, whereas conventional extracorporeal circulation itself did not present as an independent risk factor for 30-day mortality. Conclusions In this matched study sample early outcome was significantly better in patients with MECC compared to CECC, irrespective of age. Prior myocardial infarction estimated GFR < 60 mL and waiving the use of LIMA were independent risk factors for 30-day mortality, which were more present in the CECC group.
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Baikoussis NG, Papakonstantinou NA, Apostolakis E. The “benefits” of the mini-extracorporeal circulation in the minimal invasive cardiac surgery era. J Cardiol 2014; 63:391-6. [DOI: 10.1016/j.jjcc.2013.12.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 10/12/2013] [Accepted: 12/12/2013] [Indexed: 10/25/2022]
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GOMES V, GOMES MB, TIBIRICA E, LESSA MA. Post-operative endothelial dysfunction assessment using laser Doppler perfusion measurement in cardiac surgery patients. Acta Anaesthesiol Scand 2014; 58:468-77. [PMID: 24617621 DOI: 10.1111/aas.12286] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND Coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB) is associated with systemic inflammatory response and endothelial dysfunction. Our hypothesis is that CPB-induced post-operative endothelial dysfunction may be detected using laser Doppler perfusion monitoring (LDPM) in the skin microcirculation. METHODS We used LDPM to investigate the subacute effects of the CPB on systemic microvascular reactivity among patients undergoing CABG surgery with CPB. Thirty patients were submitted to the study of skin microcirculation and blood sample collection at baseline (pre-surgery) and at 7 days post-surgical procedure. The skin microcirculation was evaluated by acetylcholine (ACh) and sodium nitroprusside (SNP) iontophoresis, and thermal hyperemia (TH). Plasma levels of nitrite/nitrate were also analyzed, and cytokine profiles were determined using a multiplex system. RESULTS On-pump CABG surgery induced a significant reduction of the increased microvascular dermal flux observed after cumulative doses of ACh iontophoresis and after TH. On-pump CABG surgery did not induce any significant changes in the microvascular flux after cumulative doses of SNP. Patients still presented high levels of interleukin (IL)-6, IL-8, and C-reactive protein, and low bioavailability of nitric oxide 7 days after the CABG surgery with CPB. CONCLUSION We observed a significant impairment of systemic microvascular endothelial function and well-preserved endothelium-independent vasodilatation in the skin microcirculation of patients 1 week after CABG surgery with CPB. Our results suggest that LDPM is a useful tool for the assessment of on-pump CABG-induced subacute post-operative endothelial dysfunctions.
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Affiliation(s)
- V. GOMES
- Laboratory of Cardiovascular Investigation; Oswaldo Cruz Institute/FIOCRUZ; Rio de Janeiro Brazil
| | - M. B. GOMES
- Department of Internal Medicine; Diabetes Unit; State University of Rio de Janeiro; Rio de Janeiro Brazil
| | - E. TIBIRICA
- Laboratory of Cardiovascular Investigation; Oswaldo Cruz Institute/FIOCRUZ; Rio de Janeiro Brazil
| | - M. A. LESSA
- Laboratory of Cardiovascular Investigation; Oswaldo Cruz Institute/FIOCRUZ; Rio de Janeiro Brazil
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Soykan EA, Butzelaar L, de Kroon TL, Beelen RHJ, Ulrich MMW, Mink van der Molen AB, Niessen FB. Minimal extracorporeal circulation (MECC) does not result in less hypertrophic scar formation as compared to conventional extracorporeal circulation (CECC) with dexamethasone. Perfusion 2013; 29:249-59. [PMID: 24214029 DOI: 10.1177/0267659113511656] [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: 11/15/2022]
Abstract
INTRODUCTION Cardiopulmonary bypass surgery is associated with a systemic inflammatory response through the interaction of air, blood and synthetic components in the bypass system and the physical trauma of surgery. An alternative cardiopulmonary bypass system, minimal extracorporeal circulation (MECC), has shown promising results in terms of reducing the inflammatory response. We hypothesized that this system may reduce pathological excessive scarring. To study this assumption, the effects of MECC and the effects of conventional extracorporeal circulation (CECC) with dexamethasone on skin scarring were compared in a standardized wound-healing model. METHODS AND RESULTS Pre-sternal scars were evaluated prospectively at four and 12 months postoperatively. The height and width of the scars were measured, using a slide caliper and sonography. The scars were scored using the validated Patient and Observer Scar Assessment Scale. Additional risk factors for hypertrophic scar formation were identified by means of a questionnaire. During surgery, MECC was used in 45 patients and CECC/dexamethasone in 42 patients. Four months postoperatively, 22 patients of the MECC group (49%) and 18 patients in the CECC/dexamethasone group (43%) had developed hypertrophic scars. Twelve months postoperatively, the hypertrophic scars in four patients of the MECC group and in two patients of the CECC/dexamethasone group had become normotrophic. In 18 patients of the MECC group (38%) and 16 patients of the CECC group (41%) the scars remained hypertrophic at 12 months. These differences between the two groups were not statistically significant. CONCLUSION MECC does not reduce hypertrophic scar formation compared with CECC with dexamethasone, but its use is more beneficial than the use of CECC/dexamethasone because of the circulatory and immunological advantages and because treatment with dexamethasone can be omitted.
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Affiliation(s)
- E A Soykan
- Department of Plastic and Reconstructive Surgery, VU University Medical Centre, Amsterdam, the Netherlands
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Palmerini T, Biondi-Zoccai G, Riva DD, Mariani A, Savini C, Eusanio MD, Genereux P, Frati G, Marullo AG, Landoni G, Greco T, Branzi A, Servi SD, Credico GD, Taglieri N, Williams MR, Stone GW. Risk of stroke with percutaneous coronary intervention compared with on-pump and off-pump coronary artery bypass graft surgery: Evidence from a comprehensive network meta-analysis. Am Heart J 2013; 165:910-917.e14. [PMID: 23708161 DOI: 10.1016/j.ahj.2013.03.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 03/14/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although some trials have reported that on-pump coronary artery bypass graft (CABG) surgery may be associated with higher rates of stroke than percutaneous coronary intervention (PCI), whether stroke is more common after off-pump CABG compared with PCI is unknown. We therefore sought to determine whether off-pump CABG is associated with an increased risk of stroke compared with PCI by means of network meta-analysis. METHODS Randomized controlled trials (RCTs) comparing CABG vs PCI were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. RESULTS Eighty-three RCTs with 22,729 patients randomized to on-pump CABG (n = 10,957), off-pump CABG (n = 7,119), or PCI (n = 4,653) were analyzed. Thirty-day rates of stroke were significantly lower in patients treated with PCI compared with either off-pump CABG (odds ratio [OR]; 0.39, 95% CI, 0.19-0.83) or on-pump CABG (OR, 0.26; 95% CI, 0.12-0.47). Compared with on-pump CABG, off-pump CABG was associated with significantly lower 30-day risk of stroke (OR, 0.67; 95% CI, 0.41-0.95). However, in sensitivity analyses restricted to high-quality studies, studies with more than either 100 or 1,000 patients, or studies with protocol definition or adjudication of stroke by a clinical events committee, the precision of the point estimate for the 30-day risk of stroke between off-pump vs on-pump CABG was markedly reduced. CONCLUSIONS Percutaneous coronary intervention is associated with lower 30-day rates of stroke than both off-pump and on-pump CABG. Further studies are required to determine whether the risk of stroke is reduced with off-pump CABG compared with on-pump CABG.
