Outcomes and predictors of mortality and stroke after on-pump and off-pump coronary artery bypass surgery in octogenarians. Innovations (Phila). 2013;8:269-275. [PMID: 24145971 DOI: 10.1097/imi.0000000000000000]

Is it safe to perform total arterial grafting in elderly patients lacking vein grafts? A single surgeon comparison

OBJECTIVES

The results of coronary artery bypass graft (CABG) surgery with total arterial revascularisation (TA-CABG) in elderly patients, who may have insufficient vein graft material for conventional CABG (CO-CABG), have not been fully established. We therefore sought to compare the short- and long-term outcomes of patients >70 years old undergoing CO-CABG and TA-CABG.

METHODS

We performed a retrospective observational study analyzing all consecutive adult patients aged >70 years undergoing first-time CABG over the 15-year period from 2004 to 2020 under a single surgeon. Primary outcomes of interest were in-hospital mortality, long-term mortality, and re-intervention rate. Secondary outcomes of interest included operative durations and the incidence of peri-operative complications.

RESULTS

There were 46 patients (age 76 ± 3 SD) in the TA-CABG group and 145 patients (age 76 ± 4 SD) in the CO-CABG group. Cardio-pulmonary bypass and cross-clamp durations were comparable between groups (p = .11 and p = .23, respectively). Stroke occurred in 1.0% undergoing CO-CABG compared to 0% in the TA-CABG group (p = .42). Hospital mortality was 3.0% with CO-CABG (EuroSCORE; mean [SD] 6.81 (5.81)) and 2.0% with TA-CABG (EuroSCORE; mean [SD] 6.38 (6.57)) (p = .93). On long-term follow-up, myocardial infarction occurred in 10.0% of CO-CABG patients compared to 4.0% of TA-CABG patients (p = .25). Re-intervention rates were 7% following CO-CABG, and 2% after TA-CABG (p = .23). There was no significant difference in long-term mortality between patients undergoing CO-CABG and TA-CABG (47% vs. 57%, p = .27). Long-term survival was comparable between grafting techniques (p = .27).

CONCLUSIONS

There were no significant differences in major adverse cardiac and cerebrovascular events, re-intervention rate, hospital or long-term mortality between CO-CABG and TA-CABG. TA-CABG represents a safe and feasible alternative to CO-CABG in elderly patients offering good long-term outcomes.

Off-pump versus on-pump coronary artery bypass grafting for octogenarians: A meta-analysis involving 146 372 patients

There is an ongoing debate concerning the optimal surgical option of myocardial revascularization for octogenarians. The current meta-analysis aimed to compare clinical outcomes following off-pump coronary artery bypass grafting (OPCABG) or conventional coronary artery bypass grafting (CCABG) in octogenarians. PubMed, Cochrane, Web of Science, and EMBASE databases were searched to identify eligible studies from inception to March 2021. The analysis was performed using STATA 15.1. A literature search yielded 18 retrospective studies involving 146 372 patients (OPCABG = 44 522 vs. CCABG = 101 850). Pooled analysis showed a strong trend toward reducing mortality risk in the OPCABG group (odds ratio: 0.75, 95% confidence interval: 0.56-1.00, p = .05). However, it did not reach statistical significance. The sensitive analysis demonstrated that OPCABG was less likely to cause death than CCABG. There were comparable data in myocardial infarction, renal failure, deep sternal wound infection, and hospital stays between the two groups, although the incidence of stroke, atrial fibrillation, prolonged ventilation, and reoperation for bleeding was significantly lower in the OPCAGB group. OPCABG may be an effective surgical strategy for myocardial revascularization, especially in reducing the incidence of postoperative stroke, atrial fibrillation, prolonged ventilation, and reoperation for bleeding.

Trends in per-operative parameters and postoperative complications associated with coronary artery bypass graft surgery (CABG); A four-year retrospective study

Objective:

To determine the patterns of per-operative parameters and early outcomes of patients that underwent CABG surgery during a four-year period.

