Off-pump coronary artery bypass grafting in patients with end-stage renal disease on hemodialysis

Comparative analysis of revascularization with percutaneous coronary intervention versus coronary artery bypass surgery for patients with end-stage renal disease: a nationwide inpatient sample database

BACKGROUND

The role of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) in patients with coronary artery disease (CAD) and concomitant end-stage renal disease (ESRD) remains unknown.

RESEARCH DESIGN & METHODS

The National Inpatient Sample (NIS) (2002-2017) was queried to identify all cases of CAD and ESRD. The relative merits of PCI vs CABG were determined using a propensity-matched multivariate logistic regression model. Adjusted odds ratios (aOR) for mortality and other in-hospital complications were calculated.

RESULTS

A total of 350,623 [CABG = 112,099 (32%) and PCI = 238,524 (68%)] hospitalizations were included in the analysis. The overall adjusted odds for major bleeding (aOR 1.28, 95% CI 1.25-1.31, P < 0.0001), post-procedure bleeding (aOR 5.19, 95% CI 4.93-5.47, P < 0.0001), sepsis (aOR 1.29, 95% CI 1.26-1.33, P < 0.0001), cardiogenic shock (aOR 1.23, 95% CI 1.20-1.26, P < 0.0001), and in-hospital mortality (aOR 1.65, 95% CI 1.61-1.69, P < 0.0001) were significantly higher for patients undergoing CABG compared with PCI. The need for intra-aortic balloon pump (IABP) placement (aOR 2.52, 95% CI 2.45-2.59, P < 0.001) was higher in the CABG group, while the adjusted odds of vascular complications were similar between the two groups (aOR 0.99, 95% CI 0.94-1.06, P = 0.82). As expected, patients undergoing CABG had a higher mean length of stay and mean cost of hospitalization.

CONCLUSION

CABG in ESRD may be associated with higher in-hospital complications, increased length of stay, and higher resource utilization.

Long Term Outcomes of The Off-Pump and On-Pump Coronary Artery Bypass Grafting In A High-Volume Center

Coronary artery bypass grafting (CABG) remains the most frequent surgery in the practice of an adult cardiac surgeon and the most frequently performed cardiac surgical procedure worldwide. Despite the ongoing debates regarding the superiority or inferiority of off-pump coronary artery bypass grafting, it still comprises 15-30% of all CABG cases varying in different national registries. We performed a propensity matched study of 302 consecutive CABG patients,143 off -pump cases performed by the four experienced off-pump surgeons and the on-pump CABG cases performed by those surgeons and four other experienced coronary surgeons. The five year follow up was performed and data collected comprised of mortality, rehospitalization due to cardiac origin, repeated revascularization, myocardial infarction and cerebrovascular accident. Overall, the off-pump group of patients had a higher risk profile than the patients in the on-pump group. After matching, fewer differences were found between the groups. Propensity score matching analysis showed no difference in long-term survival as well as MACCE and repeated revascularization. The higher risk profile of the patients subjected to OPCAB and the comparable survival to lower risk CPB patients in this series indicate that in experienced hands, OPCAB is a valuable option in this important subgroup of patients.

Off-Pump versus Conventional Coronary Artery Bypass Grafting: A Meta-Analysis and Consensus Statement from the 2004 ISMICS Consensus Conference

Background

The purpose of this evidence-based consensus statement is to systematically review and meta-analyze the randomized and nonrandomized evidence comparing off-pump (OPCAB) to conventional coronary artery bypass (CCAB) surgery and to provide consensus on the role of OPCAB in low- and high-risk surgical patients.

Methods and Results

This consensus conference was conducted according to the American College of Cardiology (ACC)/American Heart Association (AHA) standards for development of clinical practice guidelines. The Steering Committee collated all published studies of OPCAB versus CCAB through May 2004 and developed six questions central to controversies surrounding OPCAB surgery in mortality, morbidity, and resource utilization. For mixed-risk patient populations, meta-analysis of 37 randomized clinical trials (3,369 patients, Level A) reported across a total of 53 papers, and two meta-analyses of nonrandomized trials (Level B) comparing OPCAB versus CCAB were identified. For high-risk patient populations, we performed a meta-analysis of 3 randomized and 42 nonrandomized trials (26,349 patients, Level B).

