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Dai Z, Chu H, Wang S, Liang Y. The effect of tranexamic acid to reduce blood loss and transfusion on off-pump coronary artery bypass surgery: A systematic review and cumulative meta-analysis. J Clin Anesth 2019; 44:23-31. [PMID: 29107853 DOI: 10.1016/j.jclinane.2017.10.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 10/10/2017] [Accepted: 10/14/2017] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE To assess the safety and efficacy of tranexamic acid (TA) on off-pump coronary artery bypass (OPCAB) surgery. DESIGN Meta-analysis. SETTING Operating room, OPCAB surgery, all surgeries were elective measurements. Searching the following data sources respectively: PubMed/MEDLINE, the Cochrane Library, EMBASE and reference lists of identified articles, we performed a meta-analysis of postoperative 24h blood loss, postoperative allogeneic transfusion, re-operation for massive bleeding, postoperative mortality, and postoperative thrombotic complications. MAIN RESULTS Using electronic databases, we selected 15 randomized control trials (RCTs), carried out between 2003 and 2016, with a total of 1250 patients for our review. TA significantly reduced the postoperative 24h blood loss (mean difference -213.32ml, 95% confidence intervals, -247.20ml to -179.43ml; P<0.0001). And, TA also significantly reduced the risk of packed red blood cell (PRBCs) transfusion (risk ratio 0.62; 95% confidence intervals 0.51 to 0.76; P<0.0001) and fresh frozen plasma (FFP) transfusion (0.65; 0.52 to 0.81; P<0.001). There were no statistical significance on platelet transfusion (risk difference -0.00, 95% confidence interval -0.02 to 0.02; P=0.73) and re-operation (0.00, -0.02 to 0.02; P=1.00). No association was found between TA and morbility (risk difference -0.00, 95% confidence interval -0.02 to 0.02; P=0.99) and thrombotic complications (-0.01, -0.01 to 0.02; P=0.70). CONCLUSIONS TA reduced the probability of receiving a PRBCs and FFP transfusion during OPCAB surgery. And no association with postoperative death and thrombotic events was found. However, further trials with an appropriate sample size are required to confirm TA safety in OPCAB surgery.
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Affiliation(s)
- Zhao Dai
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao 276000, China
| | - Haichen Chu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao 276000, China
| | - Shiduan Wang
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao 276000, China
| | - Yongxin Liang
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao 276000, China.
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Lin CH, Hsu RB. Which Procedure, or Which Patient? ACTA CARDIOLOGICA SINICA 2017; 33:551-552. [PMID: 28959110 DOI: 10.6515/acs20170626a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Cheng-Hsin Lin
- Department of Surgery, Shuang Ho Hospital, and College of Medicine, Taipei Medical University
| | - Ron-Bin Hsu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Nardi P, Pellegrino A, Bassano C, Mani R, Chiariello GA, Zeitani J, Chiariello L. The fate at mid-term follow-up of the on-pump vs. off-pump coronary artery bypass grafting surgery. J Cardiovasc Med (Hagerstown) 2014; 16:125-33. [PMID: 25022926 DOI: 10.2459/jcm.0000000000000041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS To evaluate the fate of on-pump coronary artery bypass grafting (ON-pump CABG) vs. off-pump coronary artery bypass grafting (OP-CABG) surgery at mid-term follow-up. METHODS From January 2008 to December 2010, 369 patients underwent surgical myocardial revascularization by means of OP-CABG techniques (n = 166) or with ON-pump CABG (n = 203). Data of the two groups of patients were retrospectively analyzed. RESULTS As compared with OP-CABG, in the ON-pump CABG patients, mean value of Logistic EuroSCORE (8.1 ± 7.8% vs. 6.2 ± 5.9%, P = 0.04), more extended coronary disease (2.7 ± 0.5 vs. 2.5 ± 0.7 diseased vessels/patient, P < 0.001) consequently requiring greater number of grafts/patient (2.9 ± 0.9 vs. 2.3 ± 0.9, P < 0.0001), and emergency surgery (12 vs. 6%, P = 0.03) were more frequently observed. Operative mortality was 1.9% in ON-pump CABG vs. 1.2% in OP-CABG (P = 0.6) and incidence of stroke 2.46 vs. 1.81% (P = 0.7). The incidence