Why Is Off-Pump Coronary Surgery Uncommon in Canada? Results of a Population-Based Survey of Canadian Heart Surgeons

Incidental findings in CT imaging of coronary artery bypass grafts: results from a Canadian multicenter prospective cohort

Objective

To assess the prevalence and clinical significance of incidental findings identified during computed tomography imaging of coronary artery bypass grafts.

Results

This prospective study includes 144 patients undergoing coronary graft patency assessment using computed tomography. Incidental findings were classified as significant if they were considered to need an immediate action or treatment, short-term work-up or follow-up, or minor. A total of 211 incidental findings were present in 109 (75.7%) patients. Seventy-one incidental findings (33.6%) were cardiac and 140 (66.4%) were extracardiac. Most common cardiac incidental findings were atrial dilatation [39 patients, 48 incidental findings (67.6%)] and aortic valve calcifications (7 patients, 9.9%). Among the 140 extracardiac incidental findings, the most common were lung nodules (51 patients, 54 nodules, 38.6%), and emphysema (21 patients, 15%). Thirty-six (25.7%) extracardiac incidental findings were significant and notably, 23 (63.9%) were lung nodules. Follow-up was recommended in 37 cases, among which all patients with significant lung nodules (23 patients, 62.2%). In conclusion, most common computed tomography incidental findings in patients with coronary grafts were lung nodules and emphysema.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3168-1) contains supplementary material, which is available to authorized users.

Off-pump coronary artery bypass vs percutaneous coronary intervention. Therapeutic strategies for 3-vessel coronary artery disease: OPCAB vs PCI(PCI-Side)

Coronary artery bypass graft (CABG) surgery is still the best therapy for patients with multivessel and left main coronary artery disease. Recently, the introduction of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in these patients has improved the restenosis rate compared with bare metal stents. Furthermore, according to the results of the SYNTAX trial, no differences were found in the frequencies of mortality or myocardial infarction between CABG and PCI patients. PCI with DES is being increasingly performed for the treatment of patients with either left main trunk, diffuse, or multivessel lesions. In Japan, to avoid any side effects from cardiopulmonary bypass, off-pump coronary artery bypass (OPCAB) was performed in 66% of the total isolated CABG procedures in 2009, and is markedly different from the procedures performed in North America and Europe. However, the comparative effectiveness of PCI and OPCAB remains uncertain. In the present study, the current evidence from randomized trials, a meta-analysis and several observation studies are reviewed.

Increasing rates of angioplasty versus bypass surgery in Canada, 1994-2005

BACKGROUND

Percutaneous coronary intervention (PCI) is increasingly being offered to patients with coronary artery disease. The purpose of this study was to determine the impact of this change in coronary revascularization strategy on PCI and coronary artery bypass grafting (CABG) utilization across Canada.

METHODS

All cases of PCI and isolated CABG between years 1994 and 2005 were identified through the Canadian Institute for Health Information. Age- and sex-standardized rates of PCI and CABG per 100,000 population as well as PCI-to-CABG ratios were calculated by year and province and across age, sex, income, diabetes, and recent acute coronary syndrome subgroups. In addition, risk-adjusted rates of in-hospital mortality after PCI and CABG were reported by year.

RESULTS

Between 1994 and 2005, PCI rates increased from 85.6/100,000 to 186.7/100,000 (P < .001), whereas CABG rates remained stable (75.6/100,000-70.8/100,000; P = .43), resulting in an increase in PCI-to-CABG ratio (1.13-2.64; P < .001). Significant increases in PCI-to-CABG ratios were seen across all provinces (except Newfoundland and Alberta), as well as across all age, sex, income, diabetes, and recent acute coronary syndrome categories. Decline in risk-adjusted in-hospital mortality was seen after both CABG (3.9%-2.2%; P < .001) and PCI (1.6%-1.3%; P < .001) but appeared larger after CABG.

