Off-pump coronary artery bypass grafting (OPCABG)-a 'personal' European perspective

Successful introduction of off-pump coronary artery bypass grafting in southeastern Asian countries: A single Center's experience in Thailand

Background

Off-pump coronary artery bypass grafting has not been standardized in Southeastern Asian countries because it is technically demanding. However, this method could be suitable for economically disadvantaged institutions because it saves cost on the heart–lung machine. We summarized our results to assess the validity of our early introduction of this method.

Methods

We reviewed the data from 750 patients who underwent off-pump coronary artery bypass grafting at our institution. Before the introduction of off-pump coronary artery bypass grafting, experts from Japan were enlisted to teach our surgeons technicalities of the procedure. The primary outcome was in-hospital mortality, and secondary outcomes included any major adverse cardiac or cerebrovascular event.

Results

The in-hospital mortality rate was 1.5%. The rates of survival and freedom from major adverse cardiac or cerebrovascular event 3 years after the operation were 92.5% ± 1.8% and 90.7% ± 2.2%, respectively. In the multivariable analysis, the independent risk factors for major adverse cardiac or cerebrovascular event were chronic obstructive pulmonary disease (adjusted hazard ratio = 2.35, 95% confidence interval = 1.35–4.10, P = .003) and renal insufficiency (adjusted hazard ratio = 2.70, 95% confidence interval = 1.52–4.80, P = .001), whereas risk factors for in-hospital death were pump conversion (relative risk = 17.4, 95% confidence interval = 1.63–4.41, P < .001).

Conclusion

Successful introduction of off-pump coronary artery bypass grafting provided a favorable outcome almost equal to that in high-volume centers in developed countries.

Bilateral thoracic paravertebral block combined with general anesthesia vs. general anesthesia for patients undergoing off-pump coronary artery bypass grafting: a feasibility study

BACKGROUND

Whether thoracic paravertebral block (PVB) is useful in patients undergoing off-pump coronary artery bypass grafting (OPCABG) remains unknown. This study aimed to investigate the feasibility of bilateral PVB combined with general anesthesia (GA) in patients undergoing OPCABG.

METHODS

This feasibility study assessed 60 patients scheduled for OPCABG at the Qingdao Municipal Hospital in 2016-2017. Patients were randomly assigned to receive nerve stimulator-guided bilateral PVB combined with GA (PVB + GA) or GA alone (n = 30/group). Patients were asked to rate rest and cough pain hourly after the surgery. The primary endpoint was the visual analogue scale (VAS) pain score within 48 h postoperatively. Secondary endpoints were rescue analgesia and morphine consumption, fentanyl dose within 48 h postoperatively, as well as operative time, time to extubation, intensive care unit (ICU) stay, hospital stay and other postoperative adverse events.

RESULTS

Both rest and cough pains were lower in the PVB + GA group at 12, 24, 36, and 48 h after surgery compared with the GA group. There were fewer patients who needed rescue analgesia in the PVB + GA group at 12 and 24 h than in the GA group. Morphine consumptions at 24 and 48 h were lower in the PVB + GA group compared with the GA group. Time to extubation (P = 0.035) and ICU stay (P = 0.028) were shorter in the PVB + GA group compared with the GA group. AEs showed no differences between the two groups.

CONCLUSIONS

Nerve stimulator-guided bilateral thoracic PVB combined with GA in OPCABG is associated with a reduced rescue analgesia and morphine consumption, compared to GA.

Application of different anesthetic methods in coronary artery bypass grafting and the effect on postoperative outcome

Application of different anesthetic methods in coronary artery bypass grafting and its effect on postoperative outcome were explored. Ninety-four patients undergoing coronary artery bypass grafting in Jining No. 1 People's Hospital from March 2017 to February 2018 were randomly divided into the control and observation groups. The control group was anesthetized by fentanyl and propofol. The observation group was anesthetized by sevoflurane combined anesthesia. The mean heart rates (HR), mean arterial pressure (MAP), systemic vascular resistance index (SVRI) and cardiac index (CI) in the two groups were compared. The levels of β endorphin (β-EP) and malondialdehyde (MDA) in patients were examined. Adverse reactions in the two groups were compared. The enzyme-linked immunosorbent assay (ELISA) was used to detect the changes of serum inflammatory factors. The prognosis of the two groups was analyzed and compared. MoCA and MMSE scale were used to evaluate postoperative cognitive function in the two groups. The levels of β-EP and MDA in the two groups during operation were higher than those before operation (P<0.05). On the third, fifth and seventh day after operation, the CRP, TNF-α and IL-6 levels of the two groups increased significantly compared to those before operation (P<0.05). The eating time and out of bed time in the observation group were significantly earlier than those in the control group, and the length of stay in the observation group was significantly shorter than that in the control group (P<0.05). On the first day after operation, the scores of MoCA and MMSE in the observation group were better than those in the control group (P<0.05). The two different anesthetic methods can maintain the perioperative hemodynamic stability of coronary artery bypass patients, but sevoflurane intravenous-inhalation combined anesthesia can effectively adjust the β-EP in the body, and reduce the oxidative stress response, which is favorable for postoperative outcome.

Modifying risks to improve outcome in cardiac surgery: An anesthesiologist's perspective

Challenging times are here for cardiac surgical and anesthesia team. The interventional cardiologist seem to have closed the flow of ‘good cases’ coming up for any of the surgery,; successful percutaneous interventions seem to be offering reasonable results in these patients, who therefore do not knock on the doors of the surgeons any more. It is a common experience among the cardiac anesthesiologists and surgeons that the type of the cases that come by now are high risk. That may be presence of comorbidities, ongoing medical therapies, unstable angina, uncontrolled heart failure and rhythm disturbances; and in patients with ischemic heart disease, the target coronaries are far from ideal. Several activities such as institution of preoperative supportive circulatory, ventilatory, and systemic disease control maneuvers seem to have helped improving the outcome of these ‘high risk ‘ patients. This review attempts to look at various interventions and the resulting improvement in outcomes. Several changes have happened in the realm of cardiac surgery and several more are en route. At times, for want of evidence, maximal optimization may not take place and the patient may encounter unfavorable outcomes.. This review is an attempt to bring the focus of the members of the cardiac surgical team on the value of preoperative optimization of risks to improve the outcome. The cardiac surgical patients may broadly be divided into adults undergoing coronary artery bypass graft surgery, valve surgery and pediatric patients undergoing repair/palliation of congenital heart ailments. Optimization of risks appear to be different in each genre of patients. This review also brings less often discussed issues such as anemia, nutritional issues and endocrine problems. The review is an attempt to data on ameliorating modifiable risk factors and altering non modifiable ones.