Does Age at Operation Influence the Short- and Long-Term Outcomes of Off-Pump Coronary Artery Bypass Grafting?

Outcomes of simultaneous carotid endarterectomy and coronary artery bypass grafting: A single centre experience

OBJECTIVE

Stroke following a coronary artery bypass surgery is a well-known complication often predisposed by carotid artery disease. Perioperative risk of stroke after on-pump cardiac surgery can overall affect 2% of patients. Patients with 80-99% unilateral carotid artery stenosis carry a 4% risk of stroke. Significant carotid artery stenosis is present in 3-10% of patients who are candidates for coronary artery bypass grafting (CABG). Those patients might be considered for either simultaneous or staged carotid endarterectomy and CABG to reduce the risk of stroke and death. The purpose of this study was to evaluate preoperative and intraoperative risk factors for myocardial infarction (MI), stroke and death and assess complications occurring during the early postoperative period after simultaneous CABG/CAE procedure.

METHODS

A single centre retrospective analysis of 134 patients from 2015 to 2019 who underwent simultaneous CABG/CEA was performed. At the same period, a total of 2827 CABG were performed, of which 4.7% were simultaneous interventions. We excluded staged CEA/CABG procedures, off-pump CABG and urgent CABG patients. All patients included in the study met the criteria for elective CABG for triple-vessel or left main trunk symptomatic coronary artery disease (CAD) with asymptomatic >70% carotid stenosis or symptomatic ipsilateral >50% carotid stenosis regardless of the degree of contralateral carotid artery stenosis. Patient demographics, comorbidities and operative details were reviewed. The primary endpoint was to assess the intraoperative and 30-day risk of stroke and death after simultaneous CEA/CABG procedure.

RESULTS

Simultaneous CEA/CABG is effective procedure that can be performed in high-risk symptomatic patients with acceptable results. Predictors of postoperative stroke were smoking (P = 0.011), history of MI (P = 0.046), history of CABG (P = 0.013), and history of stroke/TIA (P = 0.005). Significant risk factors for adverse major postoperative complications after simultaneous CEA/CABG procedure were cardiac arrhythmia (AF or AFL) (P = 0.045), previous MI (P < 0.001), and smoking (P = 0.001).

CONCLUSIONS

Synchronous CEA/CABG procedure can be performed with acceptable results in patients having a high risk of stroke, septuagenarians and older.

Comparison of in-hospital outcomes after coronary artery bypass graft surgery in elders and younger patients: a multicenter retrospective study

OBJECTIVES

We aimed to identify in-hospital outcomes in young (≤ 65 years) and old (> 65 years) patients after coronary artery bypass grafting (CABG) by analyzing the effect of age on adverse events after on-pump or off-pump CABG.

METHODS

Patients older than 65 years were defined as older patients and others were defined as younger patients. The qualitative data were compared by chi-square or Fisher's exact tests. The quantitative data were compared by the two-sample independent t-test or Mann-Whitney U test. Multifactor binary logistic regression was used to control for confounders and to investigate the effect of age on dichotomous outcome variables such as death.

RESULTS

In the on-pump CABG population, the postoperative in-hospital mortality, the incidence of postoperative symptomatic cerebral infarction (POSCI) and postoperative atrial fibrillation (POAF) was higher in older patients than in younger patients (P value < 0.05), and age > 65 years was associated with postoperative in-hospital mortality (OR = 2.370, P value = 0.031), POSCI (OR = 5.033, P value = 0.013), and POAF (OR = 1.499, P value < 0.001). In the off-pump CABG population, the incidence of POAF was higher in older patients than in younger patients (P value < 0.05), and age > 65 years was associated with POAF (OR = 1.392, P value = 0.011).

CONCLUSION

In-hospital outcomes after CABG are strongly influenced by age. In on-pump CABG, the risk of postoperative death, POSCI, and POAF was higher in older patients, and in off-pump CABG, the risk of POAF was higher in older patients.