CONCLUSIONS

Since 1994, rates of PCI have increased significantly as compared to CABG. During the same period, greater declines in risk-adjusted rates of in-hospital mortality were seen among CABG versus PCI patients. Further study is needed to determine the appropriateness of PCI and CABG rates in terms of clinical outcomes and resource utilization.

Mid-term outcomes of off-pump versus on-pump coronary artery bypass graft surgery

OBJECTIVE

To evaluate survival and readmissions to hospital for cardiac events or coronary revascularization (REVASC) in patients having off-pump (OPCAB) versus conventional on-pump (CCAB) coronary artery bypass graft surgery (CABG).

METHODS

Of 11,368 consecutive patients undergoing isolated CABG between 1996 and 2002, 514 had OPCAB surgery. Using propensity scores, 503 CCAB patients were randomly matched to 503 OPCAB patients.

RESULTS

There were no clinical or statistical differences between the two groups for any prognostic variable. However, OPCAB patients received significantly fewer distal anastomoses than the CCAB group (2.6+/-1.0 versus 3.1+/-1.0; P<0.001). There was no difference in operative mortality (OPCAB 1.0%, CCAB 1.4%; P=0.6), but the OPCAB group had significantly fewer operative strokes (0.2% versus 1.8%; P=0.01). Follow-up was 99.7% complete at 2.2+/-1.2 years (range 0 to 6 years). Twice as many OPCAB patients (n=24) required REVASC compared with the CCAB (n=11) group. The following five-year actuarial outcomes are presented for CCAB and OPCAB, respectively: survival: 77+/-6%, 76+/-8%, P=0.8; freedom from REVASC: 95+/-3%, 92+/-2%, P=0.02; and cardiac event-free survival: 76+/-5%, 62+/-8%; P=0.05. Cox regression revealed that OPCAB was a significant independent predictor of poorer freedom from REVASC (RR 2.2, 95% CI 1.0 to 4.6; P=0.04) and cardiac event-free survival (RR 1.6, 95%CI 1.1 to 2.2; P=0.02).

CONCLUSIONS

The use of OPCAB remains controversial. These results, from this early experience, suggest that despite improved hospital outcomes, the lesser degree of REVASC raises concerns about the need for repeat revascularization in the OPCAB group.

Introduction of an OPCAB program aimed at total arterial grafting in a multidisciplinary setting: feasible and safe?

BACKGROUND

The feasibility and the results of the introduction of an off-pump coronary artery bypass (OPCAB) program aimed at total arterial revascularization in a multidisciplinary institution were analyzed. Uniform surgical and anesthetic protocols were established and applied throughout the study period.

METHODS

From March 2003--when the first OPCAB procedure of the program was performed--to July 2004, the data related to all the coronary artery bypass grafting procedures (N = 408) were prospectively recorded. The program was divided into two stages: the purpose of the first stage was to perform OPCAB in more than 90% of the patients, and that of the second stage was to proceed toward total arterial revascularization. The patients were grouped into four periods (102 patients for each period). Comparisons were performed with analysis of variance test and chi-square test where appropriate.

RESULTS

For periods 1 to 4, the number of OPCAB procedures was 65/102 (64%), 82/102 (80%), 97/102 (95%), and 99/102 (97%), respectively (p < 0.001). The number of conversions did not vary significantly throughout the study (overall: 7/408, 1.7%), neither did the number of bypass/patient (overall: 3.05 +/- 0.86). The number of arterial graft/patient was 1.03 +/- 0.64, 1.01 +/- 0.4, 1.29 +/- 0.64, and 2.56 +/- 1, respectively (p < 0.001). During the last period, 81% (253/312) of the grafts were arterial. Overall mortality was 4.6% (19/408). For the OPCAB group, mortality was 2.9% (10/343) and perioperative myocardial infarction rate was 1.5% (5/343) with no statistically significant difference between the periods.

CONCLUSIONS

With predefined standardized and coordinated protocols, an OPCAB program aimed at total arterial revascularization can be implemented rapidly and safely in a multidisciplinary setting.

