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Sampon F, Ter Woorst J, Dekker L, Akca F. Thoracoscopic-assisted, minimally invasive versus off-pump bypass grafting for single vessel coronary artery disease - A propensity matched analysis. Int J Cardiol 2024; 409:132175. [PMID: 38754586 DOI: 10.1016/j.ijcard.2024.132175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/08/2024] [Accepted: 05/13/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE This study compared perioperative outcomes after off-pump revascularization through a thoracoscopic-assisted (non-robotic) minimally invasive approach (Endo-CAB) or sternotomy approach (OPCAB) for patients with single vessel left anterior descending (LAD) disease. METHODS In this retrospective, propensity matched cohort study, 266 consecutive patients were included in the Endo-CAB group (n = 136) and OPCAB group (n = 130). After propensity score matching 116 Endo-CAB and 116 OPCAB patients were compared. 'Textbook outcome' was defined as the absence of 30-day mortality, re-exploration for bleeding, postoperative ischemia, cardiac tamponade, cerebrovascular events, wound infection, new-onset arrhythmias, pneumonia, placement of chest drains and prolonged hospital stay (> 7 days). Multivariable regression analysis was performed to identify independent predictors for textbook outcome. RESULTS Textbook outcome occurred significantly more frequent in the Endo-CAB group compared to the OPCAB group (81.9% vs. 59.5%, p < 0.001). Patients undergoing Endo-CAB surgery had shorter hospital admission (3.0 [3.0-4.0] vs. 5.0 [4.0-6.0] days, p < 0.001), less blood loss (225 [150-355] vs. 450 [350-600] mL, p < 0.001). Other perioperative outcomes were comparable for both groups. Regression analysis demonstrated that Endo-CAB approach was an independent positive predictor for textbook outcome (OR 3.02, 95% CI 1.61-5.66, p < 0.001). CONCLUSIONS Our study suggests that patients undergoing Endo-CAB surgery have improved perioperative outcome resulting in higher rates of textbook outcome for the treatment of single vessel CAD. This technique could be widely available since routine thoracoscopic instruments are used.
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Affiliation(s)
- Fleur Sampon
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Joost Ter Woorst
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Lukas Dekker
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands; Departments of Biomedical Technology, Eindhoven University of Technology, the Netherlands
| | - Ferdi Akca
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands.
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Guan Z, Guan X, Gu K, Lin X, Lin J, Zhou W, Xu M, Wan F, Zhang Z, Song C. Short-term outcomes of on- vs off-pump coronary artery bypass grafting in patients with left ventricular dysfunction: a systematic review and meta-analysis. J Cardiothorac Surg 2020; 15:84. [PMID: 32393284 PMCID: PMC7216614 DOI: 10.1186/s13019-020-01115-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/27/2020] [Indexed: 11/16/2022] Open
Abstract
Objectives Does the manipulation of the off-pump CABG (OPCAB) in patient with depressed left ventricular function is better than on-pump CABG (ONCAB) approach in in-hospital mortality and morbidities? Here we undertook a meta-analysis of the best evidence available on the comparison of primary and second clinical outcomes of the off-pump and on-pump CABG. Design Systematic literature reviewer and meta-analysis. Data sources PubMed, EMBASE, Web of science and Cochrane Center Registry of Controlled Trials were searched the studies which comparing the use of the off-pump CABG(OPCAB) and on-pump CABG (ONCAB) for patients with LVD during January 1990.1 to January 2018. Eligibility criteria All observation studies and randomized controlled trials comparing on-pump and off-pump as main technique for multi-vessel coronary artery disease (defined as severe stenosis (>70%) in at least 2 major diseased coronary arteries) with left ventricular dysfunction(defined as ejection fraction (EF) 40% or less) were included. Data extraction and synthesis Authors will screen and select the studies extract the following data, first author, year of publication, trial characters, study design, inclusion and exclusion criteria, graft type, clinical outcome, assess the risk of bias and heterogeneity. Study-specific estimates will pool through the modification of the Newcastle-Ottawa scale for the quality of study and while leave-one-out analysis will be used to detect the impact of individual studies on the robustness of outcomes. Results Among the 987 screened articles, a total of 16 studies (32,354 patients) were included. A significant relationship between patient risk profile and benefits from OPCAB was found in terms of the 30-day mortality (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.73–0.97; P = 0.02), stroke (OR, 0.69; 95% CI, 0.55–0.86; P = 0.00), myocardial infarction (MI) (OR, 0.71; 95% CI, 0.53–0.96; P = 0.02), renal failure (OR, 0.71; 95% CI, 0.55–0.93; P = 0.01), pulmonary complication (OR, 0.68; 95% CI, 0.52–0.90; P = 0.01), infection (OR, 0.67; 95% CI, 0.49–0.91; P = 0.00),postoperative transfusion (OR, 0.25; 95% CI, 0.08–0.84; P = 0.02) and reoperation for bleeding (OR, 0.56; 95% CI, 0.41–0.75; P = 0.00). There was no significant difference in atrial fibrillation (AF) (OR, 0.96;95%; CI, 0.78–1.41; P = 0.56) and neurological dysfunction (OR, 0.88; 95% CI, 0.49–1.57; P = 0.65). Conclusions Compared with the on-pump CABG with LVD, using the off-pump CABG is a better choice for patients with lower mortality, stroke, MI, RF, pulmonary complication, infection, postoperative transfusion and reoperation for bleeding. Further randomized studies are warranted to corroborate these observational data.
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Affiliation(s)
- Zhiyuan Guan
- Department of Cardiology surgery, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191, China
| | | | - Kaiyun Gu
- Department of Cardiology surgery, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191, China
| | - Xuanqi Lin
- Beijing University of Technology, Beijing, 100124, China
| | - Jin Lin
- Department of Cardiology surgery, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191, China
| | - Wenjun Zhou
- Department of Cardiology surgery, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191, China
| | - Ming Xu
- Department of Cardiology, Peking University Third Hospital, NHC Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Beijing, 100191, China
| | - Fen Wan
- Shanghai East Hospital, Tongji University, 150 Jimo Rd., Pudong District, Shanghai, 100124, China
| | - Zhe Zhang
- Department of Cardiology surgery, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191, China.
| | - Chunli Song
- Department of Orthopedics, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191, China.
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Athanasopoulos LV, Athanasiou T. Off-pump coronary artery bypass grafting in left main stem stenosis: outcomes, concerns and controversies. J Thorac Dis 2016; 8:S787-S794. [PMID: 27942396 DOI: 10.21037/jtd.2016.09.72] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Left main stem (LMS) disease is known to be a poor prognostic factor in terms of morbidity or mortality. Traditionally, it has been treated with constitution of bypass to provide required haemodynamic stability. We searched the literature for evidence on off-pump (OFP) surgery for treating this high-risk group of patients focusing in our review on postoperative outcomes, concerns and controversies. The majority of the studies identified showed favourable or equal outcomes of OFP when compared to conventional approach. All of the studies, apart from two, which showed lower incidence of postoperative deaths, demonstrated equal mortality rates. Stroke rates were found less in three studies. Less blood transfusions, inotropic use and length of study has been also demonstrated. The main concerns of OFP surgery are: haemodynamic instability and less complete revascularization. Main controversies are: same or favourable outcomes despite lower number of grafts with OFP surgery and less stroke rates despite manipulation of aorta with side-clamping. Despite these concerns and controversies OFP surgery has been proven to be feasible and safe as demonstrated by results from numerous studies.