of stroke was reduced at 1.2% when OP-CABG PAS-Port 'clamp-less' technique was used.Intraoperatively, costs per patient were higher for OP-CABG vs. ON-pump CABG (1.930,00 +1.050,00 €, if PAS-port system was included, vs. 1.060,00 € for ON-pump surgery). ICU stay (1.9 ± 1.0 days vs. 1.4 ± 0.7 days) and total postoperative in-hospital stay (5.3 ± 3.3 days vs. 5.5 ± 3.5 days) were similar in both groups.At 4 years, survival (91 ± 13% in the ON-pump CABG vs. 84 ± 19% in the OP-CABG), freedom from major adverse cardiac events (composite end-point of all-cause death, myocardial infarction, and repeat coronary revascularization of the target lesion) (82 ± 9% vs. 76 ± 14%), and major adverse cardiac and cerebrovascular events (80 ± 11% vs. 72 ± 16%) were not significantly different. Freedom from late cardiac death was slightly significant higher after ON-pump CABG (98 ± 4% vs. 90 ± 10%, P = 0.05). CONCLUSION Mid-term freedom from composite end-points is similar after ON-pump CABG and OP-CABG. Freedom from cardiac death appears to be better after ON-pump CABG. OP-CABG needs for more expensive surgical technique. OP-CABG performed by an experienced surgical team using 'clamp-less' techniques can be an effective strategy in reducing postoperative stroke.
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Affiliation(s)
- Paolo Nardi
- Cardiac Surgery Unit, Policlinico Tor Vergata, Tor Vergata University of Rome, Rome, Italy
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Letsou GV, Wu YX, Grunkemeier G, Rampurwala MM, Kaiser L, Salaskar AL. Off-pump coronary artery bypass and avoidance of hypothermic cardiac arrest improves early left ventricular function in patients with systolic dysfunction. Eur J Cardiothorac Surg 2011; 40:227-32. [DOI: 10.1016/j.ejcts.2010.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 11/01/2010] [Accepted: 11/04/2010] [Indexed: 10/18/2022] Open
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Adler Ma SC, Brindle W, Burton G, Gallacher S, Hong FC, Manelius I, Smith A, Ho W, Alston RP, Bhattacharya K. Tranexamic acid is associated with less blood transfusion in off-pump coronary artery bypass graft surgery: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth 2010; 25:26-35. [PMID: 21115366 DOI: 10.1053/j.jvca.2010.08.012] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2010] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Tranexamic acid reduces blood loss and transfusion in on-pump coronary artery bypass graft (CABG) surgery. Compared with on-pump, off-pump surgery is associated with less blood loss and transfusion. Therefore, tranexamic acid may be less effective for off-pump surgery, and its safety profile may be different in this setting. The aim of this study was to determine the efficacy and safety of tranexamic acid for off-pump CABG surgery. DESIGN Systematic review and meta-analysis. SETTING University of Edinburgh. INTERVENTIONS The administration of tranexamic acid. METHODS A systematic review of randomized controlled trials administering tranexamic acid to patients undergoing off-pump CABG surgery. A meta-analysis of 24-hour blood loss, postoperative allogeneic transfusion, and thromboembolic events. MEASUREMENTS AND MAIN RESULTS Eight trials were identified. The lack of appropriate data limited the meta-analysis on blood loss. Tranexamic acid significantly reduced the overall risk of allogeneic blood component transfusion (risk ratio = 0.47; 95% confidence intervals, 0.33-0.66; p < 0.0001) and packed red blood cell transfusions (risk ratio = 0.51; 95% CI, 0.36-0.71; p = 0.0001). No association was found between tranexamic acid and myocardial infarction, stroke, or pulmonary embolism. Population sizes of meta-analyses ranged from 466 to 544. CONCLUSIONS Tranexamic acid reduces blood transfusion after off-pump surgery. Although no association with adverse events was found, the population sample size was too small to detect rare but clinically significant adverse events. A well-designed randomized controlled trial with an appropriate sample size is required to confirm tranexamic acid effectiveness and safety in off-pump CABG surgery.
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Affiliation(s)
- S C Adler Ma
- University of Edinburgh, College of Medicine and Veterinary Medicine, Edinburgh, United Kingdom.
