Off-Pump Coronary Artery Bypass Grafting: 30 Years of Debate

10-Year Mortality of Off-Pump Versus On-Pump Coronary Artery Bypass Grafting: An Updated Systematic Review, Meta-Analysis, and Meta-Regression

The longstanding debate on off-pump coronary artery bypass grafting (OPCAB) versus on-pump coronary artery bypass grafting (ONCAB) has primarily focused on short-term and mid-term outcomes, with limited attention to long-term survival. This study aims to address this gap by providing an updated analysis of 10-year mortality rates after OPCAB versus ONCAB. We have conducted a systematic review and meta-analysis, incorporating 22 studies comprising 69,449 patients. The primary end point was all-cause mortality at 10 years. Meta-regression analysis explored sources of heterogeneity. The meta-analysis revealed no significant difference in long-term all-cause mortality between OPCAB and ONCAB (hazard ratio 1.000, 95% confidence interval 0.92 to 1.08, p = 0.95). Although substantial heterogeneity existed across studies, meta-regression identified older age as a significant factor favoring OPCAB. However, patient characteristics like gender, co-morbidities, and graft numbers did not significantly influence the choice of surgical technique. In conclusion, this study challenges historical concerns regarding OPCAB's quality of revascularization and long-term survival demonstrating comparable outcomes to ONCAB in well-selected patients when performed by experienced surgeons. The results emphasize the importance of surgeon proficiency and advocate for recognizing surgical revascularization as a subspecialty.

Novel Strategies to Improve the Cardioprotective Effects of Cardioplegia

The use of cardioprotective strategies as adjuvants of cardioplegic solutions has become an ideal alternative for the improvement of post-surgery heart recovery. The choice of the optimal cardioplegia, as well as its distribution mechanism, remains controversial in the field of cardiovascular surgery. There is still a need to search for new and better cardioprotective methods during cardioplegic procedures. New techniques for the management of cardiovascular complications during cardioplegia have evolved with new alternatives and additives, and each new strategy provides a tool to neutralize the damage after ischemia/reperfusion events. Researchers and clinicians have committed themselves to studying the effect of new strategies and adjuvant components with the potential to improve the cardioprotective effect of cardioplegic solutions in preventing myocardial ischemia/reperfusion-induced injury during cardiac surgery. The aim of this review is to explore the different types of cardioplegia, their protection mechanisms, and which strategies have been proposed to enhance the function of these solutions in hearts exposed to cardiovascular pathologies that require surgical alternatives for their corrective progression.

Nomogram for predicting major bleeding after off-pump coronary artery bypass grafting

OBJECTIVE

The purpose of this investigation is to develop a novel nomogram for predicting major bleeding following off-pump coronary artery bypass grafting (CABG).

METHODS

Between January 2012 and December 2022, 541 patients who underwent off-pump isolated primary CABG were included in a retrospective analysis. The primary outcome measure after off-pump CABG was major bleeding. Based on the outcomes of a multivariate analysis, nomograms were constructed. Using receiver operating characteristic analysis and calibration, the predictive accuracy of the nomograms was assessed. Using decision curve analysis (DCA), the clinical benefit of the nomograms was determined.

RESULTS

We categorized 399 and 142 patients in the "no major bleeding group" and "major bleeding group", respectively. Age (odds ratio (OR) 1.038; 95% confidence interval (CI) 1.009-1.068; p = 0.009), body mass index (OR 0.913; 95% CI 0.849-0.982; p = 0.014), hemoglobin (OR 0.958; 95% CI 0.945-0.971; p < 0.001), sodium (OR 0.873; 95% CI 0.807-0.945; p = 0.001), blood urea nitrogen (OR 1.198; 95% CI 1.073-1.338; p = 0.001), and operation time (OR 1.012; 95% CI 1.008-1.017; p < 0.001) were independent predictors for major bleeding after off-pump CABG. The model based on independent predictors exhibited excellent discrimination and calibration, with good agreement between actual and nomogram-estimated probabilities of generalization. DCA demonstrated that nomogram-assisted decisions have a greater positive benefit than treating all patients or none.

CONCLUSIONS

The plotted nomogram accurately predicted major bleeding outcomes following off-pump CABG and may therefore contribute to clinical decision-making, patient treatment, and consultation services.

Sex-differences in outcome after off-pump coronary artery bypass grafting is age-dependent; data from the Netherlands Heart Registration

Background

Women are known to have worse outcome after coronary artery bypass grafting (CABG) than men. Studies have shown that off-pump coronary artery bypass grafting (OPCAB) might benefit higher-risk patients, and therefore might also benefit women. We aimed to determine differences in early and late outcomes between sexes after OPCAB.

Methods

Data from all patients undergoing OPCAB, between 2013 through 2021 was retrieved from the Netherlands Heart Registration (NHR) database. Primary outcomes were early mortality, morbidity and late survival. We divided the population into subgroups based on age (aged ≥70 years or < 70 years) and sex.

Results

This study included 8,487 men and 2,170 women (total = 10,657). Female patients received fewer anastomoses (mean (SD)) women 2.38 (1.17) vs men 2.68 (1.23), p < 0.001) and total arterial revascularization was performed less frequently in women than in men (21.3 % versus 29.5 % respectively, p < 0.001).In the subgroup of patients <70 years, early mortality was 1.7 % in women and 0.6 % in men (p < 0.001). Survival rate at 5 years was 88.4 % in women and 91.1 % in men (p < 0.001). Female sex was associated with worse late survival in the subgroup <70 years (HR (95 % CI) 1.42 (1.10-1.83) p = 0.008).

Conclusions

Sex-differences in outcome after CABG persists in OPCAB surgery. However, these differences are solely present in the younger subgroup. In our data, women undergoing OPCAB surgery seem to be treated differently during surgery as compared to their male counter parts, further research is needed to analyze this finding.

Percutaneous coronary intervention versus coronary artery by-pass grafting in premature coronary artery disease: What is the evidence? -A narrative review

Coronary artery disease (CAD) remains one of the leading causes of death globally. In the United States of America, in 2016, 19% of all patients under the age of 65 died of cardiovascular disease despite improvements in primary prevention. The premature clinical onset of symptoms in the young population (<60 years) is much more aggressive than in the older population, and the overall long-term prognosis is poor. CAD appears to have a rapidly progressive form in those under the age of 60 due to genetic predisposition, smoking, and substance abuse, however, the ideal management strategy is still yet to be established. The two primary methods of establishing coronary revascularization are percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). Despite the increasing prevalence of CAD in the young population, they are consistently underrepresented in major randomized clinical trials of each revascularization strategy. Both CABG and PCI are known to have similar survival rates, but PCI is associated with higher repeat revascularization rate. Many argue this may be due to the progressive nature of CAD combined with the vessel patency time required in a patient under 60 with potentially another 20-30 years of life. There is little in literature regarding the outcomes of these various revascularization strategies in populations under 60 years with CAD. This review summarises the current evidence for each revascularisation strategy in patients under the age of 60 and suggests future avenues of research for this unique age group.

On- vs. Off-Pump CABG in Heart Failure Patients with Reduced Ejection Fraction (HFrEF): A Multicenter Analysis

OBJECTIVE

This study aimed to compare postoperative outcomes and 30-day mortality in patients with reduced ejection fraction (<40%) who underwent isolated coronary artery bypass grafting (CABG) with (ONCAB) and without (OPCAB) the use of cardiopulmonary bypass.

METHODS

data from four university hospitals in Germany, spanning from January 2017 to December 2021, were retrospectively analyzed. A total of 551 patients were included in the study, and various demographic, intraoperative, and postoperative data were compared.