Short-term outcomes of on- vs off-pump coronary artery bypass grafting in patients with left ventricular dysfunction: a systematic review and meta-analysis

Objectives

Does the manipulation of the off-pump CABG (OPCAB) in patient with depressed left ventricular function is better than on-pump CABG (ONCAB) approach in in-hospital mortality and morbidities? Here we undertook a meta-analysis of the best evidence available on the comparison of primary and second clinical outcomes of the off-pump and on-pump CABG.

Design

Systematic literature reviewer and meta-analysis.

Data sources

PubMed, EMBASE, Web of science and Cochrane Center Registry of Controlled Trials were searched the studies which comparing the use of the off-pump CABG(OPCAB) and on-pump CABG (ONCAB) for patients with LVD during January 1990.1 to January 2018.

Eligibility criteria

All observation studies and randomized controlled trials comparing on-pump and off-pump as main technique for multi-vessel coronary artery disease (defined as severe stenosis (>70%) in at least 2 major diseased coronary arteries) with left ventricular dysfunction(defined as ejection fraction (EF) 40% or less) were included.

Data extraction and synthesis

Authors will screen and select the studies extract the following data, first author, year of publication, trial characters, study design, inclusion and exclusion criteria, graft type, clinical outcome, assess the risk of bias and heterogeneity. Study-specific estimates will pool through the modification of the Newcastle-Ottawa scale for the quality of study and while leave-one-out analysis will be used to detect the impact of individual studies on the robustness of outcomes.

Results

Among the 987 screened articles, a total of 16 studies (32,354 patients) were included. A significant relationship between patient risk profile and benefits from OPCAB was found in terms of the 30-day mortality (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.73–0.97; P = 0.02), stroke (OR, 0.69; 95% CI, 0.55–0.86; P = 0.00), myocardial infarction (MI) (OR, 0.71; 95% CI, 0.53–0.96; P = 0.02), renal failure (OR, 0.71; 95% CI, 0.55–0.93; P = 0.01), pulmonary complication (OR, 0.68; 95% CI, 0.52–0.90; P = 0.01), infection (OR, 0.67; 95% CI, 0.49–0.91; P = 0.00),postoperative transfusion (OR, 0.25; 95% CI, 0.08–0.84; P = 0.02) and reoperation for bleeding (OR, 0.56; 95% CI, 0.41–0.75; P = 0.00). There was no significant difference in atrial fibrillation (AF) (OR, 0.96;95%; CI, 0.78–1.41; P = 0.56) and neurological dysfunction (OR, 0.88; 95% CI, 0.49–1.57; P = 0.65).

Conclusions

Compared with the on-pump CABG with LVD, using the off-pump CABG is a better choice for patients with lower mortality, stroke, MI, RF, pulmonary complication, infection, postoperative transfusion and reoperation for bleeding. Further randomized studies are warranted to corroborate these observational data.

Impact of patients´ age on short and long-term outcome after carotid endarterectomy and simultaneous coronary artery bypass grafting

BACKGROUND

The purpose of this study was to investigate whether age has an effect on short and long-term outcome in patients who undergo simultaneous coronary artery bypass grafting (CABG) and carotid endarterectomy.

METHODS

From 2005 to 2017, 186 consecutive elective patients underwent CABG and synchronous endarterectomy at our institution. Patients were retrospectively classified according to age into 2 groups: patients above 70 years (elderly group: n = 97, 76.1 ± 3.9 years) and patients below 70 years (younger group: n = 89, 63.2 ± 4.8 years).

RESULTS

The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, 4.4% vs. 2.5%; p < 0.001) and Society of Thoracic Surgeons (STS) score (0.7% vs. 1.6%; p < 0.001) were significantly higher in the elderly group. Otherwise, there was no difference between the two groups concerning important preoperative risk factors or the intraoperative data. Postoperatively, the incidence of temporary dialysis was significantly higher in the elderly group (14.4% vs. 3.4%; p = 0.009). The rate of tracheotomy (16.5% vs. 2.2%; p = 0.001), of re-intubation (7.9% vs. 18.6%; p = 0.033) and drainage loss (600 ml vs. 800 ml; p = 0.035) was significantly higher in this elderly group. Neurological complications and 30-day mortality were comparable. Long-term survival was satisfactory for both groups. Nevertheless, 5-year survival rates (63% vs. 85%) were significantly lower in the elderly group (p = 0.003). Logistic regression analysis identified chronic obstructive pulmonary disease (COPD) and arrhythmia as significant risk factors for 30-day-mortality, but not age.