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Peterson ED, Roe MT, Rumsfeld JS, Shaw RE, Brindis RG, Fonarow GC, Cannon CP. A call to ACTION (acute coronary treatment and intervention outcomes network): a national effort to promote timely clinical feedback and support continuous quality improvement for acute myocardial infarction. Circ Cardiovasc Qual Outcomes 2010; 2:491-9. [PMID: 20031882 DOI: 10.1161/circoutcomes.108.847145] [Citation(s) in RCA: 176] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a recognized need for a national unified registry to track presenting features, care, and outcomes for patients with acute myocardial infarction. To address this need, the American Heart Association's Get With the Guidelines-Coronary Artery Disease program joined the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry to create the National Cardiovascular Data Registry ACTION-Get With the Guidelines (AR-G) in June of 2008. This article outlines the objectives, operational structure, patient population, data elements, data collection methodology, and reporting components of this landmark registry. METHODS AND RESULTS The AR-G was launched in January of 2007. The registry is led by a team of volunteers from the American Heart Association and the American College of Cardiology, and its data coordinating center resides at the Duke Clinical Research Institute. As of December 2008, 344 US hospitals already contributed detailed clinical information on 103 890 myocardial infarction patients (inclusive of 39% ST-segment myocardial infarction and 61% non-ST-segment myocardial infarction patients). Overall data quality has been excellent, with <5% clinical fields missing. Site quality improvement efforts are supported via detailed quarterly feedback reports, routine web educational programs, and sharing of "best practice" clinical support tools. CONCLUSIONS The AR-G represents a unified, national, acute myocardial infarction registry and supports a robust quality improvement effort designed to encourage evidence-based acute myocardial infarction care and, ultimately, improve patient outcomes.
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Affiliation(s)
- Eric D Peterson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27705, USA.
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Shroff GR, Li S, Herzog CA. Survival of patients on dialysis having off-pump versus on-pump coronary artery bypass surgery in the United States. J Thorac Cardiovasc Surg 2009; 139:1333-8. [PMID: 19853864 DOI: 10.1016/j.jtcvs.2009.08.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Revised: 05/20/2009] [Accepted: 08/10/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Patients on dialysis sustain at least a threefold higher in-hospital mortality rate and markedly higher long-term mortality following coronary artery bypass graft surgery than the general population. Smaller studies have suggested that dialysis patients have superior outcomes with off-pump compared with on-pump coronary artery bypass surgery. METHODS From the United States Renal Data System database, 13,085 patients on dialysis having first coronary artery bypass surgery between 2001 and 2006 were identified. Of these, 2335 (17.8%) had off-pump coronary artery bypass surgery. The Kaplan-Meier method was used to estimate survival of patients having off-pump coronary artery bypass and patients having on-pump coronary artery bypass. A Cox proportional hazards model was used to assess effects of off-pump coronary artery bypass on mortality with adjustment for baseline patient characteristics. RESULTS Off-pump coronary artery bypass surgery was associated with significantly reduced all-cause mortality compared with on-pump coronary artery bypass surgery (hazard ratio 0.92, 95% confidence interval 0.86-0.99, P = .02). The observed survival benefit was most notable in the first year after surgery (70.3% vs 68.7%) and was lost 2 years after surgery (55.4% vs 55.2%). No difference was noted in the in-hospital mortality rate with off-pump coronary artery bypass surgery versus on-pump coronary artery bypass surgery (9.7% vs 11.0%, P = .06). Cardiac mortality during the follow-up period was similar (23.6% vs 23.8%; adjusted hazard ratio 0.95, 95% confidence interval 0.86-1.04, P = .26). Use of internal thoracic grafts was independently associated with improved survival after coronary artery bypass surgery (hazard ratio, 0.92; 95% confidence interval, 0.87-0.98, P = .0057). CONCLUSIONS Patients on dialysis sustain high in-hospital and 2-year mortality rates after coronary artery bypass surgery. Off-pump coronary artery bypass is associated with modestly increased survival compared with on-pump coronary artery bypass, a benefit most marked early after off-pump coronary artery bypass.