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Affiliation(s)
- Leonidas V Athanasopoulos
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Thanos Athanasiou
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
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Al-Ruzzeh S, Athanasiou T, George S, Amrani M. Methodological approach in adopting off-pump coronary artery bypass surgery in a British cardiothoracic unit: Harefield experience. Perfusion 2016; 19 Suppl 1:S61-6. [PMID: 15161066 DOI: 10.1191/0267659104pf715oa] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The theoretical and practical disadvantages of coronary artery bypass graft surgery using cardiopulmonary bypass with cardioplegic arrest are well reported in the literature. Encouraged by our work and others, we adopted a systematic approach to the application of off-pump coronary artery bypass surgery. We aimed to validate the non-selective use of the off-pump technique in all patients and assess the outcome in specific patient groups including: patients with ischaemic left ventricular dysfunction, female and high-risk patients. We investigated specific technical details related to off-pump surgery including: the potential effect of the distortion of the mitral valve on haemodynamic stability intraoperatively and the feasibility of sequential coronary artery bypass grafting using the off-pump technique. We also compared the outcome to the national United Kingdom performance in a risk-stratified manner. An extensive retrospective data review for comparative analysis of outcome was carried out at both local and multi-centre levels. This showed that off-pump surgery was feasible for all patients, and provided a better outcome in patients with ischaemic left ventricular dysfunction, female and high-risk patients. The distortion of the mitral valve contributed to the haemodynamic instability. In conclusion, off-pump surgery is safe and provides better outcome in specific patient groups.
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Affiliation(s)
- Sharif Al-Ruzzeh
- The National Heart and Lung Institute, Imperial College of Science, Technology and Medicine, Harefield Hospital, Middlesex, United Kingdom
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Chen JW, Lin CH, Hsu RB. Role of Left Main Coronary Artery Stenosis on Intraoperative Conversion and Mortality in Off-Pump Coronary Artery Bypass. ACTA CARDIOLOGICA SINICA 2014; 30:522-8. [PMID: 27122830 DOI: 10.6515/acs20140929a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Intraoperative conversion is a major threat in off-pump coronary artery bypass (OPCAB). The conversion rate depends on patient selection and surgeon experience. Previous studies have demonstrated the feasibility of OPCAB for patients with left main coronary artery stenosis (LMCAS) ≥ 50%. However, no studies have focused on the role of LMCAS ≥ 90%. We sought to assess the impact of LMCAS ≥ 90% on the conversion rate and mortality in OPCAB. METHODS We conducted a retrospective review of 1055 consecutive unselected patients undergoing OPCAB between 2000 and 2012. The patients in our study were divided into 3 groups by the severity of LMCAS. RESULTS LMCAS was < 50% in 704, 50-90% in 266, and ≥ 90% in 85 patients. LMCAS was not associated with major postoperative complications and hospital mortality, although preoperative cardiogenic shock was present in 6.3%. Overall, the conversion rate was 10.1%:11.4% in LMCAS < 50%, 5.6% in LMCAS 50-90%, and 14.1% in LMCAS ≥ 90%. Operation status, cardiogenic shock, left ventricular ejection fraction < 30% and operation before 2007 were noted as independent predictors of conversion. The overall hospital mortality rate was 5.1%: 4.8% in LMCAS < 50%, 4.5% in LMCAS 50-90%, and 9.4% in LMCAS ≥ 90%. Operation status, cardiogenic shock, left ventricular ejection fraction < 30% and intraoperative conversion were observed to be independent predictors of mortality. However, LMCAS did not predict either conversion or hospital mortality. CONCLUSIONS LMCAS ≥ 90% was not an independent predictor of intraoperative conversion or hospital mortality in OPCAB. KEY WORDS Conversion; Left main coronary artery stenosis; Off-pump coronary artery bypass.
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Affiliation(s)
- Jeng-Wei Chen
- Department of Surgery, National Taiwan University Hospital, Hsin- Chu Branch; ; Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Cheng-Hsin Lin
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ron-Bin Hsu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Liu P, Wang F, Ren S, Lin F, Yang Y, Fan X, Sun G, Zheng X, Liu J, Yuan J, Ye Z. A propensity score analysis on the effect of on-pump versus off-pump coronary artery bypass grafting for patients with coronary artery disease. J Thorac Dis 2014; 6:838-44. [PMID: 24977010 DOI: 10.3978/j.issn.2072-1439.2014.05.08] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 05/13/2014] [Indexed: 11/14/2022]
Abstract
AIM The aim of this retrospective observational study was to investigate the effect of on-pump versus off-pump coronary artery bypass grafting (CABG) for patients with coronary artery diseases (CAD). METHODS A retrospective observational study was performed using a propensity score analysis in 290 consecutive patients undergoing CABG between April 2009 and March 2014, of them, 54 patients undergoing off-pump CABG (OPCABG) were matched with 54 patients undergoing on-pump CABG (ONCABG) by propensity score. The perioperative complications and hospital mortality were documented. RESULTS Preoperative characteristics were comparable in both groups following propensity matching. Postoperative myocardial infarction (MI) incidence was lower in OPCABG group than in ONCABG group (3.7% vs. 14.8%, P=0.046); both hospital mortality and the major complications rates were similar in the two groups after propensity adjustment for preoperative characteristics. CONCLUSIONS The perioperative complications are similar in both off-pump and on pump CABG groups, the short-term effect of OPCABG is similar to that of ONCABG.
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Affiliation(s)
- Peng Liu
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Fei Wang
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Shiyan Ren
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Fan Lin
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Yuguang Yang
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Xueqiang Fan
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Guang Sun
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Xia Zheng
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jiangtao Liu
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jing Yuan
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Zhidong Ye
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
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Liu P, Wang F, Ren S, Lin F, Yang Y, Fan X, Sun G, Zheng X, Liu J, Yuan J, Ye Z. A propensity score analysis on the effect of on-pump versus off-pump coronary artery bypass grafting for patients with coronary artery disease. J Thorac Dis 2014. [PMID: 24977010 DOI: 10.3978/j.issn.2072-1439.2014.05.08.pmid:] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIM The aim of this retrospective observational study was to investigate the effect of on-pump versus off-pump coronary artery bypass grafting (CABG) for patients with coronary artery diseases (CAD). METHODS A retrospective observational study was performed using a propensity score analysis in 290 consecutive patients undergoing CABG between April 2009 and March 2014, of them, 54 patients undergoing off-pump CABG (OPCABG) were matched with 54 patients undergoing on-pump CABG (ONCABG) by propensity score. The perioperative complications and hospital mortality were documented. RESULTS Preoperative characteristics were comparable in both groups following propensity matching. Postoperative myocardial infarction (MI) incidence was lower in OPCABG group than in ONCABG group (3.7% vs. 14.8%, P=0.046); both hospital mortality and the major complications rates were similar in the two groups after propensity adjustment for preoperative characteristics. CONCLUSIONS The perioperative complications are similar in both off-pump and on pump CABG groups, the short-term effect of OPCABG is similar to that of ONCABG.