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Møller CH, Penninga L, Wetterslev J, Steinbrüchel DA, Gluud C. Off-pump versus on-pump coronary artery bypass grafting for ischaemic heart disease. Cochrane Database Syst Rev 2012:CD007224. [PMID: 22419321 DOI: 10.1002/14651858.cd007224.pub2] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is performed both without and with cardiopulmonary bypass, referred to as off-pump and on-pump CABG respectively. However, the preferable technique is unclear. OBJECTIVES To assess the benefits and harms of off-pump versus on-pump CABG in patients with ischaemic heart disease. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 1, 2011), MEDLINE (OVID, 1950 to February 2011), EMBASE (OVID, 1980 to February 2011), Science Citation Index Expanded on ISI Web of Science (1970 to February 2011) and CINAHL (EBSCOhost, 1981 to February 2011) on 2 February 2011. No language restrictions were applied. SELECTION CRITERIA Randomised clinical trials of off-pump versus on-pump CABG irrespective of language, publication status and blinding were selected for inclusion. DATA COLLECTION AND ANALYSIS For statistical analysis of dichotomous data risk ratio (RR) and for continuous data mean difference (MD) with 95% confidence intervals (CI) were used. Trial sequential analysis (TSA) was used for analysis to assess the risk of random error due to sparse data and to multiple updating of accumulating data. MAIN RESULTS Eighty-six trials (10,716 participants) were included. Ten trials (4,950 participants) were considered to be low risk of bias. Pooled analysis of all trials showed that off-pump CABG increased all-cause mortality compared with on-pump CABG (189/5,180 (3.7%) versus 160/5144 (3.1%); RR 1.24, 95% CI 1.01 to 1.53; P =.04). In the trials at low risk of bias the effect was more pronounced (154/2,485 (6.2%) versus 113/2,465 (4.6%), RR 1.35,95% CI 1.07 to 1.70; P =.01). TSA showed that the risk of random error on the result was unlikely. Off-pump CABG resulted in fewer distal anastomoses (MD -0.28; 95% CI -0.40 to -0.16, P <.00001). No significant differences in myocardial infarction, stroke, renal insufficiency, or coronary re-intervention were observed. Off-pump CABG reduced post-operative atrial fibrillation compared with on-pump CABG, however, in trials at low risk of bias, the estimated effect was not significantly different. AUTHORS' CONCLUSIONS Our systematic review did not demonstrate any significant benefit of off-pump compared with on-pump CABG regarding mortality, stroke, or myocardial infarction. In contrast, we observed better long-term survival in the group of patients undergoing on-pump CABG with the use of cardiopulmonary bypass and cardioplegic arrest. Based on the current evidence, on-pump CABG should continue to be the standard surgical treatment. However, off-pump CABG may be acceptable when there are contraindications for cannulation of the aorta and cardiopulmonary bypass. Further randomised clinical trials should address the optimal treatment in such patients.
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Affiliation(s)
- Christian H Møller
- Department of Cardiothoracic Surgery, RT 2152, Copenhagen University Hospital, Rigshospitalet, Copenhagen,
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Nozohoor S, Johnsson P, Scicluna S, Wallentin P, Andell E, Nilsson J. A case-controlled evaluation of the Medtronic Resting Heart System compared with conventional cardiopulmonary bypass in patients undergoing isolated coronary artery bypass surgery. Interact Cardiovasc Thorac Surg 2012; 14:599-604. [PMID: 22286599 DOI: 10.1093/icvts/ivr158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The Medtronic Resting Heart System (RHS) is a heparin-coated, closed perfusion circuit. Clinical results indicate less haemodilution and reduced complement activation, when compared with a traditional circuit leading to fewer postoperative blood transfusions. We evaluated the potential clinical benefits, including reduced transfusion requirements, when using the RHS compared with conventional cardiopulmonary bypass (cCPB). The study group (n = 330) consisted of patients undergoing isolated coronary artery bypass grafting (CABG) using the RHS system during 2005-2009, matched with a control group (n = 609) including patients operated for isolated CABG during 2002-2009, utilizing cCPB. Significantly fewer patients received peri- and postoperative blood transfusions in the RHS group (25 vs. 37%, P < 0.001; mean 1.0 ± 2.6 vs. mean 1.6 ± 2.9 units of packed red blood cells). The incidence of reoperations due to bleeding was low, RHS 2% (n = 8) vs. cCPB 5% (n = 29), with a trend towards no significant difference between groups (P = 0.079). The duration of mechanical ventilation was shorter (mean 7 ± 16 vs. 9 ± 12 h, P < 0.001) for patients in the RHS group. This study demonstrates that CABG performed with the RHS reduces the incidence and magnitude of allogenic blood transfusion and results in a satisfactory clinical outcome.
