On-pump beating heart versus conventional coronary artery bypass grafting: comparative study on early and long-term clinical outcomes

Comparative efficacy on outcomes of C-CABG, OPCAB, and ONBEAT in coronary heart disease: a systematic review and network meta-analysis of randomized controlled trials

IMPORTANCE

Coronary artery bypass grafting (CABG) remains the gold standard for the treatment of multivessel and left main coronary heart disease. However, the current evidence about the optimal surgical revascularization strategy is inconsistent and is not sufficient to allow for definite conclusions. Thus, this topic needs to be extensively discussed.

OBJECTIVE

The aim of this present study was to compare the clinical outcomes of off-pump CABG (OPCAB), conventional on-pump CABG (C-CABG), and on-pump beating heart (ONBEAT) CABG via an updated systematic review and network meta-analysis of randomized controlled trials.

DATA SOURCES

PubMed, Web of Science, and the Cochrane Central Registry were searched for relevant randomized controlled trials that were published in English before 1 December 2021.

STUDY SELECTION

Published trials that included patients who received OPCAB, C-CABG, and ONBEAT CABG were selected.

DATA EXTRACTION AND SYNTHESIS

Two authors independently screened the search results, assessed the full texts to identify eligible studies and the risk of bias of the included studies, and extracted data. All processes followed the Preferred Reporting Items for Systematic Review and Meta-analysis of Individual Participant Data.

MAIN OUTCOMES AND MEASURES

The primary outcome was postoperative mortality in patients who underwent C-CABG, OPCAB, or ONBEAT CABG. The secondary outcomes were postoperative myocardial infarction, stroke, and renal impairment in the three groups. The time point for analysis of outcomes was all time periods during the postoperative follow-up.

RESULTS

A total of 39 385 patients (83 496.2 person-years) in 65 studies who fulfilled the prespecified criteria were included. In the network meta-analysis, OPCAB was associated with an increase of 12% in the risk of all-cause mortality when compared with C-CABG [odds ratio (OR): 1.12; 95% CI: 1.04-1.21], a reduction of 49% in the risk of myocardial infarction when compared with ONBEAT (OR: 0.51; 95% CI: 0.26-0.99), a reduction of 16% in the risk of stroke when compared with C-CABG (OR: 0.84; 95% CI: 0.72-0.99) and a similar risk of renal impairment when compared with C-CABG and ONBEAT.

CONCLUSIONS AND RELEVANCE

OPCAB was associated with higher all-cause mortality but lower postoperative stroke compared with C-CABG. OPCAB was associated with a lower postoperative myocardial infarction than that of ONBEAT. Early mortality was comparable among OPCAB, ONBEAT, and C-CABG.

The ebb and flow of cardiac lymphatics: a tidal wave of new discoveries

The heart is imbued with a vast lymphatic network that is responsible for fluid homeostasis and immune cell trafficking. Disturbances in the forces that regulate microvascular fluid movement can result in myocardial edema, which has profibrotic and proinflammatory consequences and contributes to cardiovascular dysfunction. This review explores the complex relationship between cardiac lymphatics, myocardial edema, and cardiac disease. It covers the revised paradigm of microvascular forces and fluid movement around the capillary as well as the arsenal of preclinical tools and animal models used to model myocardial edema and cardiac disease. Clinical studies of myocardial edema and their prognostic significance are examined in parallel to the recent elegant animal studies discerning the pathophysiological role and therapeutic potential of cardiac lymphatics in different cardiovascular disease models. This review highlights the outstanding questions of interest to both basic scientists and clinicians regarding the roles of cardiac lymphatics in health and disease.

On-pump beating heart versus conventional on-pump coronary artery bypass grafting on clinical outcomes: a meta-analysis

Background

A hybrid surgery method, on-pump beating heart coronary artery bypass graft (ON-BH CABG), is supposed to be a promising technology for coronary artery revascularization. Here, we conducted a comprehensive meta-analysis of the data derived from published studies on ON-BH CABG and conventional on-pump coronary artery bypass graft (C-CABG) to compare their short-term and long-term clinical outcomes.

Methods

We searched major electronic databases and 24 studies incorporating 6,862 patients (1,847 ON-BH CABG and 5,015 C-CABG) were included eventually, and 9 studies of them were focusing on high-risk patients.

Results

Compared with ON-BH CABG, C-CABG was associated with a higher risk in early mortality [odds ratio (OR), 1.45; 95% confidence interval (CI), 1.09 to 1.93; P=0.01], myocardial infarction (MI) (OR, 2.60; 95% CI, 1.41 to 4.78; P<0.01), low output syndrome (LOS) (OR, 2.56; 95% CI, 1.55 to 4.23; P<0.01), renal failure (OR, 1.84; 95% CI, 1.38 to 2.44; P<0.01). In contrast, there was no significant difference in long-term survival [hazard ratio (HR), 1.08; 95% CI, 0.81 to 1.43; P=0.60]. In systematic analysis of the studies in high-risk patients, ON-BH CABG showed a lower risk in terms of early mortality, intra-aortic balloon pump (IABP) usage, renal failure, hemodialysis, MI and pulmonary complication. No significant difference was observed in the long-term survival between ON-BH CABG and C-CABG.

