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Sajja LR. Six decades of cardiothoracic surgery: navigating new horizons, mending hearts with science and precision. Indian J Thorac Cardiovasc Surg 2024; 40:280-291. [PMID: 38681701 PMCID: PMC11045708 DOI: 10.1007/s12055-024-01719-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 05/01/2024] Open
Affiliation(s)
- Lokeswara Rao Sajja
- Division of Cardiothoracic Surgery, Star Hospitals, Road No. 10, Banjara Hills, Hyderabad, Telangana India 500034
- Division of Clinical Research in Cardiovascular Medicine/Surgery, Sajja Heart Foundation, Hyderabad, India 500073
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2
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Lorusso R, Bari G, Di Mauro M, Mariani S. The 'eternal' dilemma of OPCABG versus ONCABG continues: superior, equal, inferior or just different? J Cardiovasc Med (Hagerstown) 2022; 23:559-560. [PMID: 35906985 DOI: 10.2459/jcm.0000000000001335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre.,Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Gabor Bari
- Department of Cardiac Surgery, University of Szeged, Szeged, Hungary
| | - Michele Di Mauro
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre.,Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Silvia Mariani
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre.,Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
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Gomes WJ, Gomes EN, Bertini A, Reis PH, Hossne NA. The Anaortic Technique with Bilateral Internal Thoracic Artery Grafting - Filling the Gap in Coronary Artery Bypass Surgery. Braz J Cardiovasc Surg 2021; 36:397-405. [PMID: 34387975 PMCID: PMC8357393 DOI: 10.21470/1678-9741-2020-0451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Coronary artery bypass grafting (CABG) has consolidated its role as the most effective procedure for treating patients with advanced atherosclerotic coronary artery disease, reducing the long-term risk of myocardial infarction and death compared to other therapies and relieving angina. Despite the recognized benefits afforded by surgical myocardial revascularization, a subset of higher-risk patients bears a more elevated risk of perioperative stroke. Stroke remains the drawback of conventional CABG and has been strongly linked to aortic manipulation (cannulation, cross-clamping, and side-biting clamping for the performance of proximal aortic anastomoses) and the use of cardiopulmonary bypass. Adoption of off-pump CABG (OPCAB) is demonstrated to lower the risk of perioperative stroke, as well as reducing the risk of short-term mortality, renal failure, atrial fibrillation, bleeding, and length of intensive care unit stay. However, increased risk persists owing to the need for the tangential ascending aorta clamping to construct the proximal anastomosis. The concept of anaortic (aorta no-touch) OPCAB (anOPCAB) stems from eliminating ascending aorta manipulation, virtually abolishing the risk of embolism caused by aortic wall debris into the brain circulation. The adoption of anOPCAB has been shown to further decrease the risk of postoperative stroke, especially in higher-risk patients, entailing a step forward and a refinement of outcomes provided by the primeval OPCAB technique. Therefore, anOPCAB has been the recommended technique in patients with cerebrovascular disease and/or calcification or atheromatous plaque in the ascending aorta and should be preferred in patients with high-risk factors for neurological damage and stroke.
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Affiliation(s)
- Walter J Gomes
- Cardiovascular Surgery Discipline, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Eduardo N Gomes
- Affiliated Hospitals of Associação Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, São Paulo, Brazil
| | - Ayrton Bertini
- Affiliated Hospitals of Associação Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, São Paulo, Brazil
| | - Pedro H Reis
- Affiliated Hospitals of Associação Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, São Paulo, Brazil
| | - Nelson A Hossne
- Cardiovascular Surgery Discipline, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
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Tzoumas A, Giannopoulos S, Kakargias F, Kokkinidis DG, Giannakoulas G, Faillace RT, Bakoyiannis C, Doulamis IP, Avgerinos DV. Repeat Coronary Artery Bypass Grafting: A Meta-Analysis of Off-Pump versus On-Pump Techniques in a Large Cohort of Patients. Heart Lung Circ 2021; 30:1281-1291. [PMID: 33810970 DOI: 10.1016/j.hlc.2021.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Redo coronary artery bypass grafting (CABG) can be performed with either the off-pump (OPCAB) or the on-pump (ONCAB) technique. METHOD Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), this meta-analysis compared the safety and efficacy of OPCAB versus ONCAB redo CABG. RESULTS Twenty-three (23) eligible studies were included (OPCAB, n=2,085; ONCAB, n=3,245). Off-pump CABG significantly reduced the risk of perioperative death (defined as in-hospital or 30-day death rate), myocardial infarction, atrial fibrillation, and acute kidney injury. The two treatment approaches were comparable regarding 30-day stroke and late all-cause mortality. CONCLUSIONS Off-pump redo CABG resulted in lower perioperative death and periprocedural complication rates. No difference was observed in perioperative stroke rates and long-term survival between the two techniques.