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Affiliation(s)
- Shahab Nozohoor
- Department of Cardiothoracic Surgery, Cardiothoracic Anesthesia and Intensive Care, Skane University Hospital and Lund University, Lund, Sweden
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Afilalo J, Rasti M, Ohayon SM, Shimony A, Eisenberg MJ. Off-pump vs. on-pump coronary artery bypass surgery: an updated meta-analysis and meta-regression of randomized trials. Eur Heart J 2011; 33:1257-67. [DOI: 10.1093/eurheartj/ehr307] [Citation(s) in RCA: 134] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Schultz SC, Woodward S, Ebra G. Resource utilization in off-pump versus conventional coronary artery bypass grafting in a community hospital: a comparative analysis using propensity scoring. Heart Surg Forum 2011; 14:E81-6. [PMID: 21521681 DOI: 10.1532/hsf98.201011115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND At a time when cost containment in health care is under increased scrutiny, coronary artery bypass grafting remains the most widely performed cardiac surgical procedure in the world. This study compares 30-day mortality, morbidity, and resource use for off-pump coronary artery bypass (OPCAB) versus conventional coronary artery bypass (CCAB) revascularization. METHODS From January 2000 through December 2008, 1003 patients underwent OPCAB grafting by a single surgeon (S.C.S.). Data were prospectively collected, entered into a Society of Thoracic Surgeons adult cardiac surgery database, and analyzed retrospectively. We used propensity-matching techniques to match this cohort to a group of 1003 patients who underwent CCAB. RESULTS The hospital mortality rate was lower for the OPCAB patients than for the CCAB patients: 2.0% (20/1003) versus 2.8% (28/1003). Predictors of hospital mortality for the entire cohort included age (P = .001), cardiogenic shock (P = .001), congestive heart failure (P = .019), history of myocardial infarction (P = .001), and reoperation (P = .007). The overall incidence of morbidity was lower for the OPCAB patients (reoperation for bleeding, P = .011; prolonged ventilation, P = .035; stroke, P = .045; cardiac arrest, P = .004). OPCAB patients experienced significantly reduced procedure times (P = .001), postoperative ventilation times (P = .035), post-operative lengths of stay (P = .035), and blood product use (intraoperative, P = .001; postoperative, P = .001). CONCLUSION These outcomes clearly demonstrate that OPCAB is a safe and effective procedure for myocardial revascularization. This retrospective, nonrandomized observational study has shown that the patients who underwent OPCAB had reduced morbidity and mortality, as well as decreased resource use, compared with those who underwent CCAB.
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Affiliation(s)
- Scot C Schultz
- Gulf Coast Cardiothoracic and Vascular Surgeons, Naples, Florida Naples Community Hospital, Naples, FL, USA.
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Myocardial protection in patients undergoing coronary artery bypass grafting surgery using minimized extracorporeal circulation in combination with volatile anesthetic. ASAIO J 2011; 56:532-7. [PMID: 21245800 DOI: 10.1097/mat.0b013e3181f120a2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The minimized extracorporeal circulation (ECC) is a safe alternative for coronary artery bypass grafting (CABG) and allows a reduction of the negative effects associated with conventional extracorporeal circulation. Experimental and clinical data indicate that the anesthetic regime might influence the ischemia-reperfusion injury in CABG surgery. The aim of our retrospective study was to investigate the cardioprotective effects of two different minimized ECC systems in combination with two different anesthetic concepts and to determine the impact on oxygen consumption during aortic cross-clamping (ACC). Data of 1,182 patients who underwent elective isolated CABG with minimized ECC from January 1, 2003, to December 31, 2008, were enrolled in a retrospective manner. Patients were allocated either to sevoflurane-based volatile anesthesia using PRECiSe system (SEVO group) or to propofol-based intravenous anesthesia using MECC system (PROP group). Postoperatively, the SEVO group showed lower concentrations of myocardial fraction of creatine kinase compared with the PROP group (p < 0.001). During the period of ACC, the values of systemic vascular resistance (SVR) were higher in SEVO group (p < 0.005). Also, the SEVO group showed lower oxygen consumption at each time point ACC (p < 0.0001). In conclusion, PRECiSe system using a microporous capillary oxygenator in combination with sevoflurane-based volatile anesthetic regimen seem to provide lower postoperative myocardial cell damage and to allow improved perfusion with higher SVRs and lower oxygen consumption during ACC.
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The inflammatory response to miniaturised extracorporeal circulation: a review of the literature. Mediators Inflamm 2010; 2009:707042. [PMID: 20101278 PMCID: PMC2809242 DOI: 10.1155/2009/707042] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2009] [Accepted: 11/03/2009] [Indexed: 12/21/2022] Open
Abstract
Conventional cardiopulmonary bypass can trigger a systemic inflammatory response syndrome similar to sepsis. Aetiological factors include surgical trauma, reperfusion injury, and, most importantly, contact of the blood with the synthetic surfaces of the heart-lung machine. Recently, a new cardiopulmonary bypass system, mini-extracorporeal circulation (MECC), has been developed and has shown promising early results in terms of reducing this inflammatory response. It has no venous reservoir, a reduced priming volume, and less blood-synthetic interface. This review focuses on the inflammatory and clinical outcomes of using MECC and compares these to conventional cardio-pulmonary bypass (CCPB). MECC has been shown to reduce postoperative cytokines levels and other markers of inflammation. In addition, MECC reduces organ damage, postoperative complications and the need for blood transfusion. MECC is a safe and viable perfusion option and in certain circumstances it is superior to CCPB.
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Comparison of two different minimized extracorporeal circulation systems: hematological effects after coronary surgery. ASAIO J 2010; 55:592-7. [PMID: 19812477 DOI: 10.1097/mat.0b013e3181be2f5c] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cardiopulmonary bypass induces hemolysis and activation of inflammatory and coagulation systems as a result of a combination of mechanical trauma and biological mechanisms. The aim of our study was to evaluate the performance of two different minimized extracorporeal circulation (ECC) systems and to compare their influence on blood components. From January 2003 to December 2008, 1,218 patients underwent coronary artery bypass grafting with minimized ECC. The PRECiSe system (41%) consists of a microporous capillary membrane oxygenator (MO) and a diagonal pump (DeltaStream DP2). The MECC system (59%) is composed of a polymethylpentene MO with a plasma-tight diffusion membrane and a centrifugal pump (RotaFlow). Serial blood samples were taken preoperatively (T0), on arrival to intensive care unit (T1), 6 hours postoperatively (T2), and at discharge (T3). Demographic data, intraoperative, and technical parameters were similar in both groups. At T1 and T2, the platelet count in the PRECiSe group was significantly lower than that in the MECC group (p < 0.01). Furthermore, at T1, levels of lactate dehydrogenase were significantly higher in the PRECiSe group (p < 0.05). In addition, postoperative blood loss was significantly higher using the PRECiSe system (p < 0.05). In conclusion, cardiac surgery with the MECC system is associated with less postoperative bleeding and improved blood cell preservation.
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Pöling J, Leptien A, Klaus S, Rees W, Kraatz E, Wiebe K, Bahlmann L. Analysis of the myocardial metabolism by microdialysis during open beating heart surgery. SCAND CARDIOVASC J 2009; 41:114-9. [PMID: 17454837 DOI: 10.1080/14017430601091706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Microdialysis allows the in vivo biochemical analysis of interstitial fluids. Our aim was to reveal in vivo reliable data of the myocardium during open beating heart surgery. DESIGN In ten patients undergoing routine beating coronary artery bypass grafting a microdialysis catheter was inserted into the left ventricle. Measurements were performed up to 45 min after anastomosis. Data were retrospectively compared with standard on-pump procedures. RESULTS The myocardial lactate remained stable during anastomosis, followed by a significant decrease of lactate after revascularisation. Myocardial glucose levels showed a slight decrease, followed by a significant increase after revascularisation. Myocardial purines showed a slight increase during anastomosis, followed by a sharp decrease during reperfusion period. CONCLUSIONS In contrast to on-pump procedures myocardial lactate and purines showed less increasing trend during the ischemic period, while myocardial glucose remained stable as a sign of preserved tissue blood flow. Myocardial microdialysis showed different values compared to the elective on-pump CABG and previous animal studies. This technique allows bedside monitoring of biochemical changes, suggesting its possible role as a clinical monitoring tool.