CONCLUSIONS

CABG in combination with synchronous endarterectomy can also be performed with satisfactory results in elderly patients.

Clinical Outcomes of Elderly Patients with Non ST-Segment Elevation Myocardial Infarction Undergoing Coronary Artery Bypass Surgery

The aim of this study is to investigate the clinical outcomes of the elderly patients with Non ST-segment elevation myocardial infarction (NSTEMI) undergoing coronary artery bypass surgery (CABG) compared to non-elderly patients. Patients with NSTEMI and undergoing CABG (n=451) who were registered in the Korea Acute Myocardial Infarction Registry between December 2003 and August 2012 were divided into two groups.; the non-elderly group (<75 years, n=327) and the elderly group (≥75 years, n=124). In-hospital mortality was higher in the elderly group (4.9% vs. 11.3%, p=0.015), but cardiac death, myocardial infarction, and major adverse cardiovascular events (MACE) including cardiac death, myocardial infarction, percutaneous revascularization, and redo-CABG after a one-year follow up were not different between the two groups. Predictors of in-hospital mortality in patients with NSTEMI undergoing CABG were left ventricular (LV) dysfunction (ejection fraction ≤40%) [hazard ratio (HR): 2.76, 95% confidence interval (CI): 1.16–6.57, p=0.022] and age (HR: 1.05, 95% CI: 1.01–1.10, p=0.047). So elderly NSTEMI patients should be considered for CABG if appropriate, but careful consideration for surgery is required, especially if the patients have severe LV systolic dysfunction.

Single-Centre Experience of Off-Pump Multi-Vessel Coronary Artery Bypass Grafting Using Proximal Suture Device

BACKGROUND

To investigate the results of off-pump coronary artery grafting (OPCAB) with the proximal suture device (PSD) regarding postoperative stroke and graft patency.

METHODS

The PSD was used in 376 patients (32.0%), aorta-no-touch OPCAB was performed in 523 patients (45.2%), on-pump beating coronary artery bypass surgery (CABG) (on-beat group) in 125 patients (10.6%) including 51 conversions (conversion rate: 5.4%), and CABG with aortic clamp use (clamp group) in 152 patients. In the PSD group, Enclose II was used in 267 patients (71.0%).

RESULTS

The hospital mortality rate was 1.95%. There was no early stroke in the OPCAB group, whereas the early-stroke rate was 0.8% in the on-beat group and 2.6% in the clamp group. The incidences of stroke at one month were: PSD group, 1.6%; no-touch group, 1.1%; on-beat group, 1.6%; and clamp group, 4.6% (p=0.014). The rates of complete revascularisation were higher in the PSD and clamp groups (94.7 and 94.0%, respectively) compared with the no-touch and on-beat groups (81.5 and 84.9%, respectively; p<0.001). The vein graft patency rates were comparable between the PSD and clamp groups. In multiple logistic regression analysis, OPCAB using the PSD did not increase the risk of stroke compared with the no-touch group (adjusted odds ratio [AOR]: 1.40; p=0.594) or on-beat group (AOR: 0.99; p=0.206), but reduced the risk of stroke compared with the clamp group (AOR: 0.19; p=0.005).

CONCLUSIONS

Off-pump coronary artery grafting using the PSD was a safe and effective procedure. It led to lower incidences of postoperative stroke and excellent rates of graft patency and complete revascularisation compared with conventional CABG.