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Affiliation(s)
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | | | - Damianos G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - George Giannakoulas
- Department of Cardiology, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Robert T Faillace
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Christos Bakoyiannis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Ilias P Doulamis
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Dimitrios V Avgerinos
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian, New York, NY, USA
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Sajja LR, Sarkar K, Mannam G, Kodali VKK, Padmanabhan C, Peter S, Mulay A, Beri P. Graft patency at 3 months after off- and on-pump coronary bypass surgery: a randomized trial. Indian J Thorac Cardiovasc Surg 2020; 36:93-104. [PMID: 33061107 PMCID: PMC7525555 DOI: 10.1007/s12055-019-00869-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/17/2019] [Accepted: 09/01/2019] [Indexed: 11/03/2022] Open
Abstract
Purpose Coronary artery bypass grafting (CABG) is performed either with the aid of cardiopulmonary bypass (on-pump) or without cardiopulmonary bypass (off-pump). There is a scarcity of angiographic data to support the non-inferiority of off-pump technique to on-pump technique. The objective of this study is to ascertain the non-inferiority of off-pump CABG when compared to on-pump CABG in terms of angiographically assessed graft patency at 3 months. Methods A total of 320 patients with multivessel coronary artery disease were enrolled in a multicenter prospective randomized trial either to on-pump CABG (n = 162) or off-pump CABG (n = 158) between March 2016 through March 2017. Graft patency was evaluated by using either multidetector computerized tomographic angiography or conventional coronary angiography at 3 months. The major adverse cardiac and cardiovascular events (MACCE) were also analyzed at 3 months. Results The median number of grafts per patient in off-pump was 3.00 (Q1:3.00 and Q3:4.00) vs on-pump 4.00 (Q1:3.00 to Q3:4.00), and the mean number of grafts per patient was lower in the off-pump CABG at 3.45 ± 0.75 vs 3.64 ± 0.70 in the on-pump CABG (p = 0.01). There was no significant difference in mortality at 3 months between the off-pump (0.63%) and on-pump groups (1.85%) with p value of 0.62. The cumulative combined MACCE showed significant difference between off-pump group (0.63%) and on-pump group (5.55%), p = 0.01. Follow-up angiograms were done in 239 (75%) patients with 120 off-pump and 119 in the on-pump group. The analysis was also done regarding graft patency in a graded manner—when analysis of A (excellent) grafts vs B (stenosed) grafts and O (occluded) grafts were made, there was no statistically significant difference in overall graft patency at 3 months between on-pump [376 /429 grafts (87.6%)] and off-pump [366 /420 grafts (87.1%)] groups (p = 0.82). The patency rates were similar among bypass conduits (left internal thoracic artery (ITA) in off-pump (91.4%) vs on-pump (92.9%) p = 0.66, right ITA in off-pump (82.1%) vs on-pump (81.8%) p = 0.97, radial artery in off-pump (84.4%) vs on-pump (82.6%) p = 0.81; saphenous vein in off-pump (85.8%) vs on-pump (86.3%), p = 0.86 and among 3 coronary territories. Conclusions Off-pump CABG is non-inferior to on-pump CABG in terms of overall graft patency at 3 months and was associated with a fewer combined cumulative MACCE compared to on-pump CABG. Electronic supplementary material The online version of this article (10.1007/s12055-019-00869-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lokeswara Rao Sajja
- Division of Cardiothoracic Surgery, STAR Hospitals, Road no. 10, Banjara Hills, Hyderabad, Telangana 500 034 India.,Division of Cardiovascular Surgical Research, Sajja Heart Foundation, Srinagar Colony, Hyderabad, 500073 India
| | - Kunal Sarkar
- Division of Cardiothoracic Surgery, Medica Superspeciality Hospital, 127-Mukundapur, EM bypass, Kolkata, 700025 India
| | - Gopichand Mannam
- Division of Cardiothoracic Surgery, STAR Hospitals, Road no. 10, Banjara Hills, Hyderabad, Telangana 500 034 India
| | - Venkata Krishna Kumar Kodali
- Division of Cardiothoracic Surgery, Krishna Institute of Medical Sciences, 1-8-31/1,Minister Road, Secunderabad, Telangana 500003 India
| | - Chandrasekar Padmanabhan
- Division of Cardiothoracic Surgery, G Kuppuswamy Naidu Memorial Hospital, Pappanaicken Palayam, Coimbatore, 641 037 India
| | - Sanjeeth Peter
- Division of Cardiothoracic Surgery, DDMM Heart Institute, Mission Road, Nadiad, Gujarat 387002 India
| | - Anvay Mulay
- Division of Cardiothoracic Surgery, Fortis Hospital, Multi-Specialty Hospital Mulund West, Mumbai, 400078 India
| | - Prashanthi Beri
- Division of Clinical Research, Sajja Heart Foundation, Srinagar Colony, Hyderabad, 500073 India