RESULTS

demographic parameters did not exhibit any differences. However, the OPCAB group displayed notably higher rates of preoperative renal insufficiency, urgent surgeries, and elevated EuroScore II and STS score. During surgery, the ONCAB group showed a significantly higher rate of complete revascularization, whereas the OPCAB group required fewer intraoperative transfusions. No disparities were observed in 30-day/in-hospital mortality for the entire cohort and the matched population between the two groups. Subsequent to surgery, the OPCAB group demonstrated significantly shorter mechanical ventilation times, reduced stays in the intensive care unit, and lower occurrences of ECLS therapy, acute kidney injury, delirium, and sepsis.

CONCLUSIONS

the study's findings indicate that OPCAB surgery presents a safe and viable alternative, yielding improved postoperative outcomes in this specific patient population compared to ONCAB surgery. Despite comparable 30-day/in-hospital mortality rates, OPCAB patients enjoyed advantages such as decreased mechanical ventilation durations, shorter ICU stays, and reduced incidences of ECLS therapy, acute kidney injury, delirium, and sepsis. These results underscore the potential benefits of employing OPCAB as a treatment approach for patients with coronary heart disease and reduced ejection fraction.

Impact of on-pump and off-pump coronary artery bypass grafting on 10-year mortality versus percutaneous coronary intervention

OBJECTIVES

The very long-term mortality of off-pump and on-pump coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in a randomized complex coronary artery disease population is unknown. This study aims to investigate the impact of on-pump and off-pump CABG versus PCI on 10-year all-cause mortality.

METHODS

The SYNTAX trial randomized 1800 patients with three-vessel and/or left main coronary artery disease to PCI or CABG and assessed their survival at 10 years. In this sub-study, the hazard of mortality over 10 years was compared according to the technique of revascularization: on-pump CABG (n = 725), off-pump CABG (n = 128) and PCI (n = 903).

RESULTS

There was substantial inter-site variation in the use of off-pump CABG despite baseline characteristics being largely homogeneous among the 3 groups. The crude rate of mortality was significantly lower following on-pump CABG versus PCI [25.6% vs 28.4%, hazard ratio (HR) 0.79, 95% confidence interval (CI) 0.65-0.96], while it was comparable between off-pump CABG and PCI (28.5% vs 28.4%, HR 0.98, 95% CI 0.69-1.40). After adjusting for the 9 variables included in the SYNTAX score II 2020, 10-year mortality remained significantly lower with on-pump CABG than PCI (HR 0.75 against PCI, P = 0.009).

CONCLUSIONS

In the SYNTAXES trial, 10-year mortality adjusted for major confounders was significantly lower following on-pump CABG compared to PCI. There was no evidence for unadjusted difference between off-pump CABG and PCI, although the unadjusted estimated HR had a wide CI. Site heterogeneity in the technique used in bypass surgery has had measurable effects on treatment performance.

Early and midterm outcomes after off pump coronary artery bypass surgery

Purpose

There has been debate whether off pump coronary artery bypass surgery (OPCAB) has results comparable to conventional on pump bypass surgery. This has led to the low uptake of OPCAB in the West. In India, OPCAB is the default mode of coronary revascularization. However, there is scarce data on mid-term outcomes of OPCAB in our patients. This study aims to evaluate both short and mid-term mortality and analyze factors associated with mortality.

Methods

This is a single center study of all consecutive patients undergoing isolated OPCAB from October 2014 to December 2019. Patient data was collected from hospital records and follow-up was from the hospital electronic medical records and telephone interviews. Mortality and factors contributing to survival were analyzed.

Results

Operative mortality was 2.3%. Mid-term mortality was 5.5%. Preoperative renal dysfunction, post-operative renal failure, use of the intra-aortic balloon pump (IABP), re-exploration for bleeding, postoperative stroke, ventilation > 24 h, and postoperative atrial fibrillation were associated with operative mortality. Factors associated with mid-term mortality were age > 62 years, postoperative renal failure, IABP usage, ventilation time > 24 h, and postoperative atrial fibrillation. The mean survival time was 2343.55 + / - 15.27 days and 6-year survival was 88.7%.

Conclusion

OPCAB can safely be performed with satisfactory short and mid-term outcomes. Further corroborative studies from different regions of the country or a multi-center study will help to establish the suitability of the technique in Indian patients.

Systemic Immune-Inflammation Index Predicts Prolonged Mechanical Ventilation and Intensive Care Unit Stay After off-Pump Coronary Artery Bypass Graft Surgery: A Single-Center Retrospective Study

Purpose

Coronary artery disease (CAD) is the primary cause of mortality in developing countries. Off-pump coronary artery bypass grafting (OPCAB) offers more upside in revascularization by preventing cardiopulmonary bypass trauma and minimizing aortic manipulation. Even though cardiopulmonary bypass is not involved, OPCAB still causes a significant systemic inflammatory response. This study determines the prognostic values of the systemic immune-inflammation index (SII) towards perioperative outcomes in patients who underwent OPCAB surgery.

Patients and methods

This was a single-center retrospective study at the National Cardiovascular Center Harapan Kita, Jakarta, using secondary data from electronic medical records and medical record archives of all patients who underwent OPCAB from January 2019 through December 2021. A total of 418 medical records were obtained, and 47 patients were excluded based on the exclusion criteria. The values of SII were calculated from preoperative laboratory data of segmental neutrophil count, lymphocyte count, and platelet count. Patients were divided into two groups based on the SII cutoff value of 878.056 x 10³/mm³.

Results

The baseline SII values of 371 patients were calculated, among which 63 (17%) patients had preoperative SII values of ≥878.057 x 10³/mm³. High SII values were a significant predictor of prolonged ventilation (RR 1.141, 95% CI 1.001-1.301) and prolonged ICU stay (RR 1.218, 95% CI 1.021-1.452) after OPCAB surgery. A positive correlation was observed between SII and hospital length of stay after OPCAB surgery. From the receiver operating characteristic curve analysis, SII predicted prolonged ventilation duration, with an area under the curve of 0.658 (95% CI 0.575-0.741, p = 0.001).

Conclusion

High preoperative SII values are capable of predicting prolonged mechanical ventilation and intensive care unit stay after OPCAB surgery.

Rapid cardiac ischemia detection with an epicardial graphene probe

Introduction

In this study, a new probe was designed to enable electrocardiography of a rotated heart during cardiac surgery when skin electrodes became non-functional. This probe adhered non-invasively to the epicardium and collected the ECG signal independently from the position of the heart. The study compared the accuracy of cardiac ischemia detection between classic skin and epicardial electrodes in an animal model.

Methods

Using six pigs, an open chest model was devised with cardiac ischemia induction by coronary artery ligation in two non-physiologic heart positions. Both the accuracy and the time of detection of electrocardiographic symptoms of acute cardiac ischemia were compared between skin and epicardial methods of signal collection.

Results

Heart rotation to expose either the anterior or the posterior wall resulted in a distortion or loss of the ECG signal collected by skin electrodes after coronary artery ligation, standard skin ECG monitoring did not reveal any ischemia symptoms. Attachment of an epicardial probe on the anterior and posterior walls helped in the recovery of the normal ECG wave. After ligation of the coronary artery, the epicardial probes recorded cardiac ischemia within 40 s.

Discussion

This study highlighted the effectiveness of ECG monitoring with epicardial probes in a rotated heart. It can be concluded that epicardial probes can detect the presence of acute ischemia of a rotated heart when skin ECG monitoring becomes ineffective.

The outcomes of three different techniques of coronary artery bypass grafting: On-pump arrested heart, on-pump beating heart, and off-pump

OBJECTIVE

Conventional coronary artery bypass grafting (CABG) or on-pump arrested heart CABG (ONCAB) is a standard and simple technique. However, adverse effects can occur due to the use of aortic cross-clamp and cardiopulmonary bypass. Performing off-pump CABG (OPCAB) aims to avoid these adverse effects but may result in incomplete revascularization. On-pump beating heart CABG (ONBHCAB) combines the benefits of both ONCAB and OPCAB. This study focuses on comparing the short- and long-term outcomes of different CABG techniques.