Conclusion

Meta-analysis of Level A and B evidence provided the basis for the following consensus statements in patients undergoing surgical myocardial revascularization: (1) OPCAB should be considered a safe alternative to CCAB with respect to risk of mortality [Class I, Level A]; (2) With appropriate use of modern stabilizers, heart positioning devices, and adequate surgeon experience, similar completeness of revascularization and graft patency can be achieved [Class IIa, Level A]; (3) OPCAB is recommended to reduce perioperative morbidity [Class I, Level A]; (4) OPCAB may be recommended to minimize midterm cognitive dysfunction [Class IIa, Level A]; (5) OPCAB should be considered as an equivalent alternative to CCAB in regard to quality of life [Class I, Level A]; (6) OPCAB is recommended to reduce the duration of ventilation, ICU and hospital stay, and resource utilization [Class I, Level A]; (7) OPCAB should be considered in high-risk patients to reduce perioperative mortality, morbidity, and resource utilization [Class IIa, Level B].

Off-pump versus on-pump complete coronary artery bypass grafting: Comparison of the effects on the renal damage in patients with renal dysfunction

BACKGROUND

We aimed to compare off-pump technique with on-pump technique on renal function in patients with nondialysis-dependent renal dysfunction who underwent coronary artery bypass grafting.

METHODS

The 94 patients with renal dysfunction undergoing isolated coronary artery bypass grafting were retrospectively analyzed. No patient was receiving dialysis. Patients were randomly assigned to conventional revascularization with cardiopulmonary bypass and beating heart. Both groups were compared in terms of renal dysfunction parameters and dialysis requirement. The logistic regression models were constructed to identify risk factors associated with dialysis requirement.

RESULTS

Renal dysfunction requiring dialysis developed in 9 patients in the on-pump group. The measures analysis of variance was performed on the data that showed worsening of renal function in the on-pump group compared with the off-pump group. Cardiopulmonary bypass is significant as independent predictor for the development of postoperative dialysis.

CONCLUSION

These results suggest that off-pump coronary revascularization offers a superior renal protection and has a significantly lower risk for renal complications in patients with nondialysis-dependent renal dysfunction when compared with conventional coronary revascularization with cardiopulmonary bypass.

Comparison of Mid-Term Graft Patency between On-Pump and Off-Pump Coronary Artery Bypass Grafting

BACKGROUND

Multiple studies have compared on-pump coronary artery bypass (ONCAB) grafting with off-pump coronary artery bypass (OPCAB) grafting, but the optimal surgical strategy has yet to be established. Furthermore, there is limited evidence regarding mid-term graft patency rates.

METHODS

Between April 2001 and March 2014, 365 consecutive patients underwent isolated coronary artery bypass grafting (CABG; male: 75%; mean age: 69 ± 10 years). After propensity-score-matched analysis, we assessed the results of 67 patients in each group (ONCAB: group A, OPCAB: group B). The mean follow-up period of graft patency and survival rate was 35 ± 37 months and 54 ± 47 months, respectively.

RESULTS

There were no significant differences in baseline characteristics between the two groups. There was a trend for an increased number of distal anastomoses in group B as compared to group A (group A vs. group B: 3.8 ± 1.1 vs. 4.1 ± 1.6, P = 0.17). The total graft patency rate was tend to be lower in group A, but not statistically significant (group A: 156 months, 45.2%; group B: 96 months, 72.6%; P = 0.21). There was no difference for survival and major-adverse-cardiac-and-cerebrovascular-events (MACCE) free rate (P = 0.42 and 0.76, respectively).

CONCLUSION

Propensity-score-matched analysis revealed no difference in mid-term survival rate, MACCE free rate, graft patency rates, and number of distal anastomoses between ONCAB and OPCAB groups.

Does off-pump coronary artery bypass confer any advantage in patients with end-stage renal failure? A systematic review and meta-analysis

OBJECTIVES

Patients with end-stage renal disease (ESRD) are often excluded from trials comparing off and on-pump coronary artery bypass grafting (CABG). Thus data in this cohort is limited to small retrospective studies. Hence we compared the adverse clinical events and outcome in patients with ESRD undergoing off (OPCABG) and on-pump surgery (ONCABG).

METHODS

Pubmed, Scopus and Web of Science were searched (inception - June 2013) to identify studies comparing clinical results of OPCABG and ONCABG in dialysis dependent patients. A random effect inverse variance weighted meta-analysis was conducted. Results are presented as risk ratios (RR) with 95% confidence intervals; p<0.05 is significant.