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Sajja LR, Sarkar K, Mannam G, Kodali VKK, Padmanabhan C, Peter S, Mulay A, Sardar S, Beri P. One-year outcomes of off- and on-pump coronary artery bypass grafting: PROMOTE patency trial. Indian J Thorac Cardiovasc Surg 2020; 36:469-475. [PMID: 33061158 PMCID: PMC7525622 DOI: 10.1007/s12055-020-00940-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/10/2020] [Accepted: 02/12/2020] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Earlier we reported 3-month graft patency and clinical outcomes of prospective randomized comparison of off-pump and on-pump multivessel coronary artery bypass surgery to evaluate outcomes and graft patency (PROMOTE patency) trial. We now report major adverse cardiac and cerebrovascular events (MACCE) at 1 year of patients who underwent coronary artery bypass grafting (CABG) using either off-pump technique or on-pump technique. METHODS The PROMOTE patency trial is a two-arm, prospective, randomized, multicentre trial, and enrolled 320 patients with multivessel coronary artery disease from March 2016 through March 2017 at 6 centres and were randomly assigned to undergo either off-pump CABG (OPCAB) (n = 158 patients) or on-pump CABG (n = 162 patients). The outcomes at 1 year were assessed. RESULTS One mortality (0.64%) occurred in off-pump group (at 30 days) and 4 (2.48%) in on-pump group (1 at 30 days, 2 at 3 months, and 1 at 1 year) (p = 0.37). There was no difference between off-pump and on-pump groups in the outcomes of nonfatal myocardial infarction (1 in off-pump and 2 in on-pump group, p = 1.00) and cerebrovascular accident (none in off-pump and 2 in on-pump group, p = 0.49). Repeat revascularization was done in one patient in each group (p = 1.00). CONCLUSION There was no significant difference in the incidence of MACCE between off-pump and on-pump CABG group at 1 year.
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Affiliation(s)
- Lokeswara Rao Sajja
- Division of Cardiothoracic Surgery, Star Hospitals, Road no. 10, Banjara Hills, Hyderabad, AP 500 034 India
- Division of Cardiothoracic Surgery, Sajja Heart Foundation, Srinagar Colony, Hyderabad, 500 073 India
| | - Kunal Sarkar
- Division of Cardiothoracic Surgery, Medica Superspeciality Hospital, 127-Mukundapur, EM Bypass, Kolkata, 700025 India
| | - Gopichand Mannam
- Division of Cardiothoracic Surgery, Star Hospitals, Road no. 10, Banjara Hills, Hyderabad, AP 500 034 India
| | - Venkata Krishna Kumar Kodali
- Division of Cardiothoracic Surgery, Krishna Institute of Medical Sciences, 1-8-31/1, Minister Road, Secunderabad, Telangana 500003 India
| | - Chandrasekar Padmanabhan
- Division of Cardiothoracic Surgery, G Kuppuswamy Naidu Memorial Hospital, Pappanaickenpalayam, Coimbatore, 641 037 India
| | - Sanjeeth Peter
- Division of Cardiothoracic Surgery, DDMM Heart Institute, Mission Road, Nadiad, Gujarat 387 002 India
| | - Anvay Mulay
- Division of Cardiothoracic Surgery, Fortis Hospital, Multi-Specialty Hospital Mulund West, Mumbai, 400 078 India
| | - Sandip Sardar
- Division of Cardiothoracic Surgery, Medica Superspeciality Hospital, 127-Mukundapur, EM Bypass, Kolkata, 700025 India
| | - Prashanthi Beri
- Division of Clinical Research, Sajja Heart Foundation, Srinagar Colony, Hyderabad, 500 073 India
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Van den Eynde J, Heeren A, Szecel D, Meuris B, Jacobs S, Verbrugghe P, Oosterlinck W. Skeletonisation contributing to a reduction of sternal wound complications: a retrospective study in OPCAB patients. J Cardiothorac Surg 2019; 14:162. [PMID: 31500639 PMCID: PMC6734214 DOI: 10.1186/s13019-019-0985-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/02/2019] [Indexed: 11/15/2022] Open
Abstract
Background Sternal wound complications (SWC) are a rare but potentially life-threatening complication after coronary artery bypass grafting (CABG) surgery. Especially the use of bilateral IMA (BIMA) grafts as opposed to single IMA (SIMA) grafts is associated with an increased risk of SWC. Skeletonised harvesting has been proposed to reduce this risk. The purpose of this study was to retrospectively investigate the effect of skeletonisation on SWC after off-pump coronary artery bypass grafting (OPCAB) in a centre with a high volume of off-pump procedures and high frequencies of BIMA. Methods From January 2010 to November 2016, 1900 consecutive patients underwent OPCAB surgery at the University Hospitals of Leuven. The first group (n = 1487) received non-skeletonised IMA grafts, whereas the second group (n = 413) received skeletonised grafts. Optimal wound management was pursued in all patients. A new four-grade classification for SWC was developed. Incidence and grade of SWC as well as overall survival were assessed. Results Analysis of diabetic patients showed a lower incidence of SWC in