Methods:

This is a cross-sectional descriptive study conducted in a tertiary care of hospital from November 2020 to January 2021. All the patients that underwent the isolated coronary artery bypass grafting (CABG) procedure were included in the study from June 2017 till June 2020. Data was collected on a data extraction form and stored in SPSS format which was analyzed for qualitative statistics keeping p<0.05 as significant. All the results were represented in the form of tables.

Results:

A total of 1,613 patients were operated upon for Coronary Artery Bypass Grafting (CABG) procedure during the study period with 1,222 (75.8%) males and 391 (24.2%) females. Dyslipidemia (71.8%) was the most common risk factor. The average perfusion time decreased only slightly (~1 minute) from 96.01 minutes to 95.07 minutes (2017 to 2020). This change however was not significant (p=0.301). The rate of Left Internal Mammary Artery (LIMA) use stayed relatively stable over the 4-year period fluctuating between 88.7% and 92.9% (p=0.360). The average initial ICU stay (in hours), drain at 12 hours and 24 hours stays almost the same. The rate of mortality peaked in 2018 (4.76%) and subsequently fell to 3.57% by 2020.

Conclusion:

More males underwent CABG surgery at this tertiary care hospital and the overall complication rate and per-operative parameters improved over the years. The non-risk stratified mortality in this study was found to be higher than developed nations.

Do in-hospital outcomes of isolated coronary artery bypass grafting vary between male and female octogenarians?

OBJECTIVES

Female gender and advanced age are regarded as independent risk factors for adverse outcomes after isolated coronary artery bypass grafting (CABG). There is paucity of evidence comparing outcomes of CABG between male and female octogenarians. We aimed to analyse in-hospital outcomes of isolated CABG in this cohort.

METHODS

All octogenarians that underwent isolated CABG, from January 2000 to October 2017, were included. A retrospective analysis of a prospectively collected cardiac surgery database (PATS; Dendrite Clinical Systems, Oxford, UK) was performed. A propensity score was generated for each patient from a multivariable logistic regression model based on 25 pre-treatment covariates. A total of 156 matching pairs were derived.

RESULTS

Five hundred and sixty-seven octogenarians underwent isolated CABG. This included 156 females (mean age 82.1 [SD: 0.9]) and 411 males (mean age 82.4 [SD: 2.1 years]). More males were current smokers (P = 0.002) with renal impairment (P = 0.041), chronic obstructive pulmonary disease (P = 0.048), history of cerebrovascular accident (P = 0.039) and peripheral vascular disease (P = 0.027) while more females had New York Heart Association class 4 (P = 0.02), left ventricular ejection fraction 30-49% (P = 0.038) and left ventricular ejection fraction <30% (P = 0.049). On-pump, CABG was performed in 140 males and 52 females (P = 0.921). There was no difference in in-hospital mortality (5.4% vs 6.4%; P = 0.840), stroke (0.9% vs 1.3%; P = 0.689), need for renal replacement therapy (17.0% vs 13.5%; P = 0.732), pulmonary complications (9.5% vs 8.3%; P = 0.746) and sternal wound infection (2.7% vs 2.6%; P = 0.882). The outcomes were comparable for the propensity-matched cohorts.

CONCLUSIONS

No gender difference in outcomes was seen in octogenarians undergoing isolated CABG.

The impact of age on outcomes of coronary artery bypass grafting

OBJECTIVE

As the population ages, increasing number of older patients are undergoing adult cardiac surgery. The purpose of the study is to assess the impact of age on postoperative outcomes in patients that undergo coronary artery bypass grafting (CABG).

METHODS

Patients that are ≥70 years old who underwent CABG were selected from the Nationwide/National Inpatient Sample from 2010 to 2015 using ICD-9-CM diagnosis and procedure codes. The patients who were 70-79 years old were compared to patients aged 80-89 years old to determine if the age difference of the patients had an impact on surgical outcomes. In addition, a secondary endpoint is to compare surgical outcomes between the 2 genders of the patients 80-89 years old. The rates of postoperative complications, and mortality were compared.