RESULT

Ten retrospective studies (2762 OPCABG and 11310 ONCABG) fulfilled criteria and were pooled. Patients undergoing off-pump surgery were less than 100 in most of the articles. Early mortality [OPCABG (8.4%); ONCABG (10.4%)] was comparable [RR 0.80(0.51-1.17); p=0.35; I(2)=30%]. Re-exploration for bleeding [RR 0.81(0.47-1.39); p=0.44] and blood transfusion [RR 0.79(0.57-1.08); p=0.14] were also comparable. While patients undergoing off-pump surgery were extubated earlier (p<0.01), other post-operative events like stroke (p=0.34) and atrial fibrillation (p=0.10) were similar. Mid-term survival (three to five years) was also comparable.

CONCLUSION

Patients with end-stage renal disease undergoing coronary artery bypass grafting demonstrate comparable results irrespective of method. While available data is limited to retrospective studies, we failed to demonstrate any significant advantage for performing OPCABG in this group of patients.

Heart surgery in end-stage renal disease: is outcome worse for african american patients?

General results of open heart surgery in end-stage renal disease patients (ESRD) have been well-documented. However, it is unknown if the African American subgroup with known decreased access to advanced healthcare services and a higher prevalence rate of ESRD have a worse long-term survival after heart surgery. Thirty of 150 African American patients who underwent open heart surgery by a single surgeon at an urban community hospital between 1996 and 2010 were identified to have ESRD and were on chronic maintenance hemodialysis prior to surgery. Clinical and outcome data from both groups were retrospectively analyzed. There were no significant differences in the baseline demographic characteristics of the patients, but the ESRD cohort showed a significantly higher prevalence of peripheral vascular and cardiovascular diseases [P < 0.001]. Compared to the non-ESRD subjects, the predicted logistic EuroSCORE was 16.4% vs. 9.4%, [P < 0.001], while the observed 30 days operative mortality was 16.6% vs. 4.2% [P < 0.02], respectively. In isolated coronary artery bypass graft cases, operative mortality was 20.8% and 3.0%, respectively. The 5- and 10-year post-surgery survival was 40% and 25% vs. 72% and 57% [P < 0.01], respectively, in the ESRD and non-ESRD groups. Operative mortality and survival was worse in ESRD patients compared to non-ESRD patients based on their preoperative risk scores. Although the operative mortality of our ESRD patients was high, long-term survival was comparable to reports from both the United States Renal Data System and a Japanese ESRD cohort.

Hemodiafiltration During Cardiac Surgery in Patients on Chronic Hemodialysis

BACKGROUND

We have developed a hemodiafiltration (HDF) protocol used during cardiac surgery to preserve fluid and electrolyte balance and prevent postoperative bleeding in patients on chronic hemodialysis. This retrospective study examined the operative results associated with our new protocol.

METHODS

The study included 33 consecutive patients on long-term hemodialysis who underwent cardiac surgery at our hospital between January 2001 and April 2005, including off-pump coronary artery bypass grafting (CABG) in 19 patients. Vascular access was achieved via a 12-French double-lumen catheter inserted into the left femoral vein under general anesthesia, and HDF begun when the operation was started. After completion of cardiopulmonary bypass or, in patients who underwent off-pump CABG, after the distal anastomoses were completed, HDF was continued until target hematocrit between 30% and 35%, central venous pressure between 3 and 5 mmHg, and serum potassium concentration between 3.0 and 3.5 mEq/L were reached. The chest was closed after confirmation of hemostasis.

RESULTS

There was no in-hospital death. Three patients were extubated in the operating room. There were no postoperative wound infection, mediastinitis, respiratory tract infection, or hemorrhage. The patients were discharged at a mean of 15.6 days after operation.

CONCLUSIONS

These results suggest that intraoperative HDF lowers postoperative morbidity and mortality in chronic dialysis patients. Other advantages include early extubation and ambulation, and a shortened hospitalization.

On-pump versus off-pump coronary surgery outcomes in patients requiring dialysis: perspectives from a single center and the United States experience

OBJECTIVE

Coronary artery bypass graft surgery carries increased risk for patients requiring dialysis compared with other groups. Little data exist comparing outcomes of on-pump and off-pump techniques in dialysis patients. This study compares outcomes of bypass grafting in dialysis patients with these two techniques at a single institution and in the United States Renal Data System (USRDS) database.

METHODS

From March 1997 to April 2004, 37 patients requiring dialysis underwent bypass graft surgery at our institution. On-pump surgery was performed for 16 patients and off-pump surgery for 21. From January 1, 2001, to December 31, 2002, a total of 3922 patients in the USRDS underwent bypass graft surgery. On-pump surgery was performed for 3382 and off-pump surgery for 540. Comparisons were made between patients undergoing on-pump and off-pump bypass surgery with respect to demographics, risk factors, and outcomes. Univariate analysis, the Kaplan-Meier method, and a multivariate Cox model were used.