the skeletonised (12/141, 8.5%) compared to the non-skeletonised group (82/414, 19.8%) [odds ratio 0.46, 95% confidence interval (0.23;0.88), p = 0.019] as well as a lower grade [0.45 (0.24;0.871), p = 0.018]. There was no significant effect on overall survival [0.67 (0.19;2.32), p = 0.529]. Subanalysis of this population revealed that the observed effects were most prominent in patients receiving BIMA grafts, with 6/56 (10.7%) SWC in the skeletonised and 62/252 (24.6%) in the non-skeletonised group [0.37 (0.15;0.90), p = 0.028 for incidence], as well as a lower grade [0.36 (0.15;0.88), p = 0.025]. These advantages were not significant in diabetic patients receiving SIMA grafts nor in the full study population. Conclusions This study, using a more sensitive classification of SWC, shows in a large group of patients that, in combination with optimized wound management, the skeletonisation technique is associated with a clear reduction in the incidence and grade of SWC in diabetic patients receiving BIMA grafts. This encourages the extension of BIMA use in OPCAB to this risk population. Electronic supplementary material The online version of this article (10.1186/s13019-019-0985-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jef Van den Eynde
- Department of Cardiovascular Diseases, Research Unit of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Astrid Heeren
- Department of Cardiovascular Diseases, Research Unit of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Delphine Szecel
- Department of Cardiovascular Diseases, Research Unit of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Bart Meuris
- Department of Cardiovascular Diseases, Research Unit of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Steven Jacobs
- Department of Cardiovascular Diseases, Research Unit of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiovascular Diseases, Research Unit of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Wouter Oosterlinck
- Department of Cardiovascular Diseases, Research Unit of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Gomes WJ, Angelini GD. On- or Off-pump Coronary Artery Bypass Surgery. Is the Debate Settling Down? Braz J Cardiovasc Surg 2019; 34:VIII-XI. [PMID: 31454192 PMCID: PMC6713363 DOI: 10.21470/1678-9741-2019-0281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Walter J Gomes
- Universidade Federal de São Paulo Escola Paulista de Medicina Hospital São Paulo São Paulo SP Brazil Cardiovascular Surgery Discipline, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Gianni D Angelini
- University of Bristol Bristol Heart Institute Bristol Royal Infirmary Bristol United Kingdom Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, United Kingdom
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Simon S, Coronel C, de Almeida AS, Marcadenti A. Left lateral intercostal region versus subxiphoid position for pleural drain during elective coronary artery bypass graft surgery: randomized clinical trial. SAO PAULO MED J 2019; 137:66-74. [PMID: 31116274 PMCID: PMC9721208 DOI: 10.1590/1516-3180.2018.040940119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 10/08/2018] [Accepted: 01/04/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The pleural drain insertion site after coronary artery bypass graft (CABG) surgery may alter lung function, especially respiratory muscle strength. The main objective of this study was to compare the effectiveness and safety of use of the left lateral intercostal region versus the subxiphoid position for pleural drainage during elective CABG surgery using extracorporeal circulation (ECC). DESIGN AND SETTING Randomized trial conducted in a tertiary-level hospital in Porto Alegre, Brazil. METHODS 48 patients were assigned to group 1 (pleural drain in the left lateral intercostal region) or group 2 (pleural drain in the subxiphoid position). Respiratory muscle strength was measured in terms of maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP), in cmH2O, by means of manovacuometry preoperatively, 24 and 72 hours after drain removal and before discharge from hospital. Painand dyspnea scales, presence of infections, pleural effusion and atelectasis, duration of drain use, drainage volumes and surgical reinterventions were also evaluated. RESULTS After adjustments, there were no significant differences between the groups at the end of the study (before discharge), in predicted percentages either for MIP (delta group 1: -17.21% versus delta group 2: -22.26%; P = 0.09) or for MEP (delta group 1: -9.38% versus delta group 2: -13.13%; P = 0.17). Therewere no differences between the groups in relation to other outcomes. CONCLUSION There was no difference in maximal respiratory pressures in relation to the pleural drain insertion site among patients who underwent CABG surgery using ECC. TRIAL REGISTRATION ReBEc V1111.1159.4447.