METHOD

Retrospective observational cohort included 2,028 patients who underwent ONCAB, OPCAB, and ONBHCAB. The short-term outcomes including postoperative ischemic injury, hemodynamic functions, and adverse events were compared. The long-term outcomes were overall survival and the occurrence of major adverse cardiovascular events (MACE). Propensity score matching ensured comparability among the three patient groups.

RESULTS

After matching, there were no differences in baseline characteristics. Regarding ischemic injury, OPCAB showed the lowest peak cardiac enzyme levels (all p≤0.001). There were no statistically significant differences in the change of hemodynamic function (cardiac index) between the three groups (p = 0.158). Ten-year survival for OPCAB, ONBHCAB, and ONCAB were 80.5%, 75.9%, and 73.7%, respectively. OPCAB was associated with a significant reduction in mortality risk and MACE when compared to others (Mortality HR = 0.33, p = 0.001, MACE HR = 0.52, p = 0.004).

CONCLUSION

OPCAB implementation resulted in a lower occurrence of postoperative ischemic injury than ONCAB and ONBHCAB. No differences in postoperative hemodynamic function in all three techniques were observed. OPCAB respectively were preferable techniques beneficial for long-term outcomes.

Current concepts in coronary artery revascularisation

Coronary artery revascularisation can be performed surgically or percutaneously. Surgery is associated with higher procedural risk and longer recovery than percutaneous interventions, but with long-term reduction of recurrent cardiac events. For many patients with obstructive coronary artery disease in need of revascularisation, surgical or percutaneous intervention is indicated on the basis of clinical and anatomical reasons or personal preferences. Medical therapy is a crucial accompaniment to coronary revascularisation, and data suggest that, in some subsets of patients, medical therapy alone might achieve similar results to coronary revascularisation. Most revascularisation data are based on prevalently White, non-elderly, male populations in high-income countries; robust data in women, older adults, and racial and other minorities, and from low-income and middle-income countries, are urgently needed.

Sex-Associated Differences in Short-Term Outcomes in Patients with Deep Sternal Wound Infection after Open-Heart Surgery

Deep sternal wound infection (DSWI) is a feared complication after cardiac surgery. The impact of sex-related differences on wound infection prevalence is poorly understood. Our aim was to evaluate the effect of sex on short-term outcomes in patients with DSWI after open-heart surgery. The study was a retrospective cohort study. A total of 217 patients with DSWI were identified and retrospectively analyzed using our institutional database. Patients were divided into two groups: males (n = 150) and females (n = 67). This study also includes a propensity score based matching (PSM) analysis (male group (n = 62) and female group (n = 62)) to examine the unequal groups. Mean age (p = 0.088) and mean body mass index (BMI) (p = 0.905) did not significantly differ between both groups. Vacuum assisted closure (VAC) therapy was performed among most patients (82.3% (male group) vs. 83.9% (female group), p = 0.432). The most commonly isolated bacteria from the wounds were Staphylococcus epidermidis and Staphylococcus aureus in both groups. Acute renal failure was significantly higher (p = 0.010) in the male group compared to the female group. However, dialysis rate did not significantly differ (p = 0.491) between male and female groups. Further secondary outcomes showed no major differences between the groups. Likewise, in-hospital mortality rate did not differ significantly (p = 0.680) between both groups. Based on our data, sex has no impact on deep wound infection prevalence after cardiac surgery.

Experience, exposure, and attitudes regarding off-pump coronary artery bypass grafting techniques in US cardiothoracic surgical residents: Results of a survey

Background

We sought to determine the current level of exposure to and interest in off-pump coronary artery bypass and beating heart surgery techniques regarding cardiothoracic surgical residents in the United States.

Methods

An email survey consisting of 6 questions was sent to all cardiothoracic surgery residents of approved cardiothoracic training programs in the United States. The survey was emailed using the Qualtrics XM cloud-based survey platform. When the email responses were received, the answers to the survey questions were tabulated by the Qualtrics software and the resident's institution and year of graduation from their residency was noted.

Results

Of 400 surveys sent, we received 99 responses for a response rate of 25%. A total of 78% of cardiothoracic surgery residents reported that they are at programs that do off-pump coronary artery bypass or beating heart surgery infrequently, noting that these cases are done in less than 5% of the coronary artery bypass graftings to which they are exposed. A total of 51% responded that they do not feel comfortable with off-pump coronary artery bypass grafting under any circumstances. A total of 49% reported some comfort with the technique with most of these respondents noting that they would do off-pump coronary artery bypass or beating heart surgery on a selective basis if the clinical situation arose and 4% plan to do off-pump coronary artery bypass routinely. Exposure to off-pump coronary artery bypass and beating heart surgery significantly correlated with future adoption of the technique by the cardiothoracic surgery residents. Cardiothoracic surgery residents in the lowest, middle, and highest terciles of exposure to off-pump coronary artery bypass and beating heart surgery plan to use these techniques 31%, 86%, and 75%, respectively, in selective cases when they are in independent practice.

Conclusions

Over half of graduating cardiothoracic surgery residents do not feel comfortable with off-pump coronary artery bypass or beating heart surgery techniques. Exposure to these techniques in training correlates with comfort level and plans to use them in independent practice.

CALA: Cumulative Volume of Calcified Lesions of the Aorta in Cardiac Surgery

One of the major key questions raised in this retrospective study was to identify any correlation of atherosclerotic plaque volume of the ascending aorta and aortic arch with adverse events such as postoperative stroke, critical illness polyneuropathy and myopathy, as well as delirium and all-cause in-hospital mortality. In a second phase of this study, we investigated the relationship between atherosclerotic plaque volume and adverse events regarding the construction of proximal anastomosis on coronary artery bypass grafting procedures using different clamping techniques such as construction of anastomosis on cross-clamping or cross-clamping plus consecutive partial clamping of the aorta. The key findings of our research were that the size of calcium lesions of the ascending aorta and aortic arch correlates with early mortality, critical illness polyneuropathy/myopathy, and delirium but not with stroke. On the other hand, there were no significant differences between isolated cross-clamping versus cross-clamping plus consecutive partial clamping of the aorta regarding the primary adverse events by means of mean plaque volume.

Coronary artery bypass surgery for acute coronary syndrome: A network meta-analysis of on-pump cardioplegic arrest, off-pump, and on-pump beating heart strategies

BACKGROUND

Coronary artery bypass grafting (CABG) in the setting of an acute coronary syndrome is a high-risk procedure, and the best strategy for myocardial revascularisation remains debated. This study compares the 30-day mortality benefit of on-pump CABG (ONCAB), off-pump CABG (OPCAB), and on-pump beating heart CABG (OnBHCAB) strategies.

METHODS

A systematic search of three electronic databases was conducted for studies comparing ONCAB with OPCAB or OnBHCAB in patients with acute coronary syndrome (ACS). The primary outcome, 30-day mortality, was compared using a Bayesian hierarchical network meta-analysis (NMA). A random effects consistency model was applied, and direct and indirect comparisons were made to determine the relative effectiveness of each strategy on postoperative outcomes.