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Affiliation(s)
- Peng Liu
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Fei Wang
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Shiyan Ren
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Fan Lin
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Yuguang Yang
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Xueqiang Fan
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Guang Sun
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Xia Zheng
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jiangtao Liu
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jing Yuan
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Zhidong Ye
- Cardiovascular center, China-Japan Friendship Hospital, Beijing 100029, China
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Houlind K. On-pump versus off-pump coronary artery bypass surgery: what is the status after ROOBY, DOORS, CORONARY and GOPCABE? Future Cardiol 2013; 9:569-79. [DOI: 10.2217/fca.13.39] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Off-pump coronary artery bypass surgery has been purported to be safer than conventional coronary artery bypass surgery performed using cardiopulmonary bypass. This theory was supported by a number of early series, but failed to be confirmed by a number of small, randomized, controlled trials. Conversely, it has been suggested that revascularization after off-pump surgery is associated with fewer grafts and lower graft patency, potentially leading to a higher risk of cardiovascular morbidity and need for repeated coronary interventions. Since 2009, four major randomized controlled trials have been published, increasing the level of evidence significantly.
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Affiliation(s)
- Kim Houlind
- Department of Vascular Surgery, Kolding Hospital, Skovvangen 6-8, 6000 Kolding, Denmark and Institute of Regional Health Services Research, University of Southern Denmark, Denmark
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Training residents in off-pump coronary artery bypass surgery: A 14-year experience. J Thorac Cardiovasc Surg 2012; 143:1247-53. [DOI: 10.1016/j.jtcvs.2011.09.049] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 08/29/2011] [Accepted: 09/26/2011] [Indexed: 11/22/2022]
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Murzi M, Caputo M, Aresu G, Duggan S, Miceli A, Glauber M, Angelini GD. On-pump and off-pump coronary artery bypass grafting in patients with left main stem disease: A propensity score analysis. J Thorac Cardiovasc Surg 2012; 143:1382-8. [DOI: 10.1016/j.jtcvs.2011.07.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 02/02/2011] [Accepted: 07/19/2011] [Indexed: 10/28/2022]
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Zembala MO, Filipiak K, Ciesla D, Pacholewicz J, Hrapkowicz T, Knapik P, Przybylski R, Zembala M. Surgical treatment of left main disease and severe carotid stenosis: does the off-pump technique provide a better outcome? Eur J Cardiothorac Surg 2012; 43:541-8; discussion 548. [DOI: 10.1093/ejcts/ezs277] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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Emmert MY, Salzberg SP, Cetina Biefer HR, Sundermann SH, Seifert B, Grunenfelder J, Jacobs S, Falk V. Total arterial off-pump surgery provides excellent outcomes and does not compromise complete revascularization. Eur J Cardiothorac Surg 2012; 41:e25-31. [DOI: 10.1093/ejcts/ezr225] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Emmert MY, Salzberg SP, Seifert B, Schurr UP, Theusinger OM, Hoerstrup SP, Reuthebuch O, Genoni M. Off-pump surgery is not a contraindication for patients with a severely decreased ejection fraction. Heart Surg Forum 2011; 14:E302-6. [PMID: 21997652 DOI: 10.1532/hsf98.20111027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND A severely impaired left ventricular ejection fraction (EF) (30%) increases the risk of surgical myocardial revascularization. We evaluated the safety and feasibility of off-pump coronary artery bypass (OPCAB) surgery in patients with a severely decreased EF. METHODS We compared 79 patients with an EF ≤30% (group A) with 863 patients with an EF >30% (group B) who underwent myocardial revascularization between 2003 and 2008. The relationship between EF and outcome after OPCAB was assessed by univariate and logistic regression analyses. A composite end point was constructed from 30-day mortality, renal failure, length of stay in the intensive care unit (ICU) >2 days, neurologic complications, and use of an intra-aortic balloon pump (IABP). Additionally, the completeness of revascularization was assessed. RESULTS The mortality rates for groups A and B were comparable (1.3% and 2.0%, respectively; P = .55), and the 2 groups did not differ with regard to serious postoperative complications, such as stroke (2.5% versus 1.4% for groups A and B, respectively; P = .42), peripheral neurologic complications (2.5% versus 0.7%, P = .14), renal failure (0% versus 1.1%, P = 1.00), use of an IABP (1.3% versus 0.8%, P = .50), ICU length of stay >2 days (17.7% versus 19.6%, P = .77). Similarly, groups A and B did not differ with regard to ventilation time (11.2 ± 12.7 hours versus 12.4 ± 15.5 hours, P = .82), indicating similar postoperative courses for the 2 groups of patients. In contrast, the composite end point occurred significantly more frequently in group A (43.0% versus 29.7%, P = .02), a result driven by the increased rate of rethoracotomy for bleeding in that group (11.4% versus 2.9%, P = .001). The 2 groups were similar with respect to the total number of grafts used per patient (3.82 ± 0.89 versus 3.63 ± 1.01, P = .10) and the completeness of revascularization (94% versus 93%, P = .49). CONCLUSION A standardized OPCAB approach is safe for patients with a severely decreased EF, and its use does not come at the cost of less complete revascularization.
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Tamburino C, Capodanno D, Di Salvo ME, Caggegi A, Tomasello D, Cincotta G, Miano M, Petralia A, Varone E, Patanè M, Tamburino C, Tolaro S, Patanè L, Calafiore AM. Routine versus selective coronary artery bypass for left main coronary artery revascularization: The appraise a customized strategy for left main revascularization (CUSTOMIZE) study. Int J Cardiol 2011; 150:307-14. [DOI: 10.1016/j.ijcard.2010.04.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2009] [Revised: 01/04/2010] [Accepted: 04/17/2010] [Indexed: 11/24/2022]
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Is off-pump superior to conventional coronary artery bypass grafting in diabetic patients with multivessel disease? Eur J Cardiothorac Surg 2011; 40:233-9. [DOI: 10.1016/j.ejcts.2010.11.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Revised: 10/27/2010] [Accepted: 11/02/2010] [Indexed: 11/19/2022] Open
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Gan HL, Zhang JQ, Xiao W, Zhao S, Huang FJ, Gu CX, Lu CS, Wang PS. Ostial left main coronary artery stenosis as an additional risk factor in off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg 2011; 143:103-10. [PMID: 21679974 DOI: 10.1016/j.jtcvs.2011.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 04/06/2011] [Accepted: 05/05/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Our aim was to determine whether general left main coronary artery stenosis (LMS) and ostial LMS pose additional risks after off-pump coronary artery bypass grafting (CABG) relative to non-left main coronary artery stenosis. METHODS From January 1, 2008, to December 31, 2009, 4366 patients underwent primary isolated off-pump CABG at Beijing Anzhen Hospital. Disease was retrospectively classified as non-left main disease (n = 3523), nonostial LMS (n = 765), and ostial LMS (n = 78). Groups were propensity score matched. Kaplan-Meier freedoms from major adverse cardiac and cerebrovascular events (MACCEs) were calculated. RESULTS During the first 30 postoperative days, mortality was significantly higher in the ostial LMS group (6.41%) than in non-left main disease (0.855%, χ(2) = 7.78, P = .005) and nonostial LMS (1.28%, χ(2) = 4.71, P = .03) groups. Incidence of MACCEs was significantly higher in the ostial LMS group (20.5%) than in non-left main disease (5.98%, P = .000) and nonostial LMS (9.62%, P = .002) groups. Odds ratio for early MACCEs of ostial LMS versus non-left main disease was 3.74 (95% confidence interval, 1.72-8.17). At mean follow-up 12.8 ± 7.5 months and cumulative follow-up 498.5 patient-years, difference among groups in freedom from MACCEs did not reach statistical significance (χ(2) = 2.39, P = .303). CONCLUSIONS Ostial LMS poses additional early risks of mortality and MACCEs in off-pump CABG. Off-pump CABG for ostial LMS should proceed with greater of intraoperative surveillance and lower threshold for converting to on-pump CABG.