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Affiliation(s)
- Sandra Simon
- MSc. Registered Nurse, Graduate Program in Health Sciences (Cardiology), Instituto de Cardiologia, Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre (RS), and Registered Nurse, Cardiology and Cardiac Surgery Services, Hospital Nossa Senhora da Conceição Hospital (HNSC), Porto Alegre (RS), Brazil.
| | - Christian Coronel
- MSc. Physiotherapist, Physical Therapy Service, Surgery Service, Instituto de Cardiologia, Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre (RS), and Professor, La Salle University (Unilasalle Canoas), Canoas (RS), Brazil.
| | - Adriana Silveira de Almeida
- PhD. Physician and Cardiovascular Surgeon, Cardiology and Cardiac Surgery Services, Hospital Nossa Senhora da Conceição Hospital (HNSC), Porto Alegre (RS), Brazil.
| | - Aline Marcadenti
- PhD. Professor, Graduate Program in Health Sciences (Cardiology), Instituto de Cardiologia, Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre (RS); Professor, Postgraduate Program on Nutrition Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre (RS); and Researcher, Instituto de Pesquisa do Hospital do Coração (HCor), São Paulo (SP), Brazil.
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Puehler T, Zittermann A, Dia M, Emmel E, Gercek M, Börgermann J, Hakim-Meibodi K, Gummert J. Off-pump Revascularization with Bilateral versus Single Mammary Arteries-A Propensity Score-Matched Analysis. Thorac Cardiovasc Surg 2019; 68:687-694. [PMID: 30738416 DOI: 10.1055/s-0039-1677835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Coronary artery bypass grafting is the first-line therapy for severe multivessel coronary artery disease. We aimed to investigate the clinical outcome in patients undergoing isolated off-pump surgery with the single or bilateral internal mammary artery (SIMA or BIMA) approach. METHODS We performed a propensity score-matched analysis in 1,852 consecutive patients, aged 50 to 70 years, who underwent myocardial revascularization at our institution between July 2009 and August 2016. Primary end point was the probability of survival. RESULTS Mean follow-up was 36.3 (range: 0.1-89.6) months. The probability of survival in the SIMA and BIMA groups was 98.6 and 99.0% at year 1, 92.0 and 92.5% at year 5, and 85.6 and 81.6% at year 7, respectively, with a hazard ratio (HR) of mortality for the BIMA group versus the SIMA group of 0.98 (95% confidence interval[CI]: 0.64-1.52; p = 0.94). There was evidence for interaction between diabetes and study group on mortality risk (HR = 2.59, 95% CI: 1.07-6.23; p = 0.034). Freedom from mediastinitis/wound infection was higher in the SIMA group than in the BIMA group (99.5 and 96.9%, respectively; HR of an event = 6.39, 95% CI: 2.88-14.18; p < 0.001). The corresponding values in the subgroups of diabetic patients were 98.6 and 90.9%, respectively (HR = 6.45, 95% CI: 2.24-18.58; p = 0.001). Mediastinitis/wound infection was associated with increased mortality risk (HR = 2.96, 95% CI: 1.29-6.78; p = 0.010). CONCLUSION Overall, our data indicate similar probability of survival up to a maximum follow-up of 7 years by off-pump surgery with the SIMA or BIMA approach. However, in diabetic patients, the clinical outcome indicates caution regarding the use of the BIMA approach.
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Affiliation(s)
- Thomas Puehler
- Klinik für Herz- und Gefäßchirurgie, Universitatsklinikum Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Armin Zittermann
- Department of Cardio-Thoracic Surgery, Heart Center NRW, Bad Oeynhausen, Germany
| | - Mohamad Dia
- Herzzentrum Duisburg, Duisburg, Nordrhein-Westfalen, Germany
| | - Eric Emmel
- Department of Cardio-Thoracic Surgery, Heart Center NRW, Bad Oeynhausen, Germany
| | - Mustafa Gercek
- Herzzentrum Duisburg, Duisburg, Nordrhein-Westfalen, Germany
| | | | - Kavous Hakim-Meibodi
- Department of Cardio-Thoracic Surgery, Heart Center NRW, Bad Oeynhausen, Germany
| | - Jan Gummert
- Department of Cardio-Thoracic Surgery, Heart Center NRW, Bad Oeynhausen, Germany
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Davierwala PM, Leontyev S, Garbade J, Lehmann S, Holzhey D, Misfeld M, Borger MA. Off-pump coronary artery bypass surgery with bilateral internal thoracic arteries: the Leipzig experience. Ann Cardiothorac Surg 2018; 7:483-491. [PMID: 30094212 DOI: 10.21037/acs.2018.06.15] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Contrasting results of recent randomized controlled trials (RCTs) comparing off-pump and on-pump coronary artery bypass graft (CABG) surgery, as well as the lack of evidence for any survival benefit of bilateral internal thoracic artery (ITA) grafting over single ITA use, has intensified the debate about the role of the off-pump technique and bilateral ITA use in CABG surgery. We therefore investigated our 15-year experience in off-pump CABG with bilateral ITA grafting and evaluated temporal trends in preoperative characteristics and postoperative outcomes. Methods Demographic, intra-operative, and outcome data of 1,199 consecutive patients undergoing off-pump CABG with bilateral ITA grafting was prospectively collected in a computerized database. Patients who underwent on-pump cardiac procedures and other extra-cardiac procedures were excluded from this study. Assessment of changes in perioperative characteristics and parameters with time was performed by dividing the whole cohort into three groups (2003-2007, 2008-2012, and 2013-2017) based on the year of surgery. Results The overall 30-day mortality was 0.6%, with no differences observed between the three time cohorts (0.6%, 0.7%, 0.5%; P=0.8). The perioperative stroke rate for whole cohort was 0.6% and demonstrated a significant reduction in the last two time cohorts (1%, 0.5%, 0.5%; P<0.0001). The overall incidence of deep sternal wound infections was 0.7%, but was marginally higher in the last time-cohort (0.6%, 0.5%, 0.9%; P=0.7). Overall survival for the entire cohort was 92.9%±1% and 78.9%±4% at 5 and 10 years follow-up, respectively. Older age at surgery and presence of peripheral vascular disease were the only predictors of late mortality. Conclusions Off-pump CABG with bilateral skeletonized ITAs is a safe operation and is associated with a low mortality and morbidity, which can be maintained in high volume center unit over a long period of time. The long-term survival of patients undergoing such an operation is excellent.