RESULTS

One randomised controlled trial and eighteen observational studies fulfilling the inclusion criteria were identified. A total of 4320, 5559, and 1962 patients underwent ONCAB, OPCAB, and OnBHCAB respectively. NMA showed that OPCAB had the highest probability of ranking as the most effective treatment in terms of 30-day mortality (odds ratio [OR], 0.50; 95% credible interval [CrI], 0.23-1.00), followed by OnBHCAB (OR, 0.62; 95% CrI, 0.20-1.57), however the 95% CrI crossed or included unity. A subgroup NMA of nine studies assessing only acute myocardial infarction (AMI) patients demonstrated a 72% reduction in likelihood of 30-day mortality after OPCAB (CrI, 0.07-0.83). No significant increase in rate of stroke, renal dysfunction or length of intensive care unit stay was found for either strategy.

CONCLUSIONS

Although no single best surgical revascularisation approach in ACS patients was identified, the significant mortality benefit with OPCAB seen with AMI suggests high acuity patients may benefit most from avoiding further myocardial injury associated with cardiopulmonary bypass and cardioplegic arrest.

High-Sensitivity Cardiac Troponin T in Prediction and Diagnosis of Early Postoperative Hypoxemia after Off-Pump Coronary Artery Bypass Grafting

To investigate the relationship of preoperative high-sensitivity cardiac troponin T (hs-cTnT) with early postoperative hypoxemia (EPH) following off-pump coronary artery bypass grafting (OPCAB). Records of patients undergoing OPCAB between 2018 and 2022 were reviewed. Baseline characteristics and postoperative arterial blood gas analysis were derived from the cardiovascular surgery electronic medical records. Preoperative hs-cTnT levels were measured routinely in all patients. Logistic regression analyses were performed to test the association of preoperative hs-cTnT with EPH. A total of 318 OPCAB patients were included, who had a preoperative hs-cTnT test available for review. Before surgery, 198 patients (62%) had a rise in hs-cTnT level (≥14 ng/L) and 127 patients (40%) had a more severe hs-cTnT level (≥25 ng/L). The preoperative hs-cTnT level was associated with EPH (odds ratio per ng/L, 1.86; 95% confidence interval 1.30−2.68; p < 0.001), prolonged intensive care unit stay (odds ratio, 1.58; 95% confidence interval 1.08−2.32; p = 0.019), and delayed extubating time (odds ratio, 1.63; 95% confidence interval 1.15−2.34; p = 0.007). On multivariable analysis, adjusted for BMI, hypertension, smoking status, serum creatinine, and cardiac function, preoperative hs-cTnT remained an independent factor associated with EPH. Elevation of hs-cTnT concentrations are significantly associated with EPH after OPCAB. Review of presurgical hs-cTnT concentration may help identify patients who would benefit from OPCAB to improve surgical risk assessment.

Effects of inflammation and oxidative stress on postoperative delirium in cardiac surgery

The past decade has witnessed unprecedented medical progress, which has translated into cardiac surgery being increasingly common and safe. However, complications such as postoperative delirium remain a major concern. Although the pathophysiological changes of delirium after cardiac surgery remain poorly understood, it is widely thought that inflammation and oxidative stress may be potential triggers of delirium. The development of delirium following cardiac surgery is associated with perioperative risk factors. Multiple interventions are being explored to prevent and treat delirium. Therefore, research on the potential role of biomarkers in delirium as well as identification of perioperative risk factors and pharmacological interventions are necessary to mitigate the development of delirium.

Left main coronary disease: evolving management concepts

Remarkable advances in the management of coronary artery disease have enhanced our approach to left main coronary artery (LMCA) disease. The traditional role of coronary artery bypass graft surgery has been challenged by the less invasive percutaneous coronary interventional approach. Additionally, major strides in optimal medical therapy now provide a rich menu of treatment choices in selected circumstances. Although a LMCA stenosis >70% is an acceptable threshold for revascularization, those patients with a LMCA narrowing between 40 and 69% present a more complex scenario. This review examines the relative merits of the different treatment options, addresses key diagnostic and therapeutic unknowns, and identifies future work likely to advance progress.

Efficacy of early goal-directed therapy using FloTrac/EV1000 to improve postoperative outcomes in patients undergoing off-pump coronary artery bypass surgery: a randomized controlled trial

Background

Early goal-directed therapy (EGDT) using FloTrac reduced length of stay (LOS) in intensive care (ICU) and hospital among patients undergoing coronary artery bypass graft (CABG) with a cardiopulmonary bypass. However, this platform in off-pump CABG (OPCAB) has received scant attention, so we evaluated the efficacy of EGDT using FloTrac/EV1000 as a modality for improving postoperative outcomes in patients undergoing OPCAB.

Methods

Forty patients undergoing OPCAB were randomized to the EV1000 or Control group. The Control group received fluid, inotropic, or vasoactive drugs (at the discretion of the attending anesthesiologist) to maintain a mean arterial pressure 65–90 mmHg; central venous pressure 8–12 mmHg; urine output ≥ 0.5 mL kg⁻¹ h⁻¹; SpO₂ > 95%; and hematocrit ≥ 30%. The EV1000 group achieved identical targets using information from the FloTrac/EV1000. The goals included stroke volume variation < 13%; cardiac index (CI) of 2.2–4.0 L min⁻¹ m⁻²; and systemic vascular resistance index of 1500–2500 dynes s⁻¹ cm⁻⁵ m⁻².

Results

The EV1000 group had a shorter LOS in ICU (mean difference − 1.3 d, 95% CI − 1.8 to − 0.8; P < 0.001). The ventilator time for both groups was comparable (P = 0.316), but the hospital stay for the EV1000 group was shorter (mean difference − 1.4 d, 95% CI − 2.1 to − 0.6; P < 0.001).

Conclusions

EGDT using FloTrac/EV1000 compared to conventional protocol reduces LOS in ICU and hospital among patients undergoing OPCAB.

Trial registration This study was retrospectively registered at www.ClinicalTrials.gov (NCT04292951) on 3 March 2020.

Off-pump or on-pump coronary artery bypass at 30 days: A propensity matched analysis

Introduction

This study was to determine whether coronary artery bypass grafting without cardiopulmonary bypass (off-pump CABG, OPCAB) could reduce early postoperative mortality and major complications compared with conventional coronary artery bypass grafting with cardiopulmonary bypass (on-pump CABG, ONCAB) by experienced surgeons.

Material and methods

From January 2016 to June 2020, isolated CABG was performed in 1200 patients (ONCAB 429, OPCAB 771) in Wuhan Union Hospital. The propensity score matching was used to adjust for differences in baseline characteristics between the ONCABG and OPCABG groups. After 1:1 matching, 404 pairs for each group were selected to compare outcomes within 30 days after surgery. All the operations were completed by experienced surgeons that had completed more than 500 on-pump and 200 off-pump CABG, respectively.

Results

After propensity matching, the two groups were comparable in terms of preoperative characteristics. The OPCAB group had less vein graft (2.5 ± 1.0 vs. 2.7 ± 0.9; P &lt; 0.001) and a higher rate of incomplete revascularization (12.4 vs. 8.2%; P &lt; 0.049) than the ONCAB group. There was no significant difference in early postoperative mortality between ONCAB and OPCAB groups (2.2 vs. 2.2%; P = 1.00). However, patients in the OPCAB group had a lower risk of postoperative stroke (1.5 vs. 4.7%; P = 0.008), new-onset renal insufficiency (8.9 vs. 18.8%; P &lt; 0.001), respiratory failure (2.2 vs. 7.2%; P = 0.001), reoperation for bleeding (0.5 vs. 2.7%; P = 0.001), and required less ventilator assistance time (33.4 ± 37.9 h vs. 51.0 ± 66.1 h; P &lt; 0.001) and intensive care unit (ICU) time (3.7 ± 2.7 days vs. 4.8 ± 4.3 days; P &lt; 0.001).

Conclusions

In our study, patients undergoing OPCAB had fewer postoperative complications and a faster recovery. It is a feasible and safe surgical approach to achieve revascularization when performed by experienced surgeons.