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Affiliation(s)
- Hui-Li Gan
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.
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Boudriot E, Thiele H, Walther T, Liebetrau C, Boeckstegers P, Pohl T, Reichart B, Mudra H, Beier F, Gansera B, Neumann FJ, Gick M, Zietak T, Desch S, Schuler G, Mohr FW. Randomized Comparison of Percutaneous Coronary Intervention With Sirolimus-Eluting Stents Versus Coronary Artery Bypass Grafting in Unprotected Left Main Stem Stenosis. J Am Coll Cardiol 2011; 57:538-45. [PMID: 21272743 DOI: 10.1016/j.jacc.2010.09.038] [Citation(s) in RCA: 297] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Revised: 08/24/2010] [Accepted: 09/02/2010] [Indexed: 11/26/2022]
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Fukui T, Tabata M, Manabe S, Shimokawa T, Shimizu J, Morita S, Takanashi S. Off-pump bilateral internal thoracic artery grafting in patients with left main disease. J Thorac Cardiovasc Surg 2010; 140:1040-5. [DOI: 10.1016/j.jtcvs.2009.11.069] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Revised: 11/02/2009] [Accepted: 11/27/2009] [Indexed: 10/19/2022]
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Left Main Coronary Artery Disease Does Not Affect the Outcome of Off-Pump Coronary Artery Bypass Grafting. Ann Thorac Surg 2010; 90:1501-6. [DOI: 10.1016/j.athoracsur.2010.06.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 06/02/2010] [Accepted: 06/07/2010] [Indexed: 11/19/2022]
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22
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Emmert MY, Salzberg SP, Seifert B, Schurr UP, Odavic D, Reuthebuch O, Genoni M. Despite modern off-pump coronary artery bypass grafting women fare worse than men☆. Interact Cardiovasc Thorac Surg 2010; 10:737-41. [DOI: 10.1510/icvts.2009.220277] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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23
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Routine Off-Pump Coronary Artery Bypass Grafting Is Safe and Feasible in High-Risk Patients With Left Main Disease. Ann Thorac Surg 2010; 89:1125-30. [DOI: 10.1016/j.athoracsur.2009.12.059] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Revised: 12/17/2009] [Accepted: 12/18/2009] [Indexed: 11/24/2022]
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Mehilli J, Kastrati A, Byrne RA, Bruskina O, Iijima R, Schulz S, Pache J, Seyfarth M, Massberg S, Laugwitz KL, Dirschinger J, Schömig A. Paclitaxel- Versus Sirolimus-Eluting Stents for Unprotected Left Main Coronary Artery Disease. J Am Coll Cardiol 2009; 53:1760-8. [PMID: 19422982 DOI: 10.1016/j.jacc.2009.01.035] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Revised: 12/16/2008] [Accepted: 01/06/2009] [Indexed: 11/19/2022]
Affiliation(s)
- Julinda Mehilli
- Deutsches Herzzentrum, Technische Universität, Munich, Germany.
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Caputo M, Alwair H, Rogers CA, Ginty M, Monk C, Tomkins S, Mokhtari A, Angelini GD. Myocardial, Inflammatory, and Stress Responses in Off-Pump Coronary Artery Bypass Graft Surgery With Thoracic Epidural Anesthesia. Ann Thorac Surg 2009; 87:1119-26. [DOI: 10.1016/j.athoracsur.2008.12.047] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2008] [Revised: 12/11/2008] [Accepted: 12/15/2008] [Indexed: 10/21/2022]
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26
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Imamaki M, Matsuura K, Sakurai M, Shimura H, Ishida A, Miyazaki M. Evaluation of early and midterm results of offpump coronary artery bypass in patients with left main disease. J Card Surg 2009; 24:162-6. [PMID: 19267825 DOI: 10.1111/j.1540-8191.2009.00824.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE This study evaluated the early and midterm results of offpump coronary artery bypass (OPCAB) for left main coronary artery (LMCA) stenosis. METHODS Patients treated between November 2001 and December 2006, during which isolated coronary artery bypass grafting (CABG) was performed without cardiopulmonary bypass in principle, were included. Isolated CABG was performed in 206 patients, of whom 62 (30.1%) had LMCA stenosis >50%. RESULTS The in-hospital mortality rate (LMCA stenosis > 50%, 1.6%; LMCA stenosis <or=50%, 0.7%, p = 0.512), the incidence of postoperative complications, and the midterm survival rate (LMCA stenosis succeeds50%, 86.7 +/- 5.2%/5 years, LMCA stenosis<or=50%, 89.6 +/- 3.8%/5 years, p = 0.21) did not significantly differ between the two groups. Conversion was significantly frequent in patients with LMCA stenosis >75% and severe stenosis >90% in the right coronary artery (RCA) trunk. CONCLUSIONS Patients with LMCA stenosis can undergo OPCAB safely and the midterm results are good. As conversion was significantly frequent in patients with severe LMCA and RCA trunk stenosis, adequate preparation for pump application is necessary.
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Affiliation(s)
- Mizuho Imamaki
- Department of Cardiovascular Surgery, Chiba University Hospital, Chiba, Japan.
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Mannam G, Sajja LR, Dandu SBR, Pathuri SN, Saikiran KVSS, Sompalli S. Off-pump coronary revascularization for left main coronary artery stenosis. Asian Cardiovasc Thorac Ann 2008; 16:473-8. [PMID: 18984757 DOI: 10.1177/021849230801600609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Experience of on- and off-pump coronary artery bypass in 379 patients with significant left main coronary artery stenosis was retrospectively reviewed. Beating-heart operations were performed on 219 patients between January 2001 and October 2007. Their results were compared with 160 who underwent revascularization under cardiopulmonary bypass during the same period. All patients had multivessel grafting via a median sternotomy. Both groups were comparable demographically. Off-pump patients received significantly fewer grafts per patient (3.21 +/- 0.86 vs 3.74 +/- 0.82). The use of moderate or high doses of inotropics (> 5 microg kg(-1) min(-1)) was more frequent in the on-pump group (44% vs 26%). Postoperative blood transfusion requirement was lower in off-pump patients, and fewer of them experienced worsening of preexisting renal insufficiency. There were 2 operative deaths in the on-pump group and 1 in the off-pump group. The off-pump procedure is safe and effective in patients with left main coronary artery disease.