RESULTS

A total of 67,568 patients were identified who were ≥ 70 years old and underwent CABG. Compared to the Septuagenarians, the Octogenarians were more likely to develop cardiac complications (OR [odds ratio] =1.20, 95% CI [confidence interval] 1.12-1.23. They were also more likely to develop renal complications (P < 0001), and respiratory complications (P < 0001). The Octogenarians were also more likely to bleed postoperatively (P < 0.0001) and have a higher mortality (P < 0001). Furthermore, the female Octogenarians had a higher mortality (OR 1.25 95% CI 1.07-1.46) compared to males in the same age group.

CONCLUSIONS

The patients who were ≥ 80-89 years old had worse postoperative outcomes. The Octogenarians who were females had a higher mortality compared to their male counterparts.

Prognostic role of carotid intima-media thickness in off-pump coronary artery bypass surgery

Carotid intima-media thickness (IMT) is a well-known predictor of adverse outcomes in the ischemic heart disease patients; however, evidence is lacking in patients undergoing off-pump coronary artery bypass surgery (OPCAB). Data from 407 patients who underwent OPCAB between April 2013 and August 2016 were retrospectively reviewed. A composite of cardiovascular morbidity endpoints was defined as the presence of stroke, acute myocardial infarction, new cardiac arrhythmia (newly developed atrial fibrillation, atrial flutter, or atrioventricular block), cardiovascular death, or cerebrovascular death within 30 days after surgery. Increased carotid IMT was defined as ≥0.9 mm on one or both sides. The incidence of a composite of cardiovascular morbidity endpoints was 24.0% in the normal IMT group (n = 221) and 34.4% in the increased IMT group (n = 186) (p = 0.021). Multivariable analysis revealed increased IMT (odds ratio 1.719, 95% confidence interval 1.108 to 2.666, p = 0.016) and preoperative renal replacement therapy (odds ratio 4.264, 95% confidence interval 1.679 to 10.829, p = 0.002) as independent predictors of a composite of cardiovascular morbidity endpoints. In patients undergoing OPCAB, preoperative assessment of carotid IMT may help predicting the development of a postoperative composite of cardiovascular morbidity endpoints.

A comparison of early clinical outcomes of off-pump and on-pump coronary artery bypass grafting surgery in elderly patients

BACKGROUND

The reply of question of "which coronary artery bypass grafting (CABG) technique is superior in elderly patients, off-pump or on-pump CABG surgery?" is controversial. We aimed to compare the early clinical outcomes in elderly patients undergoing off-pump and on-pump CABG.

METHODS

From January 2009 to January 2015, 344 elderly patients (aged 70 or older) underwent off-pump (n = 137) or on-pump (n = 207) CABG. Patients' medical records were retrospectively reviewed, and their baseline preoperative characteristics, operative data and postoperative outcomes were analyzed, thereby a comparison of early outcomes between off-pump and on-pump patients was performed.

RESULTS

Mean age of patients was 74.4 ± 3.8 years. Both groups were statistically similar in terms of baseline preoperative characteristics. Number of distal bypass was significantly lower in off-pump group than in on-pump group. Postoperative length of intensive care unit and hospital stay were similar between two groups. Amounts of transfused blood products were significantly lower in off-pump CABG group. There were no significant differences in terms of postoperative complications and mortality between two groups.

CONCLUSIONS

Our results did not reveal a significant benefit of either surgical technique with respect to early-term clinical outcomes in elderly CABG patients. Further investigations are needed to determine whether off-pump CABG is superior than on-pump CABG in elderly patients.

Impact of minimally invasive extracorporeal circuits on octogenarians undergoing coronary artery bypass grafting. Have we been looking in the wrong direction?

OBJECTIVES

Minimally invasive extracorporeal circuits (MiECCs) aim at the preservation of physiologic reserves, the impact of which is expected to be most evident in patients in whom these are depleted. In this context, octogenarians present a subpopulation of specific interest.

METHODS

Based on the type of the utilized ECC, we performed a retrospective comparison between all octogenarians (n = 324) who received a primary coronary artery bypass in our institution from 2003 until 2010.