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Affiliation(s)
- Jochen Pöling
- Department of Cardiac Surgery, Schüchtermann-Klinik Bad Rothenfelde, Germany.
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Pillai JB, Suri RM. Coronary Artery Surgery and Extracorporeal Circulation: The Search for a New Standard. J Cardiothorac Vasc Anesth 2008; 22:594-610. [DOI: 10.1053/j.jvca.2008.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Indexed: 01/19/2023]
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Møller CH, Penninga L, Wetterslev J, Steinbrüchel DA, Gluud C. Clinical outcomes in randomized trials of off- vs. on-pump coronary artery bypass surgery: systematic review with meta-analyses and trial sequential analyses. Eur Heart J 2008; 29:2601-16. [PMID: 18628261 DOI: 10.1093/eurheartj/ehn335] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS To assess the clinical outcomes of off- vs. on-pump coronary artery bypass surgery in randomized trials. METHODS AND RESULTS We searched electronic databases and bibliographies until June 2007. Trials were assessed for risk of bias. Outcome measures were all-cause mortality, myocardial infarction, stroke, atrial fibrillation, and renewed coronary revascularization at maximum follow-up. We applied trial sequential analysis to estimate the strength of evidence. We found 66 randomized trials. There was no statistically significant differences regarding mortality [relative risk (RR) 0.98; 95% confidence interval (CI) 0.66-1.44], myocardial infarction (RR 0.95; 95% CI 0.65-1.37), or renewed coronary revascularization (RR 1.34; 95% CI 0.83-2.18). We found a significant reduced risk of atrial fibrillation (RR 0.69; 95% CI 0.57-0.83) and stroke (RR 0.53; 95% CI 0.31-0.91) in off-pump patients. However, when continuity correction for zero-event trials was included, the reduction in stroke became insignificant (RR 0.62; 95% CI 0.32-1.19). Trial sequential analysis demonstrated overwhelming evidence supporting that off-pump bypass surgery reduces atrial fibrillation. CONCLUSION Off-pump surgery reduces the risks of postoperative atrial fibrillation compared with on-pump surgery. For death, myocardial infarction, stroke, and renewed coronary revascularization, the evidence is still weak and more low-bias risk trials are needed.
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Affiliation(s)
- Christian H Møller
- Department of Cardio-Thoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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Raja SG, Dreyfus GD. Current Status of Off-Pump Coronary Artery Bypass Surgery. Asian Cardiovasc Thorac Ann 2008; 16:164-78. [DOI: 10.1177/021849230801600220] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The expanding indications for angioplasty coupled with the successful short and mid-term results of randomized controlled trials of drug-eluting stents have already had an unquestionable impact on the practice of coronary revascularization operations. However, coronary artery bypass grafting remains a major mode of therapy for coronary artery disease. It is likely that surgery will continue to be preferred for more complex subsets and that surgeons will have to continue to maintain good results in patients with more complex problems. Concerns regarding morbidity associated with conventional surgical myocardial revascularization on cardiopulmonary bypass have led to a resurgence of interest in off-pump bypass surgery during the last decade, with the expectation that it would be safer if cardiopulmonary bypass could be avoided. This review summarizes the impact of off-pump bypass surgery in reducing the morbidity and mortality associated with conventional coronary artery bypass on cardiopulmonary bypass by evaluating the current best-available evidence from randomized controlled trials and meta-analyses comparing off-pump surgery with conventional bypass grafting.
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Drenger B, Gilon D, Chevion M, Elami A, Meroz Y, Milgalter E, Gozal Y. Myocardial metabolism altered by ischemic preconditioning and enflurane in off-pump coronary artery surgery. J Cardiothorac Vasc Anesth 2008; 22:369-76. [PMID: 18503923 DOI: 10.1053/j.jvca.2007.12.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2007] [Indexed: 11/11/2022]
Abstract
OBJECTIVE During off-pump coronary artery bypass (OPCAB) surgery, the heart is subjected to ischemia and reperfusion. The authors hypothesized that the volatile anesthetics are as effective as ischemic preconditioning (IPC) in preserving myocardial function during off-pump cardiac surgery, and this effect is because of multiple mechanisms of action. Therefore, the effects of enflurane with its calcium inhibition and antioxidative properties were compared with mechanical IPC in preserving myocardial cellular markers. DESIGN A prospective, randomized, controlled, and partly blinded study. SETTING A tertiary care university hospital. PARTICIPANTS Twenty-five patients undergoing elective single-graft OPCAB surgery. INTERVENTIONS Patients were randomized into 3 groups: (1) control (n = 8), (2) a single 5-minute ischemia/reperfusion interval of IPC before coronary occlusion (n = 9), and (3) 1.6% enflurane anesthesia 15 minutes before and during graft attachment (n = 8). Arterial and coronary sinus venous blood were analyzed for biochemical indices of ischemia and hydroxyl radical generation. MEASUREMENTS AND MAIN RESULTS Although the hemodynamic changes were small, myocardial lactate production in the control group increased by 120%, whereas in the enflurane group it decreased significantly (p < 0.01) compared with the control and IPC groups. Oxygen utilization in the control group was 44% higher (p < 0.03), and there was also a larger release of the hydroxyl radical-dependent adduct 2,3-dihydroxybenzoic acid (225% increase, p < 0.05) compared with both study groups. During reperfusion, initial anterior wall hypokinesis by TEE was observed, with slow recovery during reperfusion compared with early recovery in both study groups. CONCLUSIONS Coronary occlusion during OPCAB surgery results in increased production of ischemia-related metabolic products. The application of methods such as IPC or volatile anesthesia appears to reduce the metabolic deficit, free-radical production, and physiologic changes.
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Affiliation(s)
- Benjamin Drenger
- Department of Anesthesiology and Critical Care Medicine, Hadassah-Hebrew University Medical Center Hospital and the Hebrew University School of Medicine, Jerusalem, Israel.