Conclusions

With experienced and adept surgical team and mature ON-BH technology, ON-BH CABG may reduce the risk of postoperative death and complications in some patients. It might be an attractive alternative for high-risk patient populations.

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.

Simultaneous endovascular repair for abdominal aortic aneurysm and coronary artery bypass grafting in an octogenarian: A case report

INTRODUCTION

Coronary artery disease (CAD) is commonly associated with abdominal aortic aneurysms (AAAs) in elderly patients. When severe CAD requiring coronary artery bypass grafting (CABG) is associated with an impending AAA in a high-risk patient, the options for the suitable timing of CABG and AAA repair strategy (one-stage or two-stage) are still being debated.

PRESENTATION OF CASE

An 87-year-old man with non-ST-segment elevation myocardial infarction and a giant abdominal aortic aneurysm was transferred to our centre. Coronary angiography revealed triple-vessel coronary disease, and computed tomography confirmed a giant infrarenal fusiform abdominal aortic aneurysm 9 cm in maximal diameter. We simultaneously performed endovascular aneurysm repair prior to on-pump beating-heart coronary artery bypass grafting. The postoperative course was uneventful, and the patient was discharged on the 15th postoperative day.

CONCLUSION

Combined endovascular aneurysm repair and on-pump beating heart coronary artery bypass grafting in a one-stage operation is a promising strategy to improve therapeutic efficiency in octogenarians. More studies are needed to compare the efficacy and safety of one-stage and two-stage operations to treat concomitant coronary artery disease and aortovascular pathology in the high-risk octogenarian patients.

Intermittent on-pump beating-heart coronary artery bypass grafting-a safer option

Purpose

On-pump beating-heart coronary artery bypass grafting represents a merger of standard on and off-pump techniques and is thought to benefit patients by coupling the dual absence of cardioplegic arrest (conventional coronary surgery), with the hemodynamic instability during manipulation seen in off-pump surgery. However, the clinical benefits are still under discussion. We improvised on the standard on-pump beating-heart surgeries by introducing use of "intermittent" bypass as and when required.

Methods

This study involved 108 patients. "Intermittent" on-pump-beating heart coronary artery bypass grafting was done using suction stabilizer and placing aortic and venous cannula, electively in all patients (group 1) who were supported by pump intermittently (n = 54). Retrospective data of patients who underwent off-pump surgery electively by the same surgeon (group 2, n = 54) was collected.

Results

There was a significant advantage in the number of grafts performed for the lateral surface (circumflex branches) using the new technique compared to conventional technique (68vs22). Similarly, significant advantage was also noted in terms of total number of grafts along with shorter operating times. There were no mortalities in the new group compared to the off-pump group and blood loss was also lesser.

Conclusions

"Intermittent" on-pump coronary revascularization is a technically reliable method of coronary revascularization taking advantage of the off-pump and conventional on-pump techniques while considerably eliminating the disadvantages of both. It has shown its superiority in safety, number of grafts, blood loss, operating time and perioperative course.

Early and Medium Outcomes of On-Pump Beating-Heart versus Off-Pump CABG in Patients with Moderate Left Ventricular Dysfunction

OBJECTIVE

This study aims to compare the early and medium outcomes of on-pump beating-heart (OPBH) coronary artery bypass grafting (CABG) and off-pump CABG (OPCABG) in patients with left ventricular ejection fraction (LVEF) between 30% and 40%.

METHODS

This is a retrospective study of ischemic heart disease patients with LVEF between 30% and 40% who underwent surgical revascularization from January 2013 to December 2017. Patients were divided into OPBH group (n=44) and OPCABG group (n=68), according to the surgical method. Clinical material with early and medium outcomes were investigated and compared between these groups.

RESULTS

The two groups had similar baseline. Two OPBH patients and 3 OPCABG patients died in the hospital, which had no statistical significance (P>0.05). OPBH patients received a greater number of grafts (3.74±0.84) and presented more improved LVEF (45.92±7.11%) than OPCABG patients (3.36±0.80) and (42.81±9.29%), respectively, which had statistical significance (P<0.05). An increased amount of drainage during the first 12 hours was found in the OPBH group (P<0.05). Reoperation for bleeding, duration of mechanic ventilation, and other early outcomes had no statistical significance between the two groups. During the medium-time follow-up, OPBH patients showed significantly lower major adverse cardiovascular events (MACE)-free survival time (P=0.049) than OPCABG patients.

CONCLUSION

The OPBH technique was a safe and an acceptable alternative for surgical revascularization in patients with moderate left ventricular dysfunction which provided better mid-term MACE-free survival compared with OPCABG.