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Affiliation(s)
- Gopichand Mannam
- Division of Cardiothoracic Surgery, CARE Hospital, The Institute of Medical Sciences, Hyderabad-500034, India
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28
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Meliga E, Valgimigli M, Buszman P, Serruys PW. Percutaneous Coronary Intervention or Coronary Artery Bypass Graft for Unprotected Left Main Coronary Artery Disease: The Endless Debate. J Am Coll Cardiol 2008; 52:582-4; author reply 584-6. [DOI: 10.1016/j.jacc.2008.04.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2008] [Revised: 03/21/2008] [Accepted: 04/03/2008] [Indexed: 11/25/2022]
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van Mieghem C, Ramcharitar S, Barlis P, Oosterhuis W, Kik C, de Feyter P, Serruys P. Myocardial infarction in a patient with sickle cell trait. Treatment dilemmas and imaging findings at follow-up. EUROINTERVENTION 2008; 3:627-34. [DOI: 10.4244/eijv3i5a112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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30
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Taggart DP, Kaul S, Boden WE, Ferguson TB, Guyton RA, Mack MJ, Sergeant PT, Shemin RJ, Smith PK, Yusuf S. Revascularization for Unprotected Left Main Stem Coronary Artery Stenosis. J Am Coll Cardiol 2008; 51:885-92. [PMID: 18308155 DOI: 10.1016/j.jacc.2007.09.067] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Revised: 08/09/2007] [Accepted: 09/07/2007] [Indexed: 10/22/2022]
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31
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Madden NJ, Demarsico AJ, Schocker LA, Venkataraman R, Kellum JA. On-pump vs. off-pump coronary artery bypass surgery at a non-academic community hospital: have biocompatibility improvements eliminated the superiority of off-pump surgery? Int J Artif Organs 2007; 30:338-44. [PMID: 17520572 DOI: 10.1177/039139880703000410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Standard coronary artery bypass grafting (CABG) surgery involves cardiopulmonary bypass (CPB) but given concerns over neurological and inflammatory complications related to CPB, many patients receive so-called off-pump procedures (OPCABG). Our objective is to determine if the recent improvements in the biocompatibility of CPB circuitry have improved post-operative outcomes at the community hospital level, particularly in terms of hospital length of stay (LOS), stroke and post-operative infection. METHODS We analyzed hospital LOS, incidence of stroke, infection, and mortality along with several clinical variables in 209 patients (38% underwent OPCABG) at a single, non academic community hospital. We constructed a series of forward, stepwise, multiple-variable regression models using mediastinal infection, hospital LOS, and stroke as dependant variables. RESULTS OPCABG was associated with a shorter median hospital LOS (3 days vs. 4 days; p=0.0001) and a reduced occurrence of stroke (0% vs. 7.6%; p=0.03). However, mediastinal infections occurred more commonly in OPCABG cases (10% vs. 2.2%; p=0.02). CABG and pre-existing renal disease were predictors of increased hospital LOS (p< 0.0001) whereas CABG was the only factor associated with decreased risk of mediastinal infection (OR=0.21 (0.05-0.80); p=0.02). CONCLUSIONS At the community level, OPCABG appears to be superior in terms of LOS and incidence of stroke. Paradoxically, CABG surgery demonstrates a reduced rate of mediastinal infection.
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Affiliation(s)
- N J Madden
- The CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, Univesity of Pittsburgh, Pittsburgh 15261, USA
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Elahi MM, Khan JS. Living with off-pump coronary artery surgery: evolution, development, and clinical potential for coronary heart disease patients. Heart Surg Forum 2006; 9:E630-7. [PMID: 16687345 DOI: 10.1532/hsf98.2006-1026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The enormous progress in interventional cardiology during the last 10 years has resulted in a major change in the spectrum of patients referred for coronary bypass surgery. These patients are older and sicker and frequently have had previous percutaneous coronary interventions. Consequently, cardiac surgery is responding by adding new surgical techniques: off-pump open-chest coronary bypass surgery (OPCAB), minithoracotomy bypass surgery, videothoracoscopic (robotic) procedures, etc. Several registries published to date have proved OPCAB to be safe and clinically effective. Randomized studies and meta-analysis research in this field provide scientific support and suggest that myocardial, renal, and neurological functions, amongst others, are better preserved by OPCAB than by classic techniques that use a cardiopulmonary bypass pump (CPB). Moreover, avoidance of CPB yields significantly reduced oxidative stress and systemic inflammatory response. This results in higher safety for ischemic heart disease patients undergoing revascularization, thus offsetting the propensity to lower costs. The present review examines the physiological advantages and clinical outcomes of this simple mode of myocardial revascularisation and evaluates the wider implications arising from its evolution.
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Affiliation(s)
- Maqsood M Elahi
- Department of Cardiothoracic Surgery, Faculty of Medicine and Surgery (PIC), Lahore, Pakistan.
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Raghuram AR, Kumar S, Balamurugan K, Arulmurugan, Krishnan R, Sivakami P, John EV. Off pump coronary artery bypass (OPCAB) in critical left mainstem stenosis—Our experience. Indian J Thorac Cardiovasc Surg 2006. [DOI: 10.1007/s12055-006-0754-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Monassier F, Mattei C, Gavra G, Dallemand R, Lallemant P, Olteane C, Semenescu A, Durasnel P, Monassier JP, Bischoff N. [Off-pump coronary artery bypass: analysis of 1080 patients]. Ann Cardiol Angeiol (Paris) 2005; 54:299-304. [PMID: 17183823 DOI: 10.1016/j.ancard.2005.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
A consecutive cohort including 1080 patients undergoing "off-pump" myocardial revascularization was reviewed. An average of 2.22 bypass/patients was performed. The death-rate during the first 30 days after surgery was 0.65%. Four cases needed cross-over to on-pump. The postoperative events were: need of inotropic drugs (2.7%), atrial fibrillation (12.4%), myocardial infarction (6.6%). The extubation was performed before the first postoperative 24 h in 91.9% of cases. The majority of patients was discharged from hospital before 8 days after surgery. Off pump coronary artery bypass surgery exhibit good results for most of the patients even if they present multiple vessel disease and high operating risk.
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Affiliation(s)
- F Monassier
- Service de chirurgie cardiovasculaire, UF 3321, CHU de Strasbourg, 1, place de l'hôpital, 67000 Strasbourg, France.
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Virani SS, Lombardi P, Tehrani H, Masroor S, Yassin S, Salerno T, Bolooki H, Katariya K. Off-Pump Coronary Artery Grafting in Patients with Left Main Coronary Artery Disease. J Card Surg 2005; 20:537-41. [PMID: 16309405 DOI: 10.1111/j.1540-8191.2005.00156.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Left main coronary artery disease (LMCD) is considered a relative contraindication to off-pump coronary artery bypass (OPCAB) grafting. This study evaluates the safety and feasibility of OPCAB in these patients compared to an on-pump group (cardiopulmonary bypass, CPB) with LMCD. METHODS Between January 2000 and July 2002, 95 patients with left main coronary artery stenosis >50% underwent coronary revascularization. Seventy-three unselected patients underwent OPCAB and 22 underwent revascularization using CPB. The techniques used for OPCAB included the use of deep traction sutures in the posterior pericardium and stabilizers to expose the distal coronary targets. Intraluminal coronary shunts were routinely used during construction of the anastomoses. Variables were analyzed using a Student's paired t-test with statistical significance defined as p < 0.05. RESULTS The mean age in the OPCAB group was 59.9 years and the CPB group 61.8 years (p = 0.54). There were 56 males (77%) in the OPCAB and 18 (82%) in the CPB groups. Mean preoperative left ventricular ejection fraction (LVEF) was 40.3% in OPCAB and 47.3% in CPB (p = 0.015). Average number of grafts was 3.1 in OPCAB and 4.1 in CPB (p = 0.0038). There were no conversions to CPB in those patients initially chosen to undergo OPCAB. There were no early deaths in OPCAB. There was one death in CPB. Mean hospital length of stay was 6.9 days for OPCAB and 9.1 for CPB (p = 0.0159). CONCLUSIONS Patients with LMCD can undergo OPCAB grafting safely and effectively despite reduced LVEF. LMCD should no longer be seen as a contraindication to perform OPCAB grafting.