A cost comparison of off-pump CABG versus on-pump CABG at one-year: The Canadian off-pump CABG registry

BACKGROUND

Evidence suggests that off-pump coronary artery bypass graft surgery (CABG) is as safe and effective as on-pump CABG, and the cost of initial hospitalization for off-pump CABG is less expensive than on-pump CABG. However, it is uncertain whether the cost savings are sustained over a longer period of time.

OBJECTIVE

To assess in-hospital and one-year direct medical costs of off-pump CABG versus on-pump CABG in the context of the Canadian health care system.

METHODS AND RESULTS

From March 2001 to December 2002, 1657 consecutive patients enrolled in the Canadian Off-Pump CABG Registry were compared with 1693 consecutive on-pump patients from Hamilton Health Sciences CABG database. At one year, patients of both groups were followed by telephone interview. An economic analysis was conducted from the perspective of the Ontario Ministry of Health and Long-Term Care, and the data analysis was based on propensity score-matched registry patients (1233 pairs) to ensure the comparability of the two study groups. Clinical event and resource use information was collected from all patients. Unit costs from the Hamilton Health Sciences case-costing system were used to estimate hospital costs; all costs were reported in 2003 Canadian dollars. Sensitivity analyses were performed to account for uncertainties. The cost of initial hospitalization for off-pump CABG was significantly less than on-pump CABG (11,744 dollars versus 13,720 dollars, P < 0.001). Although follow-up costs were similar between the groups, the one-year total cost per patient for off-pump CABG remained significantly less than on-pump CABG (12,063 dollars versus 14,141 dollars, P < 0.001).

CONCLUSION

Off-pump CABG offers significant savings during initial hospitalization that are also sustained after one year.

Atrial Fibrillation Ablation: Reaching the Mainstream

INTRODUCTION AND AIMS

Ablation of atrial fibrillation (AF) has evolved rapidly in the decade since its inception. We aimed to review the results of this evolution as reflected in the published literature.

METHODS

Publications through 2005 were reviewed, and data included if there was information on the technique used, and follow-up of at least 6 months.

RESULTS

More than 23,000 patients met criteria for inclusion. There has been a steady improvement in reported outcomes (P<0.001). Variations on radiofrequency catheter ablation for pulmonary vein isolation result in apparent elimination ("cure") or improvement of AF in 75%, and surgical techniques are even better.

CONCLUSIONS

Catheter ablation of AF is now a mainstream procedure. Continuing technical advances are needed to achieve better results with more uniformity and reduced procedure times.

Off-pump coronary artery bypass graft surgery: where should we stand?

Coronary artery bypass grafting (CABG) performed with cardiopulmonary bypass has become a well-established treatment modality for patients with coronary artery disease. However, there is increasing evidence that cardiopulmonary bypass may be responsible for some of the morbidity associated with CABG surgery. Thus, it has been proposed that CABG surgery would be safer if cardiopulmonary bypass could be avoided. The development of cardiac stabilization devices has allowed for the creation of safe and reproducible coronary anastomoses on the beating heart. Several large, non-randomized, retrospective case series have demonstrated that CABG surgery can be performed safely without cardiopulmonary bypass (off-pump) and have in fact suggested benefits when compared with conventional CABG. However, the randomized controlled studies published to date have, as a whole, been unable to conclusively demonstrate the advantages of off-pump surgery. Taken together, the evidence to date suggests that a large-scale, prospective, randomized trial may be required to resolve the dilemma.

A Novel Figure A-Shape Sternal Retractor for Off-Pump Coronary Artery Bypass Grafting

A novel figure A-shape sternal retractor was developed to avoid brachial plexus injury caused by sternal wide separation, and facilitate exposure of circumflex artery by elevating a rake and dropping the heart into the right pleural cavity during off-pump coronary artery bypass grafting. In addition, it has several notches to hold deep pericardial stitches in order to enhance the exposure.