RESULTS

An MiECC was used in 52% of patients. Preoperative variables showed that the MiECC patients were older (83 ± 2 vs 82 ± 2 years; P = 0.001), had higher incidence of renal dysfunction (8% vs 3%; P = 0.04), moderately reduced left ventricular function (43 vs 33%; P = 0.07) and lower incidence of unstable angina (20% vs 28%; P = 0.06). To overcome these differences, a propensity score matching was performed and yielded 126 matched pairs of patients. The overall transfusion of packed red blood cells (2.3 ± 2.3 vs 3.4 ± 3.2 units per patint; P = <0.001), the rate of low cardiac output (0% vs 6%; P = 0.01) and the 30-day postoperative mortality (2.4% vs 9.5%; P = 0.02) were all in favour of the MiECC group in the matched patient population.

CONCLUSIONS

The MiECC concept has shown its benefits regarding both morbidity and mortality in this high-risk patient population. We believe that this beneficial effect finds its reason in a better preservation of physiologic reserves that are essential for a positive outcome in this patient group.

On- or off-pump coronary artery bypass grafting for octogenarians: A meta-analysis of comparative studies involving 27,623 patients

OBJECTIVE

Coronary artery bypass grafting (CABG) is being increasingly offered to octogenarians. Both on- and off-pump CABG are reported as effective surgical revascularization strategies for octogenarians by single institution studies. However, the issue of superiority of one strategy over the other for octogenarians remains unresolved due to limited sample size of these studies. A meta-analysis of studies comparing outcomes of on- and off-pump CABG in octogenarians was undertaken to address the issue.

METHODS

A literature search was conducted from 1966 through September 2016 using MEDLINE, EMBASE, Scopus and Web of Science to identify relevant articles. Primary outcomes of interest included in-hospital mortality and stroke. Secondary outcomes of interest were atrial fibrillation, acute renal failure, reoperation for bleeding, deep sternal wound infection, myocardial infarction, intensive therapy unit (ITU) stay and hospital stay. The random effects model was used to calculate the outcomes of both binary and continuous data to control any heterogeneity between the studies. Heterogeneity amongst the trials was determined by means of the Cochran Q value and quantified using the I² inconsistency test. All p-values were 2-sided and a 5% level was considered significant.

RESULTS

Sixteen retrospective studies (18,685 on-pump patients and 8938 off-pump patients) were included in the systematic review. In-hospital mortality (pooled OR = 0.64, 95% CI = 0.44 to 0.93; p = 0.02), stroke rate (pooled OR = 0.61, 95% CI = 0.48 to 0.76; p < 0.001) and length of hospital stay (pooled WMD = +0.29, 95% CI = +0.02 to +0.56; p = 0.04) were significantly lower in the off-pump patients. Atrial fibrillation (p = 0.36), acute renal failure (p = 0.47), reoperation for bleeding (p = 0.99), deep sternal wound infection (p = 0.59), myocardial infarction (p = 0.93), and length of ITU stay (p = 0.27) were comparable.

CONCLUSION

Off-pump compared to on-pump CABG offers surgical myocardial revascularization to octogenarians with lower in-hospital mortality, stroke rate and length of hospital stay with similar incidence of other adverse outcomes. Preferentially offering off-pump CABG to octogenarians could translate into reduced economic burden on the healthcare providers.

Mortality in isolated coronary artery bypass surgery in elderly patients. A retrospective analysis over 14 years

INTRODUCTION

We aim to describe our experience in coronary artery bypass graft in elderly patients older than 80 years and assess the associated risk and predictors of mortality in this subgroup.

MATERIAL AND METHOD

From January 1999 to June 2013, 3097 patients underwent consecutive coronary artery bypass graft surgery. Patients aged over 80 years were identified. Multivariate survival analysis using Cox's regression model was performed.