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Affiliation(s)
- Salim S Virani
- Division of Cardiology, St. Luke's Episcopal Hospital, Houston, Texas, USA
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Lu JCY, Grayson AD, Pullan DM. On-Pump Versus Off-Pump Surgical Revascularization for Left Main Stem Stenosis: Risk Adjusted Outcomes. Ann Thorac Surg 2005; 80:136-42. [PMID: 15975355 DOI: 10.1016/j.athoracsur.2005.02.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2004] [Revised: 01/21/2005] [Accepted: 02/01/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Recent publications have shown coronary surgery is safe and effective in patients with critical left main stem stenosis when using off-pump coronary surgery techniques. However, these studies were small and did not adjust for differences in case mix. METHODS Between April 1997 and March 2003, 1,197 consecutive patients with critical left main stem stenosis (> 50%) underwent coronary surgery. Two hundred and fifty-nine (21.6%) of these patients had off-pump coronary surgery, while 938 (78.4%) received on-pump coronary surgery. Multivariate logistic regression and Cox proportional hazards analysis were used to assess the effect of off-pump coronary surgery on outcomes, while adjusting for patient characteristics (treatment selection bias). Treatment selection bias was controlled by constructing a propensity score from core patient characteristics. The propensity score was the probability of receiving off-pump coronary surgery and was included along with the comparison variable in the multivariable analyses of outcome. RESULTS After adjusting for the propensity score, the requirement for inotropic support (22.4% versus 35.3%; p < 0.001) or a prolonged length of stay (5.3% versus 9.3%; p = 0.034) were significantly reduced after receiving off-pump coronary surgery. There was a trend to suggest that off-pump patients had a lower incidence of stroke and chest infection. The adjusted freedom from death in off-pump patients at 2 years was 94.6% compared with 93.6% for on-pump patients (p = 0.54). CONCLUSIONS After risk adjustment, patients with critical left main stem stenosis can undergo off-pump coronary surgery safely, with results comparable with on-pump coronary surgery.
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Affiliation(s)
- John C Y Lu
- Department of Cardiothoracic Surgery, The Cardiothoracic Centre, Liverpool, United Kingdom
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Schoenhagen P. Can intravascular ultrasound detect left main coronary artery disease accurately? NATURE CLINICAL PRACTICE. CARDIOVASCULAR MEDICINE 2005; 2:242-3. [PMID: 16265506 DOI: 10.1038/ncpcardio0191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2005] [Accepted: 03/16/2005] [Indexed: 05/05/2023]
Affiliation(s)
- Paul Schoenhagen
- Cardiovascular Imaging Center in the Department of Diagnostic Radiology and Cardiovascular Medicine at The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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Beauford RB, Saunders CR, Lunceford TA, Niemeier LA, Shah S, Karanam R, Prendergast T, Burns P, Sardari F, Goldstein DJ. Multivessel Off-Pump Revascularization in Patients with Significant Left Main Coronary Artery Stenosis:. Early and Midterm Outcome Analysis. J Card Surg 2005; 20:112-8. [PMID: 15725133 DOI: 10.1111/j.0886-0440.2005.200343.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The presence of significant left main stenosis (> or =50%) has been considered a relative contraindication to the use of off-pump coronary artery bypass (OPCAB) stemming from well-documented hemodynamic perturbations during the displacement of the heart. We examined our experience with patients with critical left main stenosis (LMS) to assess the safety and feasibility of OPCAB in this subgroup. METHODS Our prospectively updated database was queried to identify all patients with severe left main disease who underwent isolated coronary revascularization between January 1, 1999 and May 31, 2002. This query yielded 234 on-pump and 420 off-pump patients with significant LMS whose clinical information was retrospectively reviewed. RESULTS The groups were well matched with regard to gender, left ventricular function, surgical priority, and severity of angina. The conventional coronary artery bypass (CABG) group was significantly younger than the OPCAB group and had a higher incidence of a previous myocardial infarction. Patients in the CABG cohort were more likely than OPCAB patients to remain ventilated after 24 hours, require placement of intraoperative or postoperative intraaortic balloon pump, or suffer from postoperative renal failure. There was a decrease in mortality (6.4% vs. 1.9%; p = 0.006) when CPB was eliminated. Intermediate term survival analysis revealed a significant survival benefit in the off-pump group (p = 0.007). CONCLUSIONS Multivessel off-pump revascularization in patients with severe left main disease is a safe and effective alternative to conventional bypass grafting and conveys a survival benefit.
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Affiliation(s)
- Robert B Beauford
- Department of Cardiothoracic Surgery, Newark Beth Israel Medical Center, NJ 07112, USA
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Fukushima S, Kobayashi J, Tagusari O, Bando K, Niwaya K, Nakajima H, Ishida M, Kitamura S. Rationale of off-pump coronary artery bypass grafting for left main trunk disease. ACTA ACUST UNITED AC 2004; 52:560-6. [PMID: 15651401 DOI: 10.1007/s11748-004-0023-1] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Off-pump coronary artery bypass grafting (OPCAB) remains controversial in patients with left main trunk (LMT) disease because of a concern about the ability to tolerate hemodynamic instability. This study examined the safety of OPCAB for LMT disease compared with conventional coronary artery bypass grafting (CABG). METHODS Between April 1997 and December 2002, 257 consecutive patients with LMT stenosis who underwent CABG were enrolled. There were 98 patients who received CABG with the aid of cardiopulmonary bypass (CCAB group), and 159 patients who received OPCAB (OPCAB group). RESULTS There was no patient who converted to on-pump intraoperatively due to hemodynamic instability. Both intraoperative blood loss and blood transfusion incidence were lower in the OPCAB group. Postoperative course was similar, however, pulmonary complications were less observed postoperatively in the OPCAB group. No hypoperfusion syndrome was seen postoperatively in both groups. The average number of anastomosis was 3.2+/-1.1 in the CCAB group and 3.2+/-1.0 in the OPCAB group (p=0.645). Total arterial OPCAB with an aorta no-touch technique was achieved in 142 patients (89.3%) in OPCAB group. Postoperative angiography was performed in 95 patients in CCAB (96.9%), and in 141 patients in OPCAB (89.8%). Although graft patency of arterial grafts was good in both groups (100% in CCAB and 98.3% in OPCAB), saphenous vein graft patency was slightly lower in both groups (93.4% in CCAB and 76.5% in OPCAB) compared with arterial grafts. CONCLUSION OPCAB allows a safe and effective treatment of LMT disease.