Influence of Baseline HbA1c and Antiplatelet Therapy on 1-Year Vein Graft Outcome

BACKGROUND

The influence of baseline HbA1c levels on vein graft outcomes post coronary artery bypass grafting (CABG) remains unclear.

OBJECTIVE

The purpose of this study was to assess the association between baseline HbA1c and 1-year vein graft patency, and the effects of antiplatelet therapy on the 1-year vein graft patency after CABG in patients with baseline HbA1c <6.5% vs ≥6.5%.

METHODS

We examined the subgroups with baseline HbA1c <6.5% vs ≥6.5% from the DACAB trial (NCT02201771), in which 500 patients were randomly allocated to receive ticagrelor plus aspirin (T+A), ticagrelor alone (T), or aspirin alone (A) for 1 year after CABG. The primary outcome was the vein graft patency (FitzGibbon grade A) at 1 year.

RESULTS

A total of 405 patients with available baseline HbA1c data were included in this subgroup analysis. Of them, there were 233 patients (678 vein grafts) with baseline HbA1c <6.5% and 172 patients (512 vein grafts) with baseline HbA1c ≥6.5%. Compared with the HbA1c <6.5% subgroup, the HbA1c ≥6.5% subgroup showed worse 1-year vein graft patency (adjusted odds ratio [OR] for nonpatency: 1.69, 95% confidence interval [CI]: 1.08-2.64). T+A showed higher vein graft patency than A in both HbA1c <6.5% (adjusted OR for nonpatency: 0.34, 95% CI: 0.15-0.75) and HbA1c ≥6.5% subgroups (adjusted OR for nonpatency: 0.45, 95% CI: 0.19-1.09), without an interaction effect (P for interaction = 0.335), whereas T did not show more significant improvement than A in both subgroups.

CONCLUSIONS

In the DACAB trial, lower baseline HbA1c was associated with higher vein graft patency 1 year after CABG. T+A improved 1-year vein graft patency vs A, irrespective of baseline HbA1c.

Off-Pump Coronary Artery Bypass Grafting: Department of Veteran Affairs' Use and Outcomes

Background Coronary artery bypass can be performed off pump (OPCAB) without cardiopulmonary bypass. However, trends over time for OPCAB versus on-pump (ONCAB) use and long-term outcome has not been reported, nor has their long-term outcome been compared. Methods and Results We queried the national Veterans Affairs database (2005-2019) to identify isolated coronary artery bypass procedures. Procedures were classified as OPCAB on ONCAB using the as-treated basis. Trend analyses were performed to evaluate longitudinal changes in the preference for OPCAB. The median follow-up period was 6.6 (3.5-10) years. An inverse probability weighted Cox model was used to compare all-cause mortality between OPCAB and ONCAB. From 47 685 patients, 6759 (age 64±8 years) received OPCAB (14%). OPCAB usage declined from 16% (2005-2009) to 8% (2015-2019). Patients with triple vessel disease who received OPCAB received a lower mean number of grafts (2.8±0.8 versus 3.2±0.8; P<0.01). The ONCAB 5-, 10-, and 15-year survival rates were 82.9% (82.5-83.3), 60.4% (59.8-61.1), and 37.2% (36.1-38.4); correspondingly, OPCAB rates were 80.7% (79.7-81.7), 57.4% (56-58.7), and 34.1% (31.7-36.6) (P<0.01). OPCAB was associated with increased risk-adjusted all-cause mortality (hazard ratio, 1.15 [1.13-1.18]; P<0.01) and myocardial infarction (incident rate ratio, 1.16 [1.05-1.28]; P<0.01). Conclusions Over 15 years, OPCAB use declined considerably in Veterans Affairs medical centers. In Veterans Affairs hospitals, late all-cause mortality and myocardial infarction rates were higher in the OPCAB cohort.

The Significance of Systemic Immune-Inflammatory Index for Mortality Prediction in Diabetic Patients Treated with Off-Pump Coronary Artery Bypass Surgery

Diabetes mellitus (DM) represents a complex carbohydrate metabolism disorder characterized by inflammatory over-reactivity. The study aimed to investigate the potential influence of postoperative inflammatory activation on mortality risk after off-pump coronary artery bypass grafting in diabetic patients. There were 510 patients treated with off-pump coronary artery bypass grafting due to stable complex coronary artery disease, including 175 patients with type-2 DM (T2DM.) The mean follow-up time was 3.7 +/− 1.5 years with a 9% all-cause mortality rate in the diabetic group. In multivariable analysis, preoperative comorbidities (stroke, peripheral artery disease, postoperative systemic inflammatory index >952, and postoperative left ventricle ejection fraction (LVEF) < 45%) were revealed as prognostic factors. The receiver operator characteristics curve analysis for postoperative calculations of systemic immune-inflammatory index (SII) appeared significant (AUC = 0.698, p = 0.008), yielding sensitivity of 68.75% and specificity of 71.07%. Systemic immune-inflammatory index (SII) can be regarded as a predictive marker for long-term prognosis in diabetic patients after off-pump coronary artery bypass grafting. The role of perioperative inflammatory activation may play a crucial role in mortality prediction.

Randomized evidence on graft patency after off-pump versus on-pump coronary artery bypass grafting: An updated meta-analysis

BACKGROUND

The debate between off-pump CABG (OPCAB) and on-pump CABG (ONCAB) has been ongoing for decades. We aimed to provide a comprehensive update of the current randomized controlled trials (RCTs) in evaluating the graft patency of OPCAB versus ONCAB.

MATERIALS AND METHODS

A literature search was conducted in PubMed, EMBASE, and the Cochrane Library databases until April 30, 2021. All RCTs from 2003 to 2020 comparing the results of graft patency between OPCAB and ONCAB were included. We compared the overall graft occlusion between the two groups, and subgroup analyses were conducted based on different types of conduits and target territories, crossover from off-pump to on-pump rate, and the length of follow-up.

RESULTS

Sixteen RCTs were identified, with 5743 grafts in the OPCAB group and 5898 in the ONCAB group. OPCAB was associated with a higher risk of occlusion in the overall graft (RR: 1.31; 95% CI, 1.17-1.46), saphenous vein graft (SVG) (RR: 1.40; 95% CI, 1.23-1.59), grafts to left anterior descending (LAD) territory (RR: 1.52; 95% CI, 1.11-2.08) and left circumflex artery (LCX) territory (RR: 1.45; 95% CI, 1.19-1.76), while no significant difference was observed between the two groups in respect of arterial conduits and grafts to right coronary artery (RCA) territory. Furthermore, the lower crossover rate and longer length of follow-up appeared to reduce the association between OPCAB and lower graft patency.

CONCLUSIONS

The current meta-analysis indicates that, compared with ONCAB, graft patency is poorer with OPCAB for overall grafts, SVG grafts, grafts to LAD and LCX territories, whereas the results remain comparable for arterial conduits and grafts to RCA territory.

Long-Term Follow-Up of Device-Assisted Clampless Off-Pump Coronary Artery Bypass Grafting Compared with Conventional On-Pump Technique

STUDY OBJECTIVE

To evaluate the long-term outcomes of clampless off-pump coronary artery bypass grafting (C-OPCAB) compared with conventional on-pump double clamping coronary artery bypass grafting (C-CABG).

METHODS

From October 2006 to December 2011, 366 patients underwent isolated coronary artery bypass grafting. After propensity score matching of preoperative variables, 143 pairs were selected who received C-OPCAB with the use of device-assisted PAS-Port proximal venous graft anastomoses or C-CABG, performed by the same surgeon experienced in both techniques. Data of the two groups of patients were retrospectively analyzed up to 14 years of follow-up.