RESULTS

We identified 99 patients older than 80 years (80-group; mean age 82±3.5 years) and 2957 younger than 80 years (control group) (mean age 64.2±9.7 years). Additive EuroSCORE was 8.4±4.8 and 4.6±4.6 (P<.001) in the 80-group vs. control group, respectively. Off-pump coronary artery bypass graft was performed in 79.6 vs. 41.6% (P<.001) in the 80-group vs. the control group. respectively. There was significantly higher 30 day-mortality in the 80-group, 11.2 vs. 3.3%, respectively (P<.001). Patients in the 80-group underwent reintervention for bleeding more frequently (9.2 vs. 2.9%; P=.001) and had a higher incidence of major cardiovascular complications than the control group (6.1 vs. 2.1%; P=.001). Independent predictors of mortality for the 80-group were: reoperation for bleeding (HR 5.7; 95% CI 1.6-19.5) and cardiovascular complications (HR 3.7; 95% CI 1.1-12.2). The mean follow-up was 6.3±4.2 years for the octogenarian group. The cumulative survival of these patients was 65.7% during the study period.

CONCLUSION

Coronary artery bypass graft is performed preferably in patients over 80 years old under the off-pump procedure. Mortality is higher in this group of patients probably related to a higher incidence of cardiovascular complications and reintervention for bleeding in the immediate postoperative period.

Comparison of outcomes between off-pump versus on-pump coronary artery bypass surgery in elderly patients: a meta-analysis

The aim of this study was to analyze if off-pump coronary artery bypass surgery (CABG) is associated with better treatment outcomes in elderly patients (>70 years of age) than on-pump CABG, using meta-analysis. Medline, PubMed, Cochrane and Google Scholar databases were searched until September 13, 2016. Sensitivity and quality assessment were performed. Twenty-two studies, three randomized control trials (RCTs) and 20 non-RCTs were included with 24,127 patients. The risk of death associated with on-pump or off-pump CABG in the RCTs were similar (pooled OR=0.945, 95%CI=0.652 to 1.371, P=0.766). However, in the non-RCTs, mortality risk was lower in patients treated with off-pump CABG than on-pump CABG (pooled OR=0.631, 95%CI=0.587 to 0.944, P=0.003). No differences were observed between the two treatment groups in terms of the occurrence of 30-day post-operative stroke or myocardial infarction (P≥0.147). In the non-RCTs, off-pump CABG treatment was associated with a shorter length of hospital stay (pooled standardized difference in means=-0.401, 95%CI=-0.621 to -0.181, P≤0.001). The meta-analysis with pooled data from non-RCTs, but not RCTs, found that mortality was lower with off-pump compared with on-pump CABG, and suggested that there may be some benefit of off-pump CABG compared with on-pump CABG in the risk of mortality and length of hospital stay.

Two decades of off-pump coronary artery bypass surgery: Harefield experience

The morbidity and mortality associated with conventional coronary artery bypass grafting (CABG) attributed to invasiveness of cardiopulmonary bypass (CPB) has been well documented. Recognition of this invasiveness with a focus centered on abolishing, or at least reducing the CPB associated morbidity and mortality led to the resurgence of off-pump coronary artery bypass (OPCAB) surgery nearly two decades ago. At about the same time, OPCAB was adopted at Harefield hospital partly as an institutional drive to promote innovation and partly as a strategy to improve outcomes. What was deemed as a challenging technique initially and practiced by a single surgeon has now become a valid substitute to conventional CABG for achieving complete myocardial revascularization. This strategy now accounts for more than 50% of all coronary artery surgery operations at Harefield hospital and is systematically used to treat all coronary anatomies; achieve complete revascularization by accessing all territories subtended by main coronary arteries; and accomplish equivalent quality grafts without restriction in vascular conduit usage. This review article provides an overview of the evolution of OPCAB surgery at an institution with a well-established OPCAB program confirming that as surgeons' experience matures, OPCAB surgery permits safe and effective total myocardial revascularization in virtually all patients with multivessel coronary artery disease.