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Affiliation(s)
- Satsuki Fukushima
- Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan
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Lehot JJ, Lefevre M, Phan T, Bastien O, Diab C, Jegaden O. Que faut-il attendre de la chirurgie coronaire sans circulation extracorporelle ? ACTA ACUST UNITED AC 2004; 23:1063-72. [PMID: 15581721 DOI: 10.1016/j.annfar.2004.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2004] [Accepted: 08/12/2004] [Indexed: 11/23/2022]
Abstract
Coronary artery bypass surgery with beating heart (off-pump) has become more common in the last ten years allowing seven randomized studies with at least 60 patients, comparing off-pump and on-pump coronary bypass. Anaesthesia, monitoring and haemodynamic complications are described. Randomized studies concluded to less elevation of biochemical markers of myocardial and renal injury, less hydric inflation, less cerebral microemboli, reduction of homologous blood transfusions, of hospital stay and global costs. However in low risk patients no reduction in myocardial infarction, atrial fibrillation, stroke, acute renal failure, early reoperation, surgical site infection and mortality were observed. Non-randomized studies suggest a benefit in stroke and mortality in elderly patients but the possibility of incomplete revascularization remains.
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Affiliation(s)
- J J Lehot
- Service d'anesthésie-réanimation et équipe d'accueil 1896, hôpital cardiovasculaire et pneumologique Louis-Pradel, BP Lyon-Montchat, 69394 Lyon cedex 03, France.
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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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Chassot PG, van der Linden P, Zaugg M, Mueller XM, Spahn DR. Off-pump coronary artery bypass surgery: physiology and anaesthetic management †. Br J Anaesth 2004; 92:400-13. [PMID: 14970136 DOI: 10.1093/bja/aeh064] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Increasing interest is being shown in beating heart (off-pump) coronary artery surgery (OPCAB) because, compared with operations performed with cardiopulmonary bypass, OPCAB surgery may be associated with decreased postoperative morbidity and reduced total costs. Its appears to produce better results than conventional surgery in high-risk patient populations, elderly patients, and those with compromised cardiac function or coagulation disorders. Recent improvements in the technique have resulted in the possibility of multiple-vessel grafting in all coronary territories, with a graft patency comparable with conventional surgery. During beating-heart surgery, anaesthetists face two problems: first, the maintenance of haemodynamic stability during heart enucleation necessary for accessing each coronary artery; and second, the management of intraoperative myocardial ischaemia when coronary flow must be interrupted during grafting. The anaesthetic technique is less important than adequate management of these two major constraints. However, experimental and recent clinical data suggest that volatile anaesthetics have a marked cardioprotective effect against ischaemia, and might be specifically indicated. OPCAB surgery requires team work between anaesthetists and surgeons, who must be aware of each other's constraints. Some surgical aspects of the operation are reviewed along with physiological and anaesthetic data.
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Affiliation(s)
- P-G Chassot
- Departments of Anaesthesiology and Cardiovascular Surgery, University Hospital Lausanne (CHUV), CH-1011 Lausanne, Switzerland
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Hirose H. Off-Pump Coronary Artery Bypass Grafting for Patients with Left Main Disease. Cardiology 2004; 101:194-8. [PMID: 14967962 DOI: 10.1159/000076696] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2003] [Accepted: 09/22/2003] [Indexed: 11/19/2022]
Abstract
BACKGROUND Multivessel off-pump coronary artery bypass grafting (CABG) has been performed with favorable results in our institute. In this study, we analyzed the outcomes in patients who underwent off-pump CABG for left main disease, since the surgical outcomes for such patients have not been clarified. METHODS Between March 1, 1999 and July 30, 2002, a total of 147 patients with left main disease (112 males and 35 females, mean age 66.9 +/- 9.8 years) underwent off-pump CABG. Perioperative and follow-up data were entered into a structured database and the results were analyzed. RESULTS Urgent or emergent surgery was performed in 25 patients (17.0%), and a preoperative intra-aortic balloon pump was used in 12 patients (8.2%). The mean number of bypass grafts was 3.2 +/- 1.0, and complete revascularization was performed in 127 patients (86.4%). There were 4 incidences of intraoperative conversion from off-pump to on-pump surgery. The mean intubation period, intensive care unit stay and postoperative hospital stay were 9.4 +/- 13.0 h, 2.3 +/- 1.4 days and 13.4 +/- 7.3 days, respectively. There was 1 hospital death (0.7%). Postoperative myocardial infarction was observed in 2 patients (1.4%), postoperative stroke in 1 (0.7%), prolonged ventilator support in 5 (3.4%) and mediastinitis in 3 (2.0%). During the follow-up period of 2.1 +/- 1.0 years, there were 4 deaths and 7 cardiac events. The actuarial 3-year survival rate was 97.0%, and the event-free rate was 94.3%. CONCLUSION Our observations support off-pump CABG as a surgical option with a favorable outcome for patients with left main disease.
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Affiliation(s)
- Hitoshi Hirose
- Department of Cardiovascular Surgery, Juntendo University Hospital, Tokyo, Japan
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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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Abstract
Atrial fibrillation (AF) occurs in one quarter to one third of patients after coronary artery bypass graft surgery (CABG). Conventional CABG uses cardiopulmonary bypass, a process that is itself associated with a systemic vascular inflammatory response that contributes to postoperative morbidity. The avoidance of cardiopulmonary bypass is associated with a significant reduction in the inflammatory response and in the release of markers of myocardial necrosis when compared with conventional CABG. There is speculation that off-pump CABG may reduce the incidence of postoperative AF through reduced trauma, ischaemia, and inflammation. Current data, however, do not emphatically answer the question of whether the incidence of post-CABG AF is reduced by off-pump surgery. The evidence from both observational and randomised studies is conflicting and many studies have weaknesses in design, conduct, or interpretation. It remains an attractive hypothesis that postoperative AF is reduced by off-pump CABG but more robust data are required.
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Affiliation(s)
- R A Archbold
- Department of Cardiology, St Bartholomew's Hospital, West Smithfield, London, UK.
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Al-Ruzzeh S, Ambler G, Asimakopoulos G, Omar RZ, Hasan R, Fabri B, El-Gamel A, DeSouza A, Zamvar V, Griffin S, Keenan D, Trivedi U, Pullan M, Cale A, Cowen M, Taylor K, Amrani M. Off-Pump Coronary Artery Bypass (OPCAB) surgery reduces risk-stratified morbidity and mortality: a United Kingdom Multi-Center Comparative Analysis of Early Clinical Outcome. Circulation 2003; 108 Suppl 1:II1-8. [PMID: 12970199 DOI: 10.1161/01.cir.0000087440.59920.a1] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Off-Pump Coronary Artery Bypass (OPCAB) surgery is gaining more popularity worldwide. The aim of this United Kingdom (UK) multi-center study was to assess the early clinical outcome of the OPCAB technique and perform a risk-stratified comparison with the conventional Coronary Artery Bypass Grafting (CABG) using the Cardio-Pulmonary Bypass (CPB) technique. METHODS Data were collected on 5,163 CPB patients from the database of the National Heart and Lung institute, Imperial College, University of London, and on 2,223 OPCAB patients from eight UK cardiac surgical centers, which run established OPCAB surgery programs. All patients had undergone primary isolated CABG for multi-vessel disease through a midline sternotomy approach, between January 1997 and April 2001. Postoperative morbidity and mortality were compared between the CPB and OPCAB patients after adjusting for case-mix. The mortality of the OPCAB patients was also compared, using risk stratification, to the mortality figures reported by the Society of Cardiothoracic Surgeons of Great Britain and Ireland (SCTS) based on 28,018 patients in the national database who were operated on between January 1996 and December 1999. RESULTS Morbidity and mortality were significantly lower in the OPCAB patients compared with the CPB patients and the UK national database of CABG patients, over the same period of time, after adjusting for case-mix. CONCLUSIONS This study demonstrates that risk stratified morbidity and mortality are significantly lower in OPCAB patients than CPB patients and patients in the UK national database.