RESULTS

Institutional analysis revealed similar patient demographics, risk factors, use of thoracic artery grafts, and number of distal anastomoses. Outcome analysis was significant for less postoperative atrial fibrillation with the off-pump technique: 37.5% on-pump and 4.8% off-pump (P = .028). USRDS data revealed all-cause survivals at 1 and 18 months of 87.5% and 59.5% for on-pump versus 88.3% and 61.9% for off-pump procedures (P = .226). In a comorbidity-adjusted Cox model, off-pump bypass grafting was associated with a 16% reduction in all-cause mortality (P = .032).

CONCLUSION

Off-pump bypass grafting is uncommon in patients in the United States who require dialysis. Off- pump bypass grafting provides a morbidity benefit and is associated with a lower risk of death.

Impact of concomitant cardiac procedure on coronary artery surgery in hemodialysis-dependent patients

OBJECTIVE

Coronary artery bypass grafting (CABG) in hemodialysis-dependent patients is associated with high mortality and morbidity rates. This retrospective study was undertaken to identify the risk factors for in-hospital mortality for hemodialysis-dependent patients.

METHODS

Subjects included 87 consecutive hemodialysis-dependent patients (81 men and 6 women), aged 47-82 years (mean age, 65 years), who underwent CABG. Operative procedures included CABG alone (n=77) and CABG with valve replacement, repair, or the Dor procedure (n=10). Thirty-one perioperative risk factors were subjected to univariate and multivariate analyses to identify the risk factors for hospital death.

RESULTS

The overall in-hospital mortality rate, including operative death, was 14.9% (13/87). Univariate analysis showed the following 7 risk factors to be statistically significant predictors of hospital death: age > or = 70 years, a concomitant cardiac procedure, left ventricular ejection fraction <30%, left ventricular end-systolic volume index >70 ml/m2, a left main lesion, emergency/urgent surgery, and anemia (hemoglobin <10 mg/dl) (p<0.05 for each predictor). Multivariate logistic regression analysis confirmed that a concomitant cardiac procedure (chi-squared = 17.080, p=0.013) and age > or = 70 years (chi-squared = 9.112, p=0.019) are statistically significant independent risk factors for hospital death.

CONCLUSION

A concomitant cardiac procedure and age > or = 70 years were identified as significant independent risk factors for hospital mortality after CABG for hemodialysis-dependent patients. These preoperative risk factors may help in predicting operative risks and improving clinical outcomes in hemodialysis-dependent patients undergoing CABG.

Does Coronary Artery Bypass Graft Surgery Improve Survival Among Patients With End-Stage Renal Disease?

BACKGROUND

Cardiovascular disease remains the most frequent cause of death for patients with end-stage renal disease. To determine the long-term benefit of surgical revascularization in this high-risk population, we studied our patients with ESRD having coronary artery bypass graft surgery (CABG), comparing the results of off-pump to on-pump revascularization. As a baseline reference group, we used dialysis patients with a diagnosis of coronary artery disease who did not have surgical revascularization or percutaneous coronary interventions. The control group data set was obtained from the United States Renal Data System.

METHODS

From January 1995 through July 2003, 158 patients with end-stage renal disease who were on hemodialysis (excluding those in cardiogenic shock, needing resuscitation, and with emergent or salvage status) underwent CABG. Fifty-nine patients (37.3%) had off-pump revascularization, and 99 patients (62.7%) had bypass grafting utilizing extracorporeal circulation. Preoperative risk factors and operative results were analyzed, and longitudinal survival data obtained.

RESULTS

The mean follow-up time was 39.1 months (median, 33.1) for the on-pump patients and 18.3 months (median, 14.7) for off-pump. The total number of anastomoses per off-pump patient was 2.4 +/- 1.0, and with cardiopulmonary bypass (CPB), it was 3.3 +/- 0.9 (p < 0.001). Patients revascularized off-pump had an operative mortality rate of 1.7%, whereas patients grafted using CPB had an operative mortality of 17.2% (p = 0.003). The predicted risk of mortality for the off-pump group (9.3% +/- 7.4%) was not statistically different from the on-pump cohort (9.1% +/- 7.7%, p = not significant). Logistic regression analysis indicates that CPB use was an independent risk factor for early death (p = 0.01, odds ratio = 13.6, 95% confidence interval: 1.7 to 110). Long-term follow-up demonstrated that the patients revascularized using CPB had improved survival compared with the off-pump patients and the control population.