RESULTS

As compared with C-OPCAB, in the C-CABG patients, the performed number of grafts per patient was higher (2.9 ± 0.5 vs. 2.6 ± 0.6, p-value 0.0001). At 14 years, overall survival, including in-hospital death, was 64 ± 4.7% for the C-OPCAB vs. 55 ± 5.5% for the C-CABG, freedom from overall MACCEs 51 ± 6.2% vs. 41 ± 7.7%, and from late cardiac death 94 ± 2.4% vs. 96 ± 2.2% (p-value not significant, for all comparisons). No significant statistical differences were observed in the actual rates of adverse events during follow-up. Independent predictors of survival were advanced age at operation (p-value 0.001) and a lower mean value of preoperative left ventricular ejection fraction (p-value 0.015).

CONCLUSIONS

Our single-center study analysis suggests that clampless OPCAB using device-assisted proximal anastomoses proved to be not inferior to double-clamping CABG in the long-term follow-up, provided that involved surgeons are familiar with both techniques. These conclusions are supported by a large and long-term follow-up period, eliminating potential bias, i.e., by means of the propensity score matching and analyzing single-surgeon experience.

Review of the differences in outcomes between males and females after revascularization

PURPOSE OF REVIEW

This review aims to compare outcomes of males and females undergoing coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), off-pump CABG (OPCAB), minimally invasive direct CABG (MIDCAB), and robotic total endoscopic CABG (TECAB).

RECENT FINDINGS

Females demonstrated increased rates of morbidity and mortality post PCI and CABG. In studies that performed risk adjustments, these differences were reduced. Although inferior outcomes were observed for females in some measures, generally outcomes between males and females were comparable post OPCAB, MIDCAB, and TECAB.

SUMMARY

Previous literature has demonstrated that females undergoing coronary revascularization experience inferior postoperative outcomes when compared to their male counterparts. The discrepancies between males and females narrow, but do not disappear when preoperative risks are accounted for and when considering minimally invasive approaches such as MIDCAB, OPCAB, and TECAB. Minimally invasive cardiac surgery has demonstrated numerous benefits with reduced morbidity, mortality, and shorter recovery times. In patients with increased comorbidities, minimally invasive approaches confer a greater advantage. As females often fall within this category, it is paramount that the diagnosis and referral process be optimized to account for preoperative differences to provide the most beneficial approach if the disparity between the sexes is to be addressed.

Perioperative outcomes of combined heart surgery and lung tumor resection: a systematic review and meta-analysis

Objective

The prevalence of patients with concomitant heart and lung lesions requiring surgical intervention is increasing. Simultaneous cardiac surgery and pulmonary resection avoids the need for a second operation. However, there are concerns regarding the potentially increased mortality and complication rates of simultaneous surgery and the adequacy of lung exposure during heart surgery. Therefore, we performed a meta-analysis to evaluate the perioperative mortality and complication rates of combined heart surgery and lung tumor resection.

Methods

A comprehensive literature search was performed in July 2020. The PubMed, Embase, and Web of Science databases were searched to identify studies that reported the perioperative outcomes of combined heart surgery and lung tumor resection. Two reviewers independently screened the studies, extracted data, and assessed the risk of bias of included studies. Pooled proportions and 95% confidence intervals (95% CI) were calculated by R version 3.6.1 using the meta package.

Results

A total of 536 patients from 29 studies were included. Overall, the pooled proportion of operative mortality was 0.01 (95% CI: 0.00, 0.03) and the pooled proportion of postoperative complications was 0.40 (95% CI: 0.24, 0.57) for patients who underwent combined cardiothoracic surgery. Subgroup analysis by lung pathology revealed that, for patients with lung cancer, the pooled proportion of anatomical lung resection was 0.99 (95% CI: 0.95, 1.00) and the pooled proportion of systematic lymph node dissection or sampling was 1.00 (95% CI: 1.00, 1.00). Subgroup analysis by heart surgery procedure found that the pooled proportion of postoperative complications of patients who underwent coronary artery bypass grafting (CABG) patients using the off-pump method was 0.17 (95% CI: 0.01, 0.43), while the pooled proportion of complications after CABG using the on-pump method was 0.61 (95% CI: 0.38, 0.82).

Conclusion

Combined heart surgery and lung tumor resection had a low mortality rate and an acceptable complication rate. Subgroup analyses revealed that most patients with lung cancer underwent uncompromised anatomical resection and mediastinal lymph node sampling or dissection during combined cardiothoracic surgery, and showed off-pump CABG may reduce the complication rate compared with on-pump CABG. Further researches are still needed to verify these findings.

Risk-adjusted analysis of long-term outcomes after on- versus off-pump coronary artery bypass grafting

OBJECTIVES

Recent data suggested that off-pump coronary artery bypass (OPCAB) may carry a higher risk for mortality in the long term when compared to on-pump coronary artery bypass (ONCAB). We, therefore, compared long-term survival and morbidity in patients undergoing ONCAB versus OPCAB in a large single-centre cohort.

METHODS

A total of 8981 patients undergoing isolated elective/urgent coronary artery bypass grafting between January 2009 and December 2019 were analysed. Patients were stratified into 2 groups (OPCAB n = 6649/ONCAB n = 2332). The primary end point was all-cause mortality. Secondary endpoints included repeat revascularization, stroke and myocardial infarction. To adjust for potential selection bias, 1:1 nearest neighbour propensity score (PS) matching was performed resulting in 1857 matched pairs. Moreover, sensitivity analysis was applied in the entire study cohort using multivariable- and PS-adjusted Cox regression analysis.

RESULTS

In the PS-matched cohort, 10-year mortality was similar between study groups [OPCAB 36.4% vs ONCAB 35.8%: hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.87-1.12; P = 0.84]. While 10-year outcomes of secondary endpoints did not differ significantly, risk of stroke (OPCAB 1.50% vs ONCAB 2.8%: HR 0.51, 95% CI 0.32-0.83; P = 0.006) and mortality (OPCAB 3.1% vs ONCAB 4.8%: HR 0.65, 95% CI 0.47-0.91; P = 0.011) at 1 year was lower in the OPCAB group. In the multivariable- and the PS-adjusted model, mortality at 10 years was not significantly different (OPCAB 34.1% vs ONCAB 35.7%: HR 0.97, 95% CI 0.87-1.08; P = 0.59 and HR 1.01, 95% CI 0.90-1.13; P = 0.91, respectively).

CONCLUSIONS

Data do not provide evidence that elective/urgent OPCAB is associated with significantly higher risks of mortality, repeat revascularization, or myocardial infarction during late follow-up when compared to ONCAB. Patients undergoing OPCAB may benefit from reduced risks of stroke and mortality within the first year postoperatively.

Early removal of chest drains in patients following off-pump coronary artery bypass graft (OPCAB) is not inferior to standard care - study in the Enhanced Recovery After Surgery (ERAS) group

Introduction

Only a few studies have concerned the timing of chest drains’ removal in cardiac surgery patients following the coronary artery bypass graft (CABG). None of them pertained to the off-pump CABG (OPCAB) procedure.

Aim

To compare thoracic drainage time in OPCAB patients before the implementation of the institutional Enhanced Recovery After Surgery (ERAS) protocol and after that.

Material and methods

It was a single-center observational study concerning patients following OPCAB. Two groups of patients were analyzed: after implementing the ERAS protocol, the ERAS group, and before this period, the standard care group (STAND group). The primary outcome of this study was to compare postoperative drainage time in the ERAS and STAND groups. The other outcomes included comparing transfused blood products, postoperative complications, surgical technique, postoperative ventilation and the intensive care unit stay time.