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Affiliation(s)
- Piroze M Davierwala
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Sergey Leontyev
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Jens Garbade
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Sven Lehmann
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - David Holzhey
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Martin Misfeld
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
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Saha T, Naqvi S, Goldberg S. Hybrid Revascularization: A Review. Cardiology 2018; 140:35-44. [DOI: 10.1159/000488190] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 03/05/2018] [Indexed: 11/19/2022]
Abstract
Hybrid coronary revascularization (HCR) combines surgical bypass with percutaneous coronary intervention (PCI) performed either during the same procedure or in a staged approach within 60 days. Coronary artery bypass grafting using the left internal mammary artery (LIMA) has shown excellent long-term patency with improved patient survival. It remains the gold standard treatment for the majority of patients with multivessel coronary artery disease. However, saphenous vein grafts have poor long-term patency. Advances in stent technology have resulted in reduced rates of thrombosis and restenosis, making PCI a viable alternative to coronary surgery in selected patients. HCR is attractive as a less invasive method of coronary revascularization which preserves the benefits of the LIMA performed with less invasive surgical techniques with the efficacy of newer generation stents.
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Spence J, Long S, Tidy A, Raymer K, Devereaux PJ, Lamy A, Whitlock R, Syed S. Tranexamic Acid Administration During On-Pump Cardiac Surgery. Anesth Analg 2017; 125:1863-1870. [DOI: 10.1213/ane.0000000000002422] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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14
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Saha KK. Off-pump coronary bypass grafting: the new gold standard! Indian J Thorac Cardiovasc Surg 2017. [DOI: 10.1007/s12055-017-0594-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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15
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Gatti G. Sternal wound management after bilateral internal thoracic artery grafting: a significant detail. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:262. [PMID: 28706930 DOI: 10.21037/atm.2017.03.84] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Giuseppe Gatti
- Division of Cardiac Surgery, Cardiovascular Department, University Hospital of Trieste, Trieste, Italy
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16
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One or Two Internal Thoracic Grafts? Long-Term Follow-Up of 957 Off-Pump Coronary Bypass Surgeries. Ann Thorac Surg 2017; 104:70-77. [DOI: 10.1016/j.athoracsur.2016.10.049] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 09/12/2016] [Accepted: 10/24/2016] [Indexed: 11/20/2022]
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17
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Calafiore AM, Prapas S, Osman A, Di Mauro M. Coronary artery bypass grafting off-pump or on-pump: another brick in the wall. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:168. [PMID: 28480204 DOI: 10.21037/atm.2017.03.52] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Sotirios Prapas
- Department of Cardiac Surgery, Henry Dunant Hospital, Athens, Greece
| | - Ahmed Osman
- Department of Critical Care, Cairo University, Giza, Egypt
| | - Michele Di Mauro
- Department of Cardiac Surgery, University G. D'Annunzio, Chieti, Italy
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18
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Benedetto U, Caputo M, Mariscalco G, Gaudino M, Chivasso P, Bryan A, Angelini GD. Impact of multiple arterial grafts in off-pump and on-pump coronary artery bypass surgery. J Thorac Cardiovasc Surg 2017; 153:300-309.e6. [DOI: 10.1016/j.jtcvs.2016.10.084] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/30/2016] [Accepted: 10/05/2016] [Indexed: 10/20/2022]
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19
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„The ART of CABG in doubt“? ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2017. [DOI: 10.1007/s00398-016-0133-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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20