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Minimal Extracorporeal Circulation is a Promising Technique for Coronary Artery Bypass Grafting. Ann Thorac Surg 2007; 84:1515-20; discussion 1521. [DOI: 10.1016/j.athoracsur.2007.05.069] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2007] [Revised: 05/24/2007] [Accepted: 05/29/2007] [Indexed: 11/23/2022]
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Stalder M, Gygax E, Immer FF, Englberger L, Tevaearai H, Carrel TP. Minimized Cardiopulmonary Bypass Combined with a Smart Suction Device: The Future of Cardiopulmonary Bypass? Heart Surg Forum 2007; 10:E235-8. [PMID: 17599899 DOI: 10.1532/hsf98.20070703] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The standard heart-lung machine is a major trigger of systemic inflammatory response and the morbidity attributed to conventional extracorporeal circulation (CECC) is still significant. Reduction of blood-artificial surface contact and reduction of priming volume are principal aims in minimized extracorporeal circulation (MECC) cardiopulmonary bypass systems. The aim of this paper is to give an overview of the literature and to present our experience with the MECC-smart suction system. METHODS AND RESULTS At our institution, 1799 patients underwent isolated coronary artery bypass grafting (CABG) surgery, 1372 with a MECC-smart suction system and 427 with CECC. All in-hospital data were assessed and the results were compared between the 2 groups. Patient characteristics and the distribution of EuroSCORE risk profile in our collective were similar between both groups. Average age in the MECC collective was 67.5 +/- 11.4 years and average EuroSCORE was 5.0 +/- 1.5. Average number of distal anastomoses was similar to the average number encountered in patients undergoing CABG surgery with CECC (3.3 +/- 1.0 for MECC versus 3.2 +/- 1.1 for CECC; P = ns). Myocardial protection is superior in MECC patients with lower postoperative maximal cTnI values (11.0 +/- 10.8 micromol/L for MECC versus 24.7 +/- 25.3 micromol/L for CECC; P < .05). Postoperative recovery was faster in patients operated on with the MECC-smart suction system and discharge from the hospital was earlier than for CECC patients (7.4 +/- 1.9 days for MECC versus 8.8 +/- 3.8 days for CECC; P < .05). CONCLUSIONS The MECC-smart suction system is a safe perfusion technique for CABG surgery. In patients operated on with this system, the clinical outcome seems to be better than in patients operated on with CECC. This promising and less damaging perfusion technology has the potential to replace CECC systems in CABG surgery.
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Affiliation(s)
- Mario Stalder
- Department of Cardiovascular Surgery, University Hospital, Berne, Switzerland
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Natarajan A, Samadian S, Clark S. Coronary artery bypass surgery in elderly people. Postgrad Med J 2007; 83:154-8. [PMID: 17344568 PMCID: PMC2599978 DOI: 10.1136/pgmj.2006.049742] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2006] [Indexed: 11/04/2022]
Abstract
An increasing number of elderly individuals are now undergoing coronary artery bypass surgery. Elderly patients, compared with patients of a younger age group, present for surgery with a greater burden of risk factors and reduced functional levels. Short-term outcomes are hence poorer in them. But symptom relief occurs in most survivors and is accompanied by excellent rates of long-term survival and a good quality of life. Therefore, an individualised risk-benefit profile must be carefully constructed by clinicians, taking into account several different factors and not just age alone. This review summarises the current concepts of coronary artery bypass surgery from the perspective of the very old.
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Affiliation(s)
- Arun Natarajan
- School of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
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Sedrakyan A, Wu AW, Parashar A, Bass EB, Treasure T. Off-Pump Surgery Is Associated With Reduced Occurrence of Stroke and Other Morbidity as Compared With Traditional Coronary Artery Bypass Grafting. Stroke 2006; 37:2759-69. [PMID: 17008617 DOI: 10.1161/01.str.0000245081.52877.f2] [Citation(s) in RCA: 140] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
There is growing enthusiasm for coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB). Although deleterious effects of CPB are known, it remains to be proven that avoiding CPB will result in reduction in morbidity. We sought to determine whether off-pump surgery is associated with reduced occurrence of adverse outcomes as compared with CABG with CPB.
Methods—
Studies were identified by searching the MEDLINE, EMBASE and the Cochrane Register 1980 to 2006 (February). We also searched the reference lists of randomized clinical trials (RCT) and reviews to look for additional studies. Study selection: RCTs comparing off-pump surgery to CABG with CPB. No restriction applied on the size of the trial or end point reports. Data extraction: 2 reviewers independently searched for studies, read abstracts and abstracted all data. Data synthesis: combined estimates were obtained using fixed or random effect meta-analyses. Relative risks and risk differences were calculated. Heterogeneity was assessed using χ
2
and I
2
values.
Results—
There were 3996 patients enrolled in 41 RCTs (mean age 62, 22% female). No study reported information on race. Off-pump CABG was associated with a 50% reduction in the relative risk of stroke (95% CI, 7% to 73%), 30% reduction in atrial fibrillation (AF; 95% CI, 16% to 43%) and 48% reduction in wound infection (95% CI, 26% to 63%) with no heterogeneity among RCTs. This translated into avoidance of 10 strokes, 80 cases of AF and 40 infections per 1000 CABG. Fewer distal grafts were performed and there was evidence for >10 reinterventions per 1000 with off-pump CABG. Long-term follow-up is not yet reported in the trials.
Conclusions—
Off-pump CABG is associated with reduced risk of stroke, AF and infections as compared with CABG with CPB. Evidence should be generalized taking into account RCT enrollment limitations, drawbacks related to training requirements, propensity to perform fewer grafts and likely reinterventions after off-pump surgery.
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Affiliation(s)
- Artyom Sedrakyan
- Center for Outcomes and Evidence, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850, USA.
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Guerin V, Ayed SB, Varnous S, Golmard JL, Leprince P, Beaudeux JL, Gandjbakhch I, Bernard M. Release of Brain Natriuretic-Related Peptides (BNP, NT-proBNP) and Cardiac Troponins (cTnT, cTnI) in On-pump and Off-pump Coronary Artery Bypass Surgery. Surg Today 2006; 36:783-9. [PMID: 16937281 DOI: 10.1007/s00595-006-3247-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2005] [Accepted: 05/16/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND We studied the kinetic release of cardiac troponins (cTnI and cTnT) and B-type natriuretic peptides (BNP and NT-proBNP) in patients undergoing off-pump or on-pump coronary artery bypass surgery. METHODS Twenty-five consecutive patients were prospectively enrolled. The patients were divided into three groups: beating heart (I), and cardiopulmonary bypass (CPB) with warm (II) or cold cardioplegia (III). Plasma samples were obtained before anesthesia induction until the sixth day after surgery. RESULTS AND CONCLUSIONS The data were analyzed first for off-pump versus the CPB procedures and second for warm versus cold cardioplegia. The plasma troponin releases appeared to be significantly higher in the CPB groups in comparison to the beating heart group (P < 0.001 and P < 0.002 for cTnI and cTnT peak values, respectively). The peak of the B-type natriuretic peptide release appeared to be more delayed in the groups undergoing CPB than in the beating heart group (day 6 versus days 2 and 4 for NT-proBNP and BNP, respectively). Taken together, our results indicated that the new generation of cTnT assays seemed to be more sensitive than the cTnI assays for the diagnosis of myocardium injury. A lower increase in the cTnT values in the warm cardioplegic group indicated less damage of the myocardium than with cold cardioplegia. Our data also confirm better preservation of the myocardium with off-pump cardiac surgery than with CPB.