Results

Sixty patients in the ERAS and 112 in the STAND group were analyzed. The postoperative drainage time was shorter in the ERAS than in the STAND group: 20 (17–22) vs. 30 (27–35) h, p < 0.001. The number of transfused blood products was similar in both groups. No difference was noted between groups according to surgery and anesthesia time. However, patients in the ERAS group were ventilated for a significantly shorter time after the surgery and spent less time in the ICU than the STAND group. The number of postoperative complications in the ERAS and STAND group was 14 and 27, p = 1.

Conclusions

The early removal of chest drains after OPCAB does not increase the risk of postoperative complications and demand for blood products. However, its impact on patients’ morbidity needs further studies.

Neurological Complications of Cardiac Procedures

Neurological complications after cardiac surgery and percutaneous cardiac interventions are not uncommon. These include periprocedural stroke, postoperative cognitive dysfunction after cardiac surgery, contrast-induced encephalopathy after percutaneous interventions, and seizures. In this article, we review the incidence, pathophysiology, diagnosis, and management of these complications. Improved understanding of these complications could lead to their prevention, faster detection, and facilitation of diagnostic workup and appropriate treatment.

MINI OPCAB Operation: Surgical Technique

INTRODUCTION

We describe how to perform left internal mammary artery (LIMA) bypass to the left anterior descending (LAD) artery, the so-called MINI Off-pump Coronary Artery Bypass (MINI OPCAB).

MATERIALS AND METHODS

We included patients with a demonstrated predominant ischemia related to the LAD territory. Of 70 patients who were operated upon at the Benetti Foundation, 10 received hybrid revascularization.

SURGICAL TECHNIQUE

The patient is prepared as for a standard coronary bypass operation through sternotomy. The sternum is opened to the 3rd or 4th intercostal space depending on the anatomy, and a retractor is put in place. The left mammary artery is generally dissected to about 8 cm and isolated without the veins. Importantly, the angle of the superior part, where the mammary artery is attached to the sternum, needs to be below 20% to avoid any potential kinking. The pericardium is cleaned to identify the area of the pulmonary artery. The pericardium is opened to the apex and towards the right to around 5 to 6 cm initially. In most cases, the area of the LAD can be seen and the potential area of the anastomosis is defined. The patient is heparinized and the LAD is occluded with 5-0 Proline. A mechanical stabilizer is put in place and the anastomosis is performed. When the bypass is finished, and before sutures are tied, the stitches of 5-0 polypropylene around the artery are released, along with the clamp of the mammary artery; the anastomosis is then tied. The mechanical stabilizer is removed, the stitches of the pericardium are released and the flow of the graft is measured, while ensuring that there is no kinking. If the flow and Pulsatility and Resistance (PR) are acceptable, the mammary is fixed with 2 stitches of 7-0 polypropylene on both sides around 1 cm from the anastomosis. The heparin is reverted with protamine and a drain is put in place, while taking care to avoid any chance of touching the mammary artery or the anastomosis. The sternum is closed with 1 or 2 wires.

RESULTS

Operative mortality in this series was 0%; one patient was converted to sternotomy off-pump (1.4%). None of the grafts were revised after measurement with a Medistim system (Medistim ASA, Oslo, Norway). Fifty five patients (79%) were extubated in the operating room The average hospitalization stay was 60 hours (SD 17, 95% CI). Sixteen patients who underwent the LIMA-to-LAD procedure were restudied, with 100% patency. At 144 months, 82% of the patients were alive and 68% were asymptomatic.

CONCLUSION

Additional clinical experience is required to be able to reproduce this operation on a large scale and expand the MINI OPCAB operation in hybrid revascularization.

Risk factors for acute pulmonary embolism in patients with off-pump coronary artery bypass grafting: implications for nursing

Objective

Acute pulmonary embolism (APE) is a serious complication after off-pump coronary artery bypass grafting (OPCABG). We aimed to analyze the risk factors for APE in patients with OPCABG.

Methods

In this retrospective, observational study, patients with OPCABG who were treated in our hospital from 1 January 2018 to 31 March 2020 were included. The basic characteristics of patients and results of preoperative laboratory examinations were collected and analyzed.

Results

A total of 707 patients with OPCABG were included and the incidence of APE was 3.21%. Left ventricular ejection fraction (LVEF), a history of smoking, number of bypass grafting, duration of surgery, and age were significant risk factors for APE in patients with OPCABG. The areas under the curves of LVEF, number of bypass grafting, duration of surgery, and age were 0.773, 0.759, 0.738, and 0.723, respectively. The cutoff values of LVEF, number of bypass grafting, duration of surgery, and age were 59.84, 3.18, 237.42, and 73.28, respectively.

Conclusions

LVEF, a history of smoking, number of bypass grafting, duration of surgery, and age may be risk factors for APE in patients with OPCABG. Early measures should be taken to target these risks to prevent APE.

On-Pump Beating Heart versus Off-Pump Coronary Artery Bypass Graft Surgery: Short-Term Follow-up Outcomes of a Single Center

Background and Aim: Novel surgical approaches are gaining attention in an attempt to overcome possible adverse events following coronary artery bypass graft (CABG) surgery. This single-center study aimed to evaluate and compare the early postoperative outcomes of on-pump beating-heart (OPBH-CABG) versus off-pump CABG surgery in similar risk groups with a total number of 1–2 grafts.

Methods: The records of a total of 229 patients who underwent non-emergency, primary, isolated, either OPBH-CABG (n = 32) or off-pump CABG (n = 197) surgery were retrospectively evaluated. Reported outcome measures included baseline data, the number of coronary artery grafts, prophylactic intra-aortic balloon pump, time of extubation from mechanical ventilation, duration of stay in the coronary ICU and hospital, as well as early postoperative complications, in-hospital and early postoperative mortality.

Results: The groups were identical with regards to age and BMI. The patients in the off-pump group received a higher number of grafts (1.84 ± 0.36 vs. 1.18 ± 0.39, p <0.0001). The OPBH-CABG group had a higher Euroscore II score (2.514 ± 1.68 vs. 1.706 ± 1.93, p = 0.021). The time to extubation after the surgery, postoperative length of ICU stay, and total length of hospital stay were similar between the groups (p = 0.2228; p = 0.098; p = 0.717, respectively). The incidence of arrythmia and atrial fibrillation was higher in the on-pump group (12.5% vs. 2.53%, p <0.05). One patient in the on-pump, and four patients in the off-pump groups deceased due to postoperative complications.

Conclusions: OPBH-CABG surgery is comparable to off-pump CABG in terms of early postoperative outcomes. In patients who underwent OPBH-CABG, the risk of arrythmia and atrial fibrillation should be of concern and solved with optimal strategies.

Off-Pump Coronary Artery Bypass Reduces Cardiac Death in Patients with Peripheral Arteriopathy

OBJECTIVE

 The aim of this study was to investigate whether the use of off-pump coronary artery bypass (OPCAB) may enhance early outcomes in subjects with peripheral artery disease (PAD) undergoing coronary artery bypass grafting (CABG).

METHODS

 We employed a propensity-score (PS) method to compare early postoperative results of OPCAB and on-pump CABG patients with associated PAD. The study population consisted of 1,961 patients: 284 in the OPCAB and 1,677 in the on-pump CABG group. The inverse probability of treatment weighting was used as PS method.

RESULTS

 The incidence of death (1.2% [95% confidence interval, CI: -0.9 to 3.3%], p = 0.262), stroke (2.2% [95% CI: -1.4 to 5.7%], p = 0.235), acute kidney disease (1.5% [95% CI: -3.8 to 6.8%], p = 0.586), limb ischemia (3.2% [95% CI: -0.6 to 7.0%], p = 0.315), and low output syndrome (1.2% [95% CI: -0.9 to 3.3%], p = 0.262) did not differ between the two groups. On the other hand, the rate of cardiac death (1.2% [95% CI: -0.1 to 2.3%], p = 0.038) was significantly higher in on-pump CABG group.