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Taggart DP, Altman DG, Gray AM, Lees B, Gerry S, Benedetto U, Flather M. Randomized Trial of Bilateral versus Single Internal-Thoracic-Artery Grafts. N Engl J Med 2016; 375:2540-9. [PMID: 27959712 DOI: 10.1056/nejmoa1610021] [Citation(s) in RCA: 277] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The use of bilateral internal thoracic (mammary) arteries for coronary-artery bypass grafting (CABG) may improve long-term outcomes as compared with the use of a single internal-thoracic-artery plus vein grafts. METHODS We randomly assigned patients scheduled for CABG to undergo single or bilateral internal-thoracic-artery grafting in 28 cardiac surgical centers in seven countries. The primary outcome was death from any cause at 10 years. The composite of death from any cause, myocardial infarction, or stroke was a secondary outcome. Interim analyses were prespecified at 5 years of follow-up. RESULTS A total of 3102 patients were enrolled; 1554 were randomly assigned to undergo single internal-thoracic-artery grafting (the single-graft group) and 1548 to undergo bilateral internal-thoracic-artery grafting (the bilateral-graft group). At 5 years of follow-up, the rate of death was 8.7% in the bilateral-graft group and 8.4% in the single-graft group (hazard ratio, 1.04; 95% confidence interval [CI], 0.81 to 1.32; P=0.77), and the rate of the composite of death from any cause, myocardial infarction, or stroke was 12.2% and 12.7%, respectively (hazard ratio, 0.96; 95% CI, 0.79 to 1.17; P=0.69). The rate of sternal wound complication was 3.5% in the bilateral-graft group versus 1.9% in the single-graft group (P=0.005), and the rate of sternal reconstruction was 1.9% versus 0.6% (P=0.002). CONCLUSIONS Among patients undergoing CABG, there was no significant difference between those receiving single internal-thoracic-artery grafts and those receiving bilateral internal-thoracic-artery grafts with regard to mortality or the rates of cardiovascular events at 5 years of follow-up. There were more sternal wound complications with bilateral internal-thoracic-artery grafting than with single internal-thoracic-artery grafting. Ten-year follow-up is ongoing. (Funded by the British Heart Foundation and others; ART Current Controlled Trials number, ISRCTN46552265 .).
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Affiliation(s)
- David P Taggart
- From Nuffield Department of Surgical Sciences (D.P.T., B.L.), Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre (D.G.A., S.G.), and the Health Economics Research Centre, Nuffield Department of Population Health (A.M.G.), University of Oxford, Oxford, the School of Clinical Sciences, University of Bristol and Bristol Royal Infirmary, Bristol (U.B.), and Norwich Medical School, University of East Anglia and Norfolk and Norwich University Hospital, Norwich (M.F.) - all in the United Kingdom
| | - Douglas G Altman
- From Nuffield Department of Surgical Sciences (D.P.T., B.L.), Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre (D.G.A., S.G.), and the Health Economics Research Centre, Nuffield Department of Population Health (A.M.G.), University of Oxford, Oxford, the School of Clinical Sciences, University of Bristol and Bristol Royal Infirmary, Bristol (U.B.), and Norwich Medical School, University of East Anglia and Norfolk and Norwich University Hospital, Norwich (M.F.) - all in the United Kingdom
| | - Alastair M Gray
- From Nuffield Department of Surgical Sciences (D.P.T., B.L.), Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre (D.G.A., S.G.), and the Health Economics Research Centre, Nuffield Department of Population Health (A.M.G.), University of Oxford, Oxford, the School of Clinical Sciences, University of Bristol and Bristol Royal Infirmary, Bristol (U.B.), and Norwich Medical School, University of East Anglia and Norfolk and Norwich University Hospital, Norwich (M.F.) - all in the United Kingdom
| | - Belinda Lees
- From Nuffield Department of Surgical Sciences (D.P.T., B.L.), Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre (D.G.A., S.G.), and the Health Economics Research Centre, Nuffield Department of Population Health (A.M.G.), University of Oxford, Oxford, the School of Clinical Sciences, University of Bristol and Bristol Royal Infirmary, Bristol (U.B.), and Norwich Medical School, University of East Anglia and Norfolk and Norwich University Hospital, Norwich (M.F.) - all in the United Kingdom
| | - Stephen Gerry
- From Nuffield Department of Surgical Sciences (D.P.T., B.L.), Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre (D.G.A., S.G.), and the Health Economics Research Centre, Nuffield Department of Population Health (A.M.G.), University of Oxford, Oxford, the School of Clinical Sciences, University of Bristol and Bristol Royal Infirmary, Bristol (U.B.), and Norwich Medical School, University of East Anglia and Norfolk and Norwich University Hospital, Norwich (M.F.) - all in the United Kingdom
| | - Umberto Benedetto
- From Nuffield Department of Surgical Sciences (D.P.T., B.L.), Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre (D.G.A., S.G.), and the Health Economics Research Centre, Nuffield Department of Population Health (A.M.G.), University of Oxford, Oxford, the School of Clinical Sciences, University of Bristol and Bristol Royal Infirmary, Bristol (U.B.), and Norwich Medical School, University of East Anglia and Norfolk and Norwich University Hospital, Norwich (M.F.) - all in the United Kingdom