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Affiliation(s)
- Sharif Al-Ruzzeh
- National Heart and Lung Institute, Imperial College of Science, Technology and Medicine, Harefield Hospital, Middlesex UB9 6JH, United Kingdom
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Abstract
BACKGROUND AND AIM OF THE STUDY Aging of the population, increased surgical risk, and technical improvement have contributed to the recent revival of off pump coronary artery bypass surgery (OPCAB). We present our experience with the systematic use of this technique. METHODS Between September 1996 and June 2000, 500 OPCAB procedures were performed at the Montreal Heart Institute (95% of all procedures during time frame, single surgeon). Contraindications were unstable hemodynamics, intramyocardial left anterior descending artery, and reoperation with extensive adhesions. Stabilization was achieved with pericardial sutures and mechanical compression. Surgical strategy was to first bypass the culprit lesion. Anesthetic management consisted of adequate fluid loading and minimal use of alpha-agonist. This cohort was compared to a contemporary cohort of 1,444 patients operated with cardiopulmonary bypass (CPB). RESULTS Demographics and risk factors were comparable for all. OPCAB patients received more grafts (3.1 +/- 0.9 vs 2.9 +/- 0.7, p = 0.006), conversion rate was low (0.4%), and complete revascularization was achieved in 93%. Operative mortality and perioperative myocardial infarction were comparable in both groups. Transfusion need, CK-MB count, postoperative use of intra-aortic balloon pump, and creatinine increase were less significant in OPCAB. Postoperative hemorrhage, atrial fibrillation, prevalence of cerebrovascular accident, and hospital stay were comparable for both groups. These results are comparable to those currently reported in the literature. CONCLUSION OPCAB surgery in the current era has established its safety and short-term efficacy although long-term clinical results are still warranted. Considering the changing pattern in surgical practice, OPCAB surgery should remain a therapeutic option in modern cardiac surgery.
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Affiliation(s)
- Raymond Cartier
- Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada.
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Matei C, Gavra G, Billaud P, Dallemand R, Semenescu A, Lallemant P, Réal P, Jacquemin L, el Belghiti R, Monassier JP, Bischoff N. [Off-pump beating heart coronary artery bypass. Technical points of view and surgical results]. Ann Cardiol Angeiol (Paris) 2002; 51:261-7. [PMID: 12515102 DOI: 10.1016/s0003-3928(02)00133-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A consecutive series of 746 patients undergoing heart beating myocardial revascularization was reviewed. An average of 2.30 grafts/patients was performed. The rate of mortality in the first 30 postoperative days was 0.28%. Two cases had to be terminated on-pump. We used the inotropic drugs in 0.6% of cases. The postoperative events were: atrial fibrillation (12.6%), myocardial infarction (0.3%). The rate of transfusion was 7.4%. The extubation was performed in the first 24 h postoperatively in 94.7% of cases. The majority of patients (91.3%) left the hospital in the first 8 d postoperatively. Off pump coronary artery bypass grafting gives good result for the most of the patients even for those with multiple vessel disease and high operating risk.
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Affiliation(s)
- C Matei
- Service de chirurgie cardiaque, hôpital Emile-Muller, 20, rue Laennec, BP 1370, 68070 Mulhouse, France
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Abstract
Benetti and Buffolo repopularized off pump surgery (OPCAB), developing the technique and using it in all arteries of the heart with veins and arteries in the different clinical situations inclusive in patients with acute myocardial infarction. Despite my personal experience with more than 2500 cases of off pump conducted in my country and different places of the world during the teaching and education process. In 1997, we started a new approach (xiphoid) to perform the ambulatory off pump surgery (ie, discharging the patient after 24 hours of the operation). Between October 1997 and December 2001, 78 patients were operated on through the xiphoid (lower sternotomy approach). The mean age of the patients was 64.2 years (range 45-78), there were 70% males, and all were class 3-4 according to the Canadian Association. The mortality of the 78 patients was 1% (1 patient), conversion to complete sternotomy was 1% (1 patient), and perioperative infarction was 1% (1 patient). From the 16 patients restudied immediately the patency rate was 100% G A anastomosis. Six patients from this group were discharged during the next 24 hours after the operation. The mortality was 0% and perioperative infarction 0%. With the xiphoid (lower sternotomy approach) we had good initial experience in discharging the patients during the first day. Using the technology that already exists, it is possible to perform multiple arterial grafts with this approach and in the future expand the concept of ambulatory coronary surgery in multiple vessels.
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Meharwal ZS, Mishra YK, Kohli V, Bapna R, Singh S, Trehan N. Off-pump multivessel coronary artery surgery in high-risk patients. Ann Thorac Surg 2002; 74:S1353-7. [PMID: 12400816 DOI: 10.1016/s0003-4975(02)03915-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Coronary artery bypass surgery on cardiopulmonary bypass is associated with significant morbidity and mortality, which may be more marked in high-risk patients. We evaluated our results of off-pump coronary artery bypass (OPCAB) in high-risk patients with multivessel coronary artery disease and compared them with results in similar patients who underwent operation on cardiopulmonary bypass. METHODS A total of 1,075 patients who underwent OPCAB between October 1996 and June 2001 and who had one or more of the following risk factors were included in the study: poor left ventricular function (EF < or = 30%), advanced age (> 70 years), left main stenosis, acute myocardial infarction, and redo coronary artery surgery. These patients were compared with 2,312 similar patients who underwent coronary artery bypass grafting on cardiopulmonary bypass during the same period. Preoperative risk factors, intraoperative variables, and postoperative results were analyzed and compared between two groups. RESULTS The average number of grafts was 3.0 +/- 0.4 and 3.2 +/- 0.3 in the off-pump (OPCAB) and on-pump (CCAB) groups, respectively. Hospital mortality was 3.2% and 4.5% in OPCAB and CCAB groups respectively (p = 0.109). Perioperative myocardial infarction, requirement of inotropic agents, stroke, and renal dysfunction were comparable in two groups. Intubation time (19 +/- 5 vs 24 +/- 6 hours, p < 0.001), mean blood loss (362 +/- 53 vs 580 +/- 66 mL, p < 0.001), atrial fibrillation (14.3 vs 19.7%, p < 0.001), and prolonged ventilation (4.6 vs 7.6%, p = 0.002) were less in OPCAB group. Intensive care unit stay (20 +/- 8 hours) and hospital stay (6 +/- 3 days) were significantly less in the OPCAB group (p < 0.001). CONCLUSIONS Off-pump coronary artery surgery can be safely performed in high-risk patients with multivessel coronary artery disease. Operative mortality is comparable to that associated with on-pump surgery, and avoidance of cardiopulmonary bypass is associated with reduced postoperative morbidity in these patients.
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Affiliation(s)
- Zile Singh Meharwal
- Department of Cardiovascular Surgery, Escorts Heart Institute and Research Centre, New Delhi, India.
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