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Affiliation(s)
- Gautam R Shroff
- Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minn, USA
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Synchronous Carotid Endarterectomy and Off-pump Coronary Bypass: An Updated, Systematic Review of Early Outcomes. Eur J Vasc Endovasc Surg 2009; 37:375-8. [DOI: 10.1016/j.ejvs.2008.12.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Accepted: 12/16/2008] [Indexed: 11/18/2022]
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Hueb W, Lopes NHM, Gersh BJ, Castro CC, Paulitsch FS, Oliveira SA, Dallan LA, Hueb AC, Stolf NA, Ramires JAF. A randomized comparative study of patients undergoing myocardial revascularization with or without cardiopulmonary bypass surgery: The MASS III Trial. Trials 2008; 9:52. [PMID: 18755039 PMCID: PMC2553048 DOI: 10.1186/1745-6215-9-52] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Accepted: 08/28/2008] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED The MASS III Trial is a large project from a single institution, The Heart Institute of the University of Sao Paulo, Brazil (InCor), enrolling patients with coronary artery disease and preserved ventricular function. The aim of the MASS III Trial is to compare medical effectiveness, cerebral injury, quality of life, and the cost-effectiveness of coronary surgery with and without of cardiopulmonary bypass in patients with multivessel coronary disease referred for both strategies. The primary endpoint should be a composite of cardiovascular mortality, cerebrovascular accident, nonfatal myocardial infarction, and refractory angina requiring revascularization. The secondary end points in this trial include noncardiac mortality, presence and severity of angina, quality of life based on the SF-36 Questionnaire, and cost-effectiveness at discharge and at 5-year follow-up. In this scenario, we will analyze the cost of the initial procedure, hospital length of stay, resource utilization, repeat hospitalization, and repeat revascularization events during the follow-up. Exercise capacity will be assessed at 6-months, 12-months, and the end of follow-up. A neurocognitive evaluation will be assessed in a subset of subjects using the Brain Resource Center computerized neurocognitive battery. Furthermore, magnetic resonance imaging will be made to detect any cerebral injury before and after procedures in patients who undergo coronary artery surgery with and without cardiopulmonary bypass. TRIALS REGISTRATION Clinical Trial registration information ISRCTN59539154 Off-pump vs. on-pump surgery in patients with Stable CAD MASS III.
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Affiliation(s)
- Whady Hueb
- Department Clinical Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Neuza HM Lopes
- Department Clinical Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Bernard J Gersh
- Department Cardiovascular Diseases Mayo Clinic, Rochester, MN, USA
| | - Cláudio C Castro
- Department Clinical Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Felipe S Paulitsch
- Department Clinical Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Sergio A Oliveira
- Department Clinical Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Luis A Dallan
- Department Clinical Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Alexandre C Hueb
- Department Clinical Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Noedir A Stolf
- Department Clinical Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - José AF Ramires
- Department Clinical Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
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Hueb W, Lopes NH, Gersh BJ, Soares P, Machado LAC, Jatene FB, Oliveira SA, Ramires JAF. A randomized comparative study of patients undergoing myocardial revascularization with or without cardiopulmonary bypass surgery: The MASS III Trial. Circulation 2008; 115:1082-9. [PMID: 17339566 DOI: 10.1161/circulationaha.106.625475] [Citation(s) in RCA: 237] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
UNLABELLED The MASS III Trial is a large project from a single institution, The Heart Institute of the University of Sao Paulo, Brazil (InCor), enrolling patients with coronary artery disease and preserved ventricular function. The aim of the MASS III Trial is to compare medical effectiveness, cerebral injury, quality of life, and the cost-effectiveness of coronary surgery with and without of cardiopulmonary bypass in patients with multivessel coronary disease referred for both strategies. The primary endpoint should be a composite of cardiovascular mortality, cerebrovascular accident, nonfatal myocardial infarction, and refractory angina requiring revascularization. The secondary end points in this trial include noncardiac mortality, presence and severity of angina, quality of life based on the SF-36 Questionnaire, and cost-effectiveness at discharge and at 5-year follow-up. In this scenario, we will analyze the cost of the initial procedure, hospital length of stay, resource utilization, repeat hospitalization, and repeat revascularization events during the follow-up. Exercise capacity will be assessed at 6-months, 12-months, and the end of follow-up. A neurocognitive evaluation will be assessed in a subset of subjects using the Brain Resource Center computerized neurocognitive battery. Furthermore, magnetic resonance imaging will be made to detect any cerebral injury before and after procedures in patients who undergo coronary artery surgery with and without cardiopulmonary bypass. TRIALS REGISTRATION Clinical Trial registration information ISRCTN59539154 Off-pump vs. on-pump surgery in patients with Stable CAD MASS III.
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Affiliation(s)
- Whady Hueb
- Heart Institute of the University of São Paulo, São Paulo, Brazil.
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