The optimal strategy for coronary revascularization remains controversial. Currently, most surgical revascularizations are performed with the use of cardiopulmonary bypass (ONCAB), yet over the past 20 years off-pump coronary artery bypass grafting (OPCAB) has been increasingly used because of the increased awareness of the deleterious effects of cardiopulmonary bypass (CPB) and aortic manipulation. Small, prospective, randomized controlled trials have lacked sufficient sample size to demonstrate differences in early and long-term outcomes. Larger observational studies that are better powered to statistically compare outcomes have shown more favorable in-hospital outcomes and equivalent long-term outcomes with OPCAB and ONCAB. The benefits of OPCAB techniques may be more apparent for patients at high risk for complications associated with CPB and aortic manipulation. Recent studies have demonstrated improved outcomes in higher-risk patients undergoing OPCAB, as well as improved neurological outcomes. The purpose of this review is to outline the recent literature comparing OPCAB with ONCAB, and to demonstrate efficacy of OPCAB as a useful technique for coronary revascularization.
"The conventional on-pump CABG surgery (C-CABG) can be associated with a higher rate of cardiovascular events and mortality compared with off-pump coronary artery bypass (OPCAB) (Cantero et al., 2012; Chawla et al., 2012). In contrast, the OPCAB seems to result in better outcomes in elderly patients and in those with comorbidities, such as, chronic kidney disease (Demaria et al., 2002; Carrier et al., 2003; Athanasiou et al., 2004; Chawla et al., 2012; Polomsky & Puskas, 2012). However , target vessel patency as well as effectiveness and completeness of revascularization has been questioned with OPCAB (Cerqueira Neto et al., 2012; Hattler et al., 2012). "
[Show abstract][Hide abstract] ABSTRACT: Background
Conventional coronary artery bypass grafting (C-CABG) and off-pump CABG (OPCAB) surgery may produce different patients’ outcomes, including the extent of cardiac autonomic (CA) imbalance. The beneficial effects of an exercise-based inpatient programme on heart rate variability (HRV) for C-CABG patients have already been demonstrated by our group. However, there are no studies about the impact of a cardiac rehabilitation (CR) on HRV behaviour after OPCAB. The aim of this study is to compare the influence of both operative techniques on HRV pattern following CR in the postoperative (PO) period. Methods
Cardiac autonomic function was evaluated by HRV indices pre- and post-CR in patients undergoing C-CABG (n = 15) and OPCAB (n = 13). All patients participated in a short-term (approximately 5 days) supervised CR programme of early mobilization, consisting of progressive exercises, from active-assistive movements at PO day 1 to climbing flights of stairs at PO day 5. ResultsBoth groups demonstrated a reduction in HRV following surgery. The CR programme promoted improvements in HRV indices at discharge for both groups. The OPCAB group presented with higher HRV values at discharge, compared to the C-CABG group, indicating a better recovery of CA function. Conclusion
Our data suggest that patients submitted to OPCAB and an inpatient CR programme present with greater improvement in CA function compared to C-CABG.
"In the SYNTAX trial, only 15% of the patients underwent OPCAB and in the FREEDOM trial, use of cardiopulmonary bypass was left to the surgeon's discretion, with the result that only 20% patients underwent off-pump surgery . There is a compelling body of evidence that OPCAB significantly reduces cerebrovascular complications   . A propensitymatched analysis of 30-day outcomes in >42 477 consecutive primary isolated CABG patients in the STS Adult Cardiac Surgery database documented a 35% reduction in stroke for OPCAB compared to conventional CABG (OR 0.65, P = 0.001) . "
[Show abstract][Hide abstract] ABSTRACT: Surgical revascularization remains the standard of care for many patients. Off-pump coronary artery bypass grafting (OPCAB) without cardiopulmonary bypass (CPB) has evolved during the past 20 years, and as such can significantly reduce the occurrence of neurological complications. While avoiding the aortic cross-clamping required in conventional on-pump techniques, OPCAB results in a lower incidence of stroke. However, clamp-related risk of stroke remains if partial or side-biting clamps are applied for proximal anastomoses. Others and we have demonstrated that no-touch 'anaortic' approaches avoiding any clamping during off-pump procedures via complete in situ grafting result in significantly reduced stroke rates when compared with partial clamping. Therefore, OPCAB in situ grafting has been proposed as the 'standard of care' to reduce neurological complications. However, this technique may not be applicable to for every patient as the use of free grafts (arterial or venous) requiring proximal anastomosis is often still necessary to achieve complete revascularization. In these situations, proximal anastomosis can be performed without a partial clamp by using the HEARTSTRING device, and over the last few years, considerable evidence has arisen supporting the impact of HEARTSTRING-enabled anastomosis to significantly minimize atheroembolism and neurological complications when compared with partial- or side-bite clamping. This paper provides a systematic overview and technical information about the combination of OPCAB and clampless strategies using the HEARTSTRING for proximal anastomosis to reduce stroke to levels reported for percutaneous coronary intervention.
Interactive Cardiovascular and Thoracic Surgery 06/2013; 17(3). DOI:10.1093/icvts/ivt237 · 1.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In coronary artery surgery the superiority of the internal mammary artery graft in 10-year survival was documented in 1986. In 1999 it was demonstrated that death, reoperation and percutaneous transluminary coronary angioplasty were more frequent in patients undergoing single rather than bilateral internal mammary artery grafting. Today coronary artery bypass grafting surgery is challenged by the success story of modern interventional cardiology. The Syntax Study, however, clearly underlined the better outcome for patients with triple-vessel and/or left main disease undergoing coronary artery bypass grafting in terms of repeat revascularization. Another point of ongoing discussion is the comparison between on-pump and off-pump coronary artery revascularization techniques. Even if mixed results exists in the literature, in experienced hands the combination of aortic no-touch and total arterial revascularization, probably leads to the superiority in off pump coronary artery bypass grafting in terms of significantly decreased rates of mortality, stroke, major adverse cardiac and cerebral vascular events. Coronary artery surgery in the next decade will be influenced by the further progression of minimally invasive surgical principles and by a variety of other factors. The role of robotics and hybrid surgery has yet to be defined. Alternatives within surgery will not only need to move to a less disruptive strategy (e.g. from on-pump to off-pump bypass) but also have to secure sustained innovation, as we can be sure that the current coronary artery bypass grafting activity will change substantially.
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