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Affiliation(s)
- Valérie Guerin
- Department of Cardiothoracic Surgery, CHU Pitié-Salpêtrière, Pitié-Salpêtrière Hospital, AP-HP, 47-83 Boulevard de l'Hôpital, 75651 Paris, Cedex 13, France
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Raja SG, Dreyfus GD. Impact of Off-Pump Coronary Artery Bypass Surgery on Postoperative Bleeding: Current Best Available Evidence. J Card Surg 2006; 21:35-41; discussion 42-3. [PMID: 16426345 DOI: 10.1111/j.1540-8191.2006.00164.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cardiopulmonary bypass (CPB) is a prerequisite for open-heart surgery, and is a procedure routinely used. CPB exposes blood to artificial surfaces, to mechanical trauma from the pump, to alterations in temperature, and to dilution with fluids, whole blood, plasma products, and drugs, and leads to the activation of platelets, coagulation, and fibrinolysis. Coagulopathy during cardiac surgery with CPB results in impairment in hemostasis and subsequently higher morbidity and mortality. Recent advances in surgical techniques and postoperative management have aimed at reducing postoperative morbidity and mortality. Off-pump coronary artery bypass (OPCAB) surgery is one such advance that attempts to avoid the deleterious effects of extracorporeal circulation by performing myocardial revascularization without CPB. Emerging evidence from several randomized controlled trials (RCTs) as well as large registries such as the Society of Thoracic Surgeons (STS) database suggests that OPCAB reduces the postoperative morbidity and mortality. This review article attempts to evaluate the current best available evidence from RCTs on the impact of OPCAB on postoperative bleeding and transfusion requirements.
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Affiliation(s)
- Shahzad G Raja
- Royal Hospital for Sick Children, Glasgow, United Kingdom.
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Achurin R, Lepilin M, Bajalieva A, Torshin S, Lepilin P. Peculiarities of Hemodynamic Changes During High Thoracic Epidural Anesthesia in Beating Heart Surgery. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2005. [DOI: 10.29333/ejgm/82330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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37
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Kwak YL. Reduction of Ischemia During Off-Pump Coronary Artery Bypass Graft Surgery. J Cardiothorac Vasc Anesth 2005; 19:667-77. [PMID: 16202908 DOI: 10.1053/j.jvca.2005.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2005] [Indexed: 12/11/2022]
Affiliation(s)
- Young Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 134 Shinchon-Dong, Seodaemun-Ku, Seoul, Korea.
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Wijeysundera DN, Beattie WS, Djaiani G, Rao V, Borger MA, Karkouti K, Cusimano RJ. Off-Pump Coronary Artery Surgery for Reducing Mortality and Morbidity. J Am Coll Cardiol 2005; 46:872-82. [PMID: 16139139 DOI: 10.1016/j.jacc.2005.05.064] [Citation(s) in RCA: 160] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2005] [Revised: 05/15/2005] [Accepted: 05/31/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The purpose of this study was to assess the effects of off-pump coronary bypass surgery (OPCAB) on mortality and morbidity. BACKGROUND Despite its potential for reducing morbidity and mortality, OPCAB's role in clinical practice remains controversial. METHODS A meta-analysis of 37 randomized controlled trials (RCTs) (n = 3,449) and 22 risk-adjusted (logistic regression or propensity-score) observational studies (n = 293,617) was performed. Two reviewers performed literature searches (MEDLINE, EMBASE, PubMed, reference lists), quality assessment, and data extraction. Treatment effects were calculated as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS In RCTs, OPCAB was associated with reduced atrial fibrillation (OR 0.59; 95% CI 0.46 to 0.77) and trends toward reduced 30-day mortality (OR 0.91 95% CI 0.45 to 1.83), stroke (OR 0.52; 95% CI 0.25 to 1.05), and myocardial infarction (OR 0.79; 95% CI 0.50 to 1.25). Observational studies showed OPCAB to be associated with reduced 30-day mortality (OR 0.72; 95% CI 0.66 to 0.78), stroke (OR 0.62; 95% CI 0.55 to 0.69), infarction (OR 0.66; 95% CI 0.50 to 0.88), and atrial fibrillation (OR 0.78; 95% CI 0.74 to 0.82). At one to two years, OPCAB was associated with trends toward reduced mortality, but also increased repeat revascularization (RCT: OR 1.75, 95% CI 0.78 to 3.94; Observational: OR 1.35, 95% CI 0.76 to 2.39). CONCLUSIONS Randomized controlled trials did not find, aside from atrial fibrillation, the statistically significant reductions in short-term mortality and morbidity demonstrated by observational studies. These discrepancies might be due to differing patient-selection and study methodology. Future studies must focus on improving research methodology, recruiting high-risk patients, and collecting long-term data.
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Dixon B, Santamaria J, Campbell D. Coagulation Activation and Organ Dysfunction Following Cardiac Surgery. Chest 2005; 128:229-36. [PMID: 16002940 DOI: 10.1378/chest.128.1.229] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Cardiac surgery with cardiopulmonary bypass (CPB) is associated with major inflammatory triggers that cause marked activation of the microcirculation. This inflammatory response is associated with significant organ dysfunction. How this response causes organ dysfunction is not well understood; consequently, few interventions exist to prevent or treat it. In other acute inflammatory conditions, such as sepsis, increased coagulation activation in the microcirculation may be a cause of organ injury. We documented the association between coagulation activation and organ dysfunction to investigate whether coagulation activation also plays a role in organ injury following cardiac surgery with CPB. DESIGN Prospective study of 30 patients undergoing cardiac surgery with CPB. Prothrombin fragment (PTF) 1 + 2 and plasminogen activator inhibitor (PAI) activity were measured, and levels correlated with postoperative measures of organ function including the left-ventricular stroke work index, the Pao(2)/fraction of inspired oxygen (Fio(2)) ratio, and creatinine levels. RESULTS PTF levels increased eightfold (p < 0.05), and PAI activity increased threefold (p < 0.05) over the first 4 h after CPB. PTF levels were correlated with deteriorations in the left-ventricular stroke work index (p = 0.04), the Pao(2)/Fio(2) ratio (p = 0.02), and creatinine levels (p = 0.02). CONCLUSIONS Levels of coagulation activation are associated with markers of postoperative organ dysfunction. Additional studies are warranted to investigate whether strategies that limit coagulation activation are associated with reductions in postoperative organ dysfunction.