Current outcomes of off-pump coronary artery bypass grafting: evidence from real world practice

Coronary artery bypass grafting (CABG) can be performed conventionally using cardiopulmonary bypass (CPB) and aortic clamping or on a beating heart (BH) without the use of CPB, the so-called off-pump CABG. Some surgeons, who are proponents of off-pump CABG, preferentially use this technique for the majority of operations, whereas others use it only in certain situations which warrant avoidance of CPB. Ever since the conception of off-pump CABG, the never-ending debate about which technique of CABG is safe and efficacious continues to date. Several randomized controlled trials (RCTs) have been conducted that have either favored on-pump CABG or have failed to show a significant difference in outcomes between the two techniques. However, these RCTs have been fraught with claims that they do not represent the majority of patients undergoing CABG in real world practice. Therefore, assessment of the benefits and drawbacks of each technique through observational and registry studies would be more representative of patients encountered in daily practice. The present review examines various retrospective studies and meta-analyses of observational studies that compare the early and long-term outcomes of off- and on-pump CABG, which assesses their safety and efficacy. Additionally, their outcomes in older patients, females, and those with diabetes mellitus, renal dysfunction, presence of ascending aortic disease, and/or acute coronary syndrome (ACS) have also been discussed separately. The general consensus is that early results of off-pump CABG are comparable to or in some cases better than on-pump CABG. However, on-pump CABG provides a survival benefit in the long term according to a majority of publications in literature.

Predictors and Clinical Impacts of Aggravated Left Ventricular Diastolic Dysfunction After Off-Pump Coronary Artery Bypass Grafting

BACKGROUND

To determine the predictors of aggravated left ventricular diastolic dysfunction (LVDD) in patients undergoing off-pump coronary artery bypass grafting (OPCAB) and to compare late outcomes according to the aggravated LVDD.

METHODS AND RESULTS

OPCAB was performed in 1,101 patients (2001-2013). LVDD was classified as normal, mild, moderate or severe. Patients were divided into 2 groups: non-aggravated LVDD (group I) and aggravated LVDD (group II). The primary endpoint was aggravation of LVDD. The secondary endpoint was late mortality and morbidity such as major adverse cardiac and cerebrovascular events (MACCE) related to LVDD aggravation postoperatively. There were 894 patients in group I and 207 in group II. Multivariate analysis revealed that preoperative peripheral artery obstructive disease (PAOD) (P=0.04), renal failure (P<0.01), and A' velocity (P<0.01) anticipated aggravated LVDD. The Cox hazards model revealed that aggravated LVDD was a poor prognostic factor for MACCE (P<0.01) and overall survival (P<0.01). The Kaplan-Meier survival curve showed that aggravated LVDD was related to poor late outcomes (freedom from MACCE, P=0.01; overall survival, P<0.01).

CONCLUSIONS

Aggravated LVDD significantly affects late clinical outcomes after OPCAB and preoperative PAOD, renal failure, and A' velocity might be predictors. (Circ J 2016; 80: 1937-1945).

Is Bilateral Internal Mammary Arterial Grafting Beneficial for Patients Aged 75 Years or Older?

BACKGROUND

Although bilateral internal mammary artery (BIMA) grafting is performed with increasing regularity in elderly patients, whether it is truly beneficial, and therefore indicated, in these patients remains uncertain. We retrospectively investigated early and late outcomes of BIMA grafting in patients aged ≥75 years.

METHODS AND RESULTS

We identified 460 patients aged ≥75 years from among 2,618 patients who underwent either single internal mammary artery (SIMA) grafting (n=293) or BIMA grafting (n=107). Early outcomes did not differ between the SIMA and BIMA patients (30-day mortality: 1.7% vs. 0%, P=0.39; sternal wound infection: 1.0% vs. 4.7%; P=0.057). Late outcomes, 10-year survival in particular, were improved in the BIMA group (36.6% vs. 48.1%, P=0.033). In the analysis of the results in propensity score-matched groups (196 patients in the SIMA group, 98 patients in the BIMA group), improved 10-year survival was documented in the BIMA group (34.8% vs. 47.6%, P=0.030). Cox proportional regression analysis showed SIMA usage (non-use of BIMA) to be a predictor for late mortality (hazard ratio: 0.65, 95% confidence interval: 0.43-0.98, P=0.042). We further compared outcomes between the total non-elderly patients (n=2,158) and total elderly patients (n=460). BIMA usage was similar, as was 30-day mortality (1.0% vs. 1.3%, respectively).

CONCLUSIONS

A survival advantage, with no increase in early mortality, can be expected from BIMA grafting in patients aged ≥75 years. (Circ J 2016; 80: 1756-1763).