CONCLUSIONS

Off-pump CABG improves early mortality rate when compared with conventional revascularization. Despite a greater operative mortality, however, long-term survival is improved in the patients revascularized with CPB as compared with the off-pump cohort, suggesting possible advantages from a more complete revascularization in this population.

Physiological comparison of off-pump and on-pump coronary artery bypass grafting in patients on chronic hemodialysis

OBJECTIVES

Despite the long-term benefit, the operative results of conventional coronary artery bypass grafting for chronic hemodialysis patients remain unsatisfactory. The efficacy of off-pump coronary artery bypass grafting for hemodialysis patients is yet to be determined. The purpose of this study was to investigate the postoperative physiology of off-pump coronary artery bypass grafting for hemodialysis patients.

METHODS

Twenty-five hemodialysis cases who underwent isolated coronary artery bypass grafting were reviewed. Fifteen of these patients underwent off-pump coronary artery bypass grafting (off-group) and 10 underwent on-pump coronary artery bypass grafting (on-group). Comparisons were made in cardiac function (cardiac index and stroke volume index), respiratory function (AaDO2), hemodialysis management (blood urea nitrogen, creatinine, right atrial pressure, pulmonary wedge pressure), and bleeding tendency (postoperative blood loss and blood transfusion).

RESULTS

There was no operative mortality, but 3 major postoperative complications occurred (2 sternal wound infections in the off-group and 1 pneumonia in the on-group). There was no difference in cardiac index or stroke volume index. AaDO2 was significantly lower in the off-group. Plasma concentrations of blood urea nitrogen and creatinine were similar between groups. Right atrial pressure was lower and pulmonary wedge pressure tended to be lower in the off-group. Postoperative bleeding and blood transfusion were similar between groups.

CONCLUSION

Our study confirmed that off-pump coronary artery bypass grafting is feasible for hemodialysis patients. Physiologic data showed that off-pump coronary artery bypass grafting might be effective in preserving postoperative lung oxygenation.

Off-pump coronary artery bypass grafting in patients with renal dysfunction

BACKGROUND

Renal dysfunction is a predictor of increased morbidity and mortality after coronary artery bypass grafting, whether it is dialysis-dependent or not. Several studies have shown the efficacy of off-pump technique in reducing morbidity and mortality in patients with renal dysfunction. However, the actual effect of renal dysfunction in off-pump coronary artery bypass grafting has not been well understood.

METHODS

We conducted a retrospective review of 402 consecutive patients undergoing off-pump coronary artery bypass grafting from April 2001 to June 2003. Sixty-eight patients had chronic renal dysfunction (group A); 19 patients were dialysis-dependent; 334 patients had normal renal function (group B). Operative variables, morbidity, and mortality were compared between the two groups. Furthermore, multivariable analysis was performed to identify predictors for short-term survival.

RESULTS

Preoperative characteristics were similar in the two groups. Blood transfusion rate was higher in group A than group B (57.4% and 25.7%, respectively; p < 0.001). In-hospital mortality was similar (1.5% and 1.2% in group A and B, respectively; p = 0.853). Multivariable analysis revealed that unstable angina, low ejection fraction, peripheral vascular disease and redo surgery are significant risk factors for poor early result of off-pump coronary artery bypass grafting.

CONCLUSIONS

Early outcomes of off-pump coronary artery bypass grafting in patients with renal dysfunction were comparable to those in patients with normal renal function. Renal dysfunction is not a predictor of poor early outcomes after off-pump coronary artery bypass grafting.

Fatal ischemia of bowel and rectus abdominal muscle after off pump coronary artery bypass grafting in a dialysis patient

We have experienced a case which developed mesenteric ischemia followed by necrosis of the rectus abdominal muscle after off pump coronary artery bypass grafting (OPCAB). A 62-year-old man with a history of long-term hemodialysis was diagnosed with left main trunk disease. He underwent triple OPCAB uneventfully. No inotropic agents were needed perioperatively. He underwent normal hemodialysis on the first postoperative day, and then complained of severe abdominal pain with progressive metabolic acidosis. A 170 cm length of the ileocecal segment fell into necrosis and was excised and an ileostomy was constructed in an emergency setting. He developed another abdominal pain 6 days after the second operation. An additional surgery confirmed necrosis of the right rectus abdominal muscle complicated with a significant infection. He developed mediastinitis and died of multi-system organ failure 37 days after OPCAB. The mechanism of this serious complication is discussed.