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Affiliation(s)
- Barry Dixon
- Intensive Care, St. Vincent's Hospital, 41 Victoria Parade, Fitzroy, Melbourne, Victoria 3065, Australia.
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Puskas J, Cheng D, Knight J, Angelini G, DeCannier D, Diegeler A, Dullum M, Martin J, Ochi M, Patel N, Sim E, Trehan N, Zamvar V. Off-Pump versus Conventional Coronary Artery Bypass Grafting: A Meta-Analysis and Consensus Statement From The 2004 ISMICS Consensus Conference. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2005; 1:3-27. [DOI: 10.1097/01243895-200512000-00002] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Despite many years of clinical and experimental research, the contribution of cardiopulmonary bypass (CPB) and cardioplegic arrest to morbidity and mortality following cardiac surgery remains unclear. This is due, in part, to lack of suitable control group against which bypass and cardioplegic arrest can be compared. The recent success of beating heart coronary artery bypass grafting has, however, for the first time, provided an opportunity to compare the same operation, in similar patient groups, with, or without CPB and cardioplegic arrest. CPB is associated with an acute phase reaction of protease cascades, leucocyte, and platelet activation that result in tissue injury. This is largely manifest as subclinical organ dysfunction that produces a clinical effect in those patients that generate an excessive inflammatory response or in those with limited functional reserve. The contribution of myocardial ischemia/reperfusion, secondary to aortic cross-clamping, and cardioplegic arrest, to the systemic inflammatory response and wider organ dysfunction is unknown, and requires further evaluation in clinical trials.
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Affiliation(s)
- G J Murphy
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
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42
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Raja SG, Dreyfus GD. Off-pump coronary artery bypass surgery: To do or not to do? Current best available evidence. J Cardiothorac Vasc Anesth 2004; 18:486-505. [PMID: 15365936 DOI: 10.1053/j.jvca.2004.05.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, Middlesex, United Kingdom.
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Alwan K, Falcoz PE, Alwan J, Mouawad W, Oujaimi G, Chocron S, Etievent JP. Beating versus arrested heart coronary revascularization: evaluation by cardiac troponin I release. Ann Thorac Surg 2004; 77:2051-5. [PMID: 15172263 DOI: 10.1016/j.athoracsur.2003.11.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND This prospective randomized study aimed to compare beating and arrested heart revascularization in patients undergoing first elective coronary artery bypass graft, with cardiac troponin I release used to evaluate myocardial injury. METHODS Seventy patients were randomly assigned to a beating or arrested heart revascularization group. Cardiac troponin I concentrations were measured in serial venous blood samples drawn preoperatively in both groups: after aortic unclamping at 6, 9, 12, and 24 hours in the arrested heart group and after the last anastomosis at 6, 9, 12, and 24 hours in the beating heart group. Analysis of covariance with repeated measures was performed to test the effect of group and time on cardiac troponin I concentration. RESULTS The total amount of cardiac troponin I released was higher in the arrested heart revascularization group than in the beating heart revascularization group (8.25 +/- 6.16 vs 3.18 +/- 4.75 microg, p < 0.0001). Cardiac troponin I concentrations were significantly higher in the arrested heart group at hours 6, 9, 12, and 24 than in the beating heart group (p < 0.0001). CONCLUSIONS The lower release of cardiac troponin I in the beating heart revascularization group indicates that conventional coronary artery bypass graft with cardioplegic arrest causes more damage to the heart than off-pump myocardial revascularization.
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Affiliation(s)
- Kifah Alwan
- Department of Thoracic and Cardiovascular Surgery, Centre Hospitalier du Nord, Jdeidet, Zgharta, Lebanon
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44
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Affiliation(s)
- Robert A Lancey
- Bassett Heart Care Institute, Mary Imogene Bassett Hospital, Cooperstown, New York, USA
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Bortone F, Mazzoni M, Repossini A, Campolo J, Ceriani R, Devoto E, Parolini M, De Maria R, Arena V, Parodi O. Myocardial lactate metabolism in relation to preoperative regional wall motion and to early functional recovery after coronary revascularization. J Cardiothorac Vasc Anesth 2003; 17:478-85. [PMID: 12968236 DOI: 10.1016/s1053-0770(03)00153-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate myocardial lactate metabolism as a marker of functional status after surgical coronary revascularization. DESIGN Single-center, prospective, cohort study. SETTING Tertiary care teaching hospital. PARTICIPANTS Fifty patients with stable angina, ejection fraction >0.40, undergoing coronary artery bypass surgery for multiple-vessel disease. MEASUREMENTS AND MAIN RESULTS Before (T1) and 30 minutes (T2) after coronary artery bypass grafting, the authors simultaneously sampled blood from artery and coronary sinus to determine myocardial lactate dynamics and performed transesophageal echocardiography (TEE) to assess segmental wall motion. Wall motion score index (WMSI) was calculated with an online/offline comparison. At T2, WMSI improved from 1.40 +/- 0.31 to 1.17 +/- 0.23 (p = 0.0001). Preoperatively, 2 patterns of lactate balance were found: 39 patients were lactate extractors (17% +/- 10%) and 11 were lactate producers (-11% +/- 11%). At T2, lactate metabolism was shifted towards a pattern opposite to the baseline: delta lactate extraction was -8% +/- 16% in extractors at T1 versus 7% +/- 9% in producers at T1 (p = 0.003). Changes in WMSI were not correlated with changes in lactate utilization. No single preoperative variable predicted postoperative WMSI or its changes from baseline. Cardiopulmonary bypass (CPB) time was the only significant predictor of postoperative lactate extraction by multivariate regression (r = -0.46, p = 0.001): at T2, patients in the highest CPB time quartile showed frank lactate production (-6% +/- 13%) when compared with those in the lowest quartile (15% +/- 11%, p = 0.005). However, postoperative WMSI was similar in different CPB time groups. CONCLUSIONS Myocardial lactate metabolism pattern is not associated with functional status before and early after successful coronary revascularization. CPB time was the only significant predictor of postoperative lactate extraction. Measurement of lactate does not appear to be a valuable tool to assess the coupling of myocardial regional function and metabolism in the setting of coronary artery surgery and mild-to-moderate functional impairment.