CONCLUSIONS

 The OPCAB procedure considerably reduced the occurrence of cardiac death after coronary revascularization. This finding might suggest that the OPCAB procedure should be considered as the first option in patients with higher cardiovascular risk scores. Further research is warranted.

Off-pump versus on-pump redo coronary artery bypass grafting: a systematic review and meta-analysis

Background:

Redo coronary artery bypass grafting (redo CABG) is associated with increased mortality and morbidity. The aim of this study was to systematically evaluate the evidence comparing the outcomes of off-pump with on-pump redo CABG.

Methods:

Studies were systematically searched and identified using PubMed, EMBASE, the Cochrane Library, and the International Clinical Trials Registry Platform (ICTRP) by two researchers independently. The primary outcome was 30-day mortality, and the secondary outcomes were in-hospital mortality, post-operative complications, completeness of revascularization, blood transfusion rate, duration of mechanical ventilation, intensive care unit and hospital stays.

Results:

The 21 studies including 4,889 patients were enrolled in our meta-analysis. Compared with on-pump, the off-pump technique was associated with significantly reduced 30-day mortality (odds ratio [OR] = 0.43, 95% confidence interval [CI] = 0.26-0.72, p = 0.001). Moreover, a notably decreased in-hospital mortality (OR = 0.55, 95% CI = 0.39-0.76, p = 0.0004) and incidence of post-operative new-onset atrial fibrillation, myocardial infarction, acute kidney injury, low cardiac output state, blood transfusion rate (OR = 0.46, 95% CI = 0.35-0.60, p < 0.00001; OR = 0.54, 95% CI = 0.38-0.78, p = 0.0007; OR = 0.51, 95% CI = 0.37-0.70, p < 0.0001; OR = 0.31, 95% CI = 0.20-0.47, p < 0.00001; OR = 0.29, 95% CI = 0.14-0.61, p = 0.001) and significantly shortened duration of mechanical ventilation, intensive care unit and hospital stays (mean difference [MD] = −8.21 h, 95% CI = −11.74 to −4.68, p < 0.00001; MD = −0.77 d, 95% CI = −0.81 to −0.73, p < 0.00001; MD = −2.24 d, 95% CI = −3.17 to −1.32, p < 0.00001) could be observed when comparing the outcomes of off-pump with on-pump redo CABG. There was nonsignificant difference between off-pump and on-pump redo CABG in completeness of revascularization.

Conclusion:

In patients undergoing redo CABG surgery, the off-pump technique was associated with decreased mortality, less post-operative complications when compared to on-pump.

Off-pump versus on-pump coronary artery surgery in octogenarians (from the KROK Registry)

Background

According to the medical literature, both on-pump and off-pump coronary artery surgery is safe and effective in octogenarians.

Objectives

The aim of our study was to examine the epidemiology, in-hospital outcomes and long-term follow-up results in octogenarians undergoing off-pump and on-pump coronary artery surgery utilizing nationwide registry data.

Methods

All octogenarians (≥ 80 years) enrolled in the Polish National Registry of Cardiac Surgical Procedures (KROK Registry), who underwent isolated coronary surgery between January 2006 and September 2017 were identified. Preoperative data, perioperative complications, hospital mortality and long-term mortality were analyzed. Unadjusted and propensity-matched comparisons were performed between octogenarians undergoing off-pump and on-pump coronary artery bypass surgery.

Results

Octogenarians accounted for 4.1% of the total population undergoing coronary artery surgery in Poland during the analyzed period (n = 152,631) and this percentage is increasing. Among 6,006 analyzed patients, 2,744 (45.7%) were operated on-pump and 3,262 (54.3%) were operated off-pump. Propensity-matched analysis revealed that patients operated on-pump were more often reoperated due to postoperative bleeding and their in-hospital mortality was higher (6.6% vs 4.5%, p = 0.006 and 8.7% vs 5.8%, p = 0.001, respectively). Long-term all-cause mortality was lower among patients operated off-pump (p = 0.013).

Conclusion

On the basis of our findings we suggest that off pump technique should be considered as perfectly acceptable in octogenarians.

On-pump beating-heart coronary artery bypass grafting in high-risk patients: A systematic review and meta-analysis

BACKGROUND

Operative technique for surgical myocardial revascularization in high-risk patients remains an argument of debate. On-pump coronary artery bypass graft (CABG) with cardioplegic arrest and off-pump CABG have intrinsic limitations. The hybrid approach of on-pump beating-heart CABG (OPBHC) has been proposed over the years with conflicting results. This systematic review and meta-analysis intends to summarize the contemporary literature.

METHODS

A literature search was conducted through major electronic databases. The systematic review provided a total of 279 articles, of those 17 studies were included in the present study.

RESULTS

Compared with on-pump CABG, OPBHC patients showed a preoperative higher risk profile but had reduced early mortality (risk ratio [RR], 0.59, 95% CI, 0.36-0.97) and reduced postoperative stroke (RR, 0.60, 95% CI, 0.39-0.91). Also, interesting trends towards reduced postoperative intra-aortic balloon pump use (RR, 0.56, 95% CI, 0.31-1.01) and myocardial infarction (RR, 0.48, 95% CI, 0.22-1.07) were observed. Baseline characteristics and postoperative complications were similar between OPBHC and off-pump CABG, but limited data are available. The risk of incomplete revascularization in OPBHC is lower than off-pump CABG (RR, 0.53, 95% CI, 0.33-0.87) but higher than conventional on-pump CABG (RR, 1.71, 95% CI, 1.23-2.39).

CONCLUSION

OPBHC is an effective technique to perform surgical revascularization in high-risk patients as preventing haemodynamic deterioration and guaranteeing adequate end-organ perfusion. OPBHC represents an alternative technique to on-pump and off-pump CABG, in those cases in which complications deriving from cardioplegic arrest or manipulation of the heart are more likely. For these reasons, OPBHC might be useful in patients with recent myocardial infarction or with left ventricular dysfunction.

Establishing the Safety of Training in Off-Pump Coronary Artery Bypass Surgery: A Retrospective Comparison of Outcomes between Trainees and a Consultant Surgeon

BACKGROUND

The safety of training in off-pump coronary artery bypass (OPCAB) surgery and the stage at which trainees should be exposed to this technique remain controversial. This single-center retrospective study aimed to compare outcomes of OPCAB surgery in consultant and trainee cases.

METHODS

Between 2014 and 2018, all isolated OPCAB operations performed under the care of a consultant surgeon (G.A.) were analyzed. Cases where a surgeon below consultant grade performed at least 70% of the distal anastomoses were designated as "trainee cases" with the remaining cases designated as "consultant cases." The baseline characteristics of patients, perioperative data, and short-term outcomes were prospectively collated and analyzed.

RESULTS

During the study period, 245 OPCAB cases were identified: 142 (58%) consultant and 103 (42%) trainee cases. The trainee cases were performed exclusively by trainees in the final 2 years of the UK National Cardiothoracic Training Program. Both trainee and consultant groups had low mortality with two perioperative deaths occurring in either group. The rates of serious postoperative complications including stroke (n = 1 vs. 2, p = 0.759), resternotomy for bleeding (n = 3 vs. 7, p = 0.431), and mediastinal infection (n = 2 vs. 3, p = 0.926) were low and not significantly different between the two groups. Patients operated on by trainees had a slightly longer hospital stay than those operated on by the consultant surgeon, although this did not reach statistical significance (9.9 vs. 7.9 days).

CONCLUSIONS

These results demonstrate comparable outcomes in OPCAB surgery between a consultant surgeon and trainees. This study supports the conclusion that training surgeons in OPCAB is appropriate for trainees in the final years of cardiac surgery training.