| | - Marcus Flather
- From Nuffield Department of Surgical Sciences (D.P.T., B.L.), Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre (D.G.A., S.G.), and the Health Economics Research Centre, Nuffield Department of Population Health (A.M.G.), University of Oxford, Oxford, the School of Clinical Sciences, University of Bristol and Bristol Royal Infirmary, Bristol (U.B.), and Norwich Medical School, University of East Anglia and Norfolk and Norwich University Hospital, Norwich (M.F.) - all in the United Kingdom
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Fudulu D, Benedetto U, Pecchinenda GG, Chivasso P, Bruno VD, Rapetto F, Bryan A, Angelini GD. Current outcomes of off-pump versus on-pump coronary artery bypass grafting: evidence from randomized controlled trials. J Thorac Dis 2016; 8:S758-S771. [PMID: 27942394 DOI: 10.21037/jtd.2016.10.80] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Coronary artery bypass grafting remains the standard treatment for patients with extensive coronary artery disease. Coronary surgery without use of cardiopulmonary bypass avoids the deleterious systemic inflammatory effects of the extracorporeal circuit. However there is an ongoing debate surrounding the clinical outcomes after on-pump versus off-pump coronary artery bypass (ONCAB versus OPCAB) surgery. The current review is based on evidence from randomized controlled trials (RCTs) and meta-analyses of randomized studies. It focuses on operative mortality, mid- and long-term survival, graft patency, completeness of revascularisation, neurologic and neurophysiologic outcomes, perioperative complications and outcomes in the high risk groups. Early and late survival rates for both OPCAB and ONCAB grafting are similar. Some studies suggest early poorer vein graft patency with off-pump when compared with on-pump, comparable midterm arterial conduit patency with no difference in long term venous and arterial graft patency. A recent, pooled analysis of randomised trials shows a reduction in stroke rates with use off-pump techniques. Furthermore, OPCAB grafting seems to reduce postoperative renal dysfunction, bleeding, transfusion requirement and respiratory complications while perioperative myocardial infarction rates are similar to ONCAB grafting. The high risk patient groups seem to benefit from off-pump coronary surgery.
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Affiliation(s)
- Daniel Fudulu
- Bristol Heart Institute, University Hospitals Bristol, Bristol, UK
| | | | | | | | | | - Filippo Rapetto
- Bristol Heart Institute, University Hospitals Bristol, Bristol, UK
| | - Alan Bryan
- Bristol Heart Institute, University Hospitals Bristol, Bristol, UK
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Riess FC, Heller S, Cramer E, Awwad N, Amin W, Hansen L, Lehmann C, Schofer J, Stripling J, Winkel S, Kremer P. On-Pump versus Off-Pump Complete Arterial Revascularization Using Bilateral Internal Mammary Arteries and the T-Graft Technique: Clinical and Angiographic Results for 3,445 Patients in 13 Years of Follow-Up. Cardiology 2016; 136:170-179. [PMID: 27698326 DOI: 10.1159/000448428] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 07/14/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND This is an investigation of complete arterial coronary artery bypass grafting (CACABG) using bilateral internal mammary arteries (IMA) and the T-graft technique either on- or off-pump as a routine approach to treat coronary artery disease. METHODS Between January 2000 and December 2012, 3,445 patients underwent on-pump (n = 2,216) or off-pump (n = 1,229) CACABG. A 30-day follow-up was performed prospectively, a long-term follow-up by a questionnaire, and coronary angiography in selected patients. RESULTS End points at 30 days were death, myocardial infarction, stroke, repeat revascularization, renal replacement, reoperation, sternal wound infection and atrial fibrillation. FitzGibbon A patency rates were 89.8 vs. 91.4% (p = 0.464) with consecutive percutaneous coronary intervention in the grafted area of 1.8 vs. 1.1% (p = 0.693) on- vs. off-pump, and no reoperation in the grafted area in both groups. CONCLUSION CACABG by use of skeletonized bilateral IMA with the T-graft technique performed either on- or off-pump is a safe and effective approach.
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¿Hay todavía lugar para la cirugía coronaria sin circulación extracorpórea en el 2015? Solo de manera ocasional. CIRUGIA CARDIOVASCULAR 2016. [DOI: 10.1016/j.circv.2015.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Poullis M, Kolh P. Analysis of on-pump and off-pump surgery in the Arterial Revascularization Trial. Eur J Cardiothorac Surg 2014; 47:1065-6. [PMID: 25217502 DOI: 10.1093/ejcts/ezu356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Philippe Kolh
- Department of Cardiovascular Surgery, University Hospital of Liege, CHU Sart Tilman, Liege, Belgium
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