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Affiliation(s)
- Franco Bortone
- Department of Anesthesia and Cardiac Surgery, Humanitas Gavazzeni, Bergamo, Italy
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Penttilä HJ, Lepojärvi MVK, Kaukoranta PK, Kiviluoma KT, Ylitalo KV, Peuhkurinen KJ. Ischemic preconditioning does not improve myocardial preservation during off-pump multivessel coronary operation. Ann Thorac Surg 2003; 75:1246-52; discussion 1252-3. [PMID: 12683571 DOI: 10.1016/s0003-4975(02)04659-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The value of ischemic preconditioning during coronary operations has remained controversial. The aim of this study was to evaluate the effects of ischemic preconditioning on myocardial energy metabolism and tissue injury during off-pump multivessel coronary surgery. METHODS Eleven patients with preceding preconditioning were compared with 11 patients without it. The preconditioning group underwent a 5-minute period of ischemia followed by a 5-minute reperfusion period before coronary occlusion for each of the first two anastomoses. RESULTS The transmyocardial differences (coronary sinus - arterial) in inosine and the sum of adenine degradation products increased in both groups, but the differences in xanthine and hypoxanthine increased only in the preconditioning group. Myocardial lactate production increased to a maximum of 0.09 mmol/L with preconditioning and to a maximum of 0.17 mmol/L without it. Transmyocardial pH differences increased to 0.03 U in both groups. The maximum postoperative concentration of creatine kinase-MB mass was 14.8 microg/L with preconditioning and 6.3 microg/L without preconditioning, and that of troponin I 7.4 microg/L and 5.2 microg/L, respectively. There were no statistically significant differences between the groups, however. CONCLUSIONS Ischemic preconditioning of 5 minutes followed by reperfusion of 5 minutes during off-pump multivessel coronary artery surgery did not prevent myocardial metabolic derangement and tissue injury and thus cannot be routinely recommended.
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Affiliation(s)
- Hannu J Penttilä
- Department of Anesthesiology, Oulu University Hospital, Oulu, Finland.
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Sohrabi F, Mispireta LA, Fiocco M, Dibos LA, Buescher PC, Sloane PJ. Effects of off-pump coronary artery bypass grafting on patient outcome. J Investig Med 2003; 51:27-31. [PMID: 12580318 DOI: 10.2310/6650.2003.33529] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) is associated with postoperative myocardial stunning, hypothermia, formation of microemboli, and systemic inflammatory response syndrome, all of which may prolong recovery from coronary artery bypass grafting (CABG) surgery. This study sought to compare outcomes in patients undergoing CABG off pump versus on pump. METHODS Outcomes, including mortality and several morbidities, were reviewed in 1,623 on-pump patients and 683 off-pump patients. Morbidities assessed included postoperative bleeding, incidence of multiorgan dysfunction, and neurologic complications. Chi-square and t-test analysis were used to determine statistical significance. RESULTS Mortality was 42% lower in the off-pump group than the on-pump group. Both critical care and total hospital length of stay were significantly shorter in the off-pump group. The incidence of postoperative bleeding requiring transfusion or a return to the operating room was reduced by 29% in the off-pump group and the incidence of multiorgan dysfunction was reduced by 31%. The off-pump patients also presented a significantly lower incidence of cerebral vascular accidents and seizures than on-pump patients. CONCLUSIONS We conclude that there is an association between improved patient outcome and off-pump CABG surgery. The outcomes of this study show a statistically significant decrease in mortality, critical care length of stay, total hospital stay, incidence of bleeding requiring transfusion or return to the operating room, amount of blood transfused, incidence of multiorgan dysfunction, cerebral vascular accidents, and seizures in off-pump patients when compared with on-pump patients. Such results support the use of myocardial revascularization off pump as an alternative to CABG surgery on pump. CABG surgery off pump may allow a better postoperative clinical course in patients who are candidates for the procedure.
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Affiliation(s)
- Farrokh Sohrabi
- Department of Surgery, The Union Memorial Hospital, 201 East University Parkway, Baltimore, MD 21218, USA
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48
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Cerillo AG, Sabatino L, Bevilacqua S, Farneti PA, Scarlattini M, Forini F, Glauber M. Nonthyroidal illness syndrome in off-pump coronary artery bypass grafting. Ann Thorac Surg 2003; 75:82-7. [PMID: 12537197 DOI: 10.1016/s0003-4975(02)03919-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) is an established cause of nonthyroidal illness syndrome (NTIS). Off-pump coronary artery bypass (OPCAB) has been reported to be less invasive than coronary artery bypass grafting (CABG) with CPB. We prospectively evaluated thyroid metabolism in OPCAB patients. METHODS We analyzed free thyroid hormones (FT3 and FT4), thyroid-stimulating hormone (TSH), and reverse T3 (rT3) in 20 consecutive patients undergoing CABG surgery. Nine patients underwent CABG with CPB, and 11 underwent OPCAB. Blood samples were taken on admission, on the day of surgery (7:30 AM), after sternotomy, at the end of the operation, and at 2, 6, 12, 24, 36, 48, 72, 96, 120, and 144 hours postoperatively. The concentrations of FT3, FT4, and TSH were determined on each sample. Reverse T3 concentration was measured in 10 patients up to 48 hours and at 144 hours postoperatively. RESULTS Baseline, operative, and postoperative variables were similar in the two groups. FT3 concentration dropped significantly (p < 0.0001), reaching its lowest value 12 hours postoperatively. There were no significant differences between CPB and OPCAB patients. FT4 varied significantly in both groups (p < 0.0001), but remained in the normal range. TSH variation was not significant. rT3 concentration rose significantly (p = 0.0002) in both groups, peaking 24 hours after surgery. CONCLUSIONS. OPCAB induces a NTIS similar to that observed after CPB, probably due to the inhibition of T4 conversion to T3. This finding suggests that NTIS is a nonspecific response to stress. CPB should not be considered as the sole trigger of NTIS in cardiac surgical patients.
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50
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Mehta Y, Juneja R. Off-pump coronary artery bypass grafting: new developments but a better outcome? Curr Opin Anaesthesiol 2002; 15:9-18. [PMID: 17019179 DOI: 10.1097/00001503-200202000-00003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Off-pump coronary artery surgery is now performed safely and effectively without cardiopulmonary bypass. This review includes indications, approaches, anaesthetic and haemodynamic management, and compares the occurrence of postoperative complications and multiorgan dysfunction with conventional cardiac surgery.
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Affiliation(s)
- Yatin Mehta
- Department of Anaesthesiology, Escorts Heart Institute and Research Centre, New Delhi, India.
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