Off-pump coronary artery bypass grafting in octogenarians

Enhanced life expectancy has confronted cardiac surgery with a rapidly growing population of octogenarians needing coronary artery bypass grafting (CABG). Octogenarians are deemed a high-risk patient population with increased postoperative morbidity and mortality following conventional CABG using cardiopulmonary bypass (CPB). In such patients reducing the invasiveness of the surgical procedure by avoiding CPB may be tried in an attempt to improve outcomes. The increasing performance of off-pump coronary artery bypass (OPCAB) grafting within certain centers reflects surgeon preference to avoid the inherent risks of CPB and cardioplegic arrest including hemodilution, nonpulsatile arterial flow, global myocardial ischemia, atherosclerotic embolization from aortic manipulation, and systemic inflammatory response. Although OPCAB grafting is a well-established surgical myocardial revascularization strategy, its actual benefits in terms of morbidity and mortality remain questionable in the general population. In the higher risk octogenarian patients, however, there is a potential for more tangible clinical benefits when CPB is avoided. This review article provides an overview of the impact of OPCAB grafting on postoperative mortality and morbidity in octogenarians.

Off-pump coronary artery bypass reduces early stroke in octogenarians: a meta-analysis of 18,000 patients

BACKGROUND

Data comparing results of off-pump and conventional operations in octogenarians is very limited. Thus we chose to compare early adverse events between off-pump coronary artery bypass grafting (OPCABG) and on-pump CABG (ONCABG) in patients older than 80 years.

METHODS

Systematic review of multiple databases was performed to obtain original studies fulfilling search criteria. End points--early mortality, stroke, respiratory failure, atrial fibrillation, and myocardial infarction--were compared between these cohorts. A random-effects weighted analysis was performed using the trim-fill adjustment when necessary. Results are presented as risk ratios (RRs) with 95% confidence intervals (CIs); p < 0.05 is considered statistically significant.

RESULTS

Sixteen retrospective studies (9,744 ONCABG and 8,566 OPCABG patients) were included in the systematic review. OPCAGB patients received significantly fewer grafts (2.54 ± 0.16) compared with ONCABG patients (3.22 ± 0.41). Early mortality was comparable at 4.6% and 5.2% in the OPCABG and ONCABG cohorts, respectively (risk ratio [RR], 0.91; 95% CI, 0.64-1.28; p = 0.598). Stroke rates were higher in the ONCABG cohort (RR, 0.65; 95% CI, 0.49- 0.87; p < 0.01). Respiratory failure was higher with ONCABG (RR, 0.74; 95% CI, 0.57-0.97; p = 0.03). New-onset renal failure (p = 0.99), atrial fibrillation (p = 0.27), and myocardial infarction (p = 0.99) were comparable.

CONCLUSIONS

Coronary artery bypass in octogenarians can be performed safely with low early mortality. Although off-pump operations reduce the risk of early stroke, all other adverse events are comparable in on- and off-pump coronary artery bypass operations. Data regarding late mortality is at present limited; however, both on- and off-pump procedures appear to produce comparable survival.

Off-pump coronary artery bypass grafting: Misperceptions and misconceptions

Coronary artery bypass grafting (CABG) continues to be one of the most commonly performed cardiac surgical procedures worldwide. Conventional CABG performed on cardiopulmonary bypass termed on-pump CABG is regarded as the gold standard. However, on-pump CABG results in several physiologic derangements including but not limited to thrombocytopenia, activation of complement factors, immune suppression, and inflammatory responses leading to organ dysfunction. Furthermore, manipulating an atherosclerotic ascending aorta during cannulation and cross-clamping can predispose to embolization and stroke risk. Recognition of these detrimental effects of on-pump CABG resulted in resurgence of off-pump CABG nearly two decades ago. Off-pump CABG since its resurgence has been a subject of intensive scrutiny and speculation. Despite numerous retrospective nonrandomized studies, prospective randomized trials, and meta-analyses validating the safety and efficacy of off-pump CABG, opponents of the technique have persistently demanded abandonment of off-pump CABG. Several misconceptions and misperceptions are used as an excuse for such demands. This review article examines published scientific evidence to evaluate these misperceptions and misconceptions about off-pump CABG.