Off-Pump versus On-Pump Coronary-Artery Bypass Grafting in Elderly Patients.
Robert Bosch Krankenhaus Stuttgart, Stuttgart (A.U.), Herzzentrum Universität Leipzig, Leipzig (A.R., D.H.), Universitätsklinik Hamburg-Eppendorf (H.T.) and Albertinen-Krankenhaus Hamburg (F.-C.R.), Hamburg, Klinikum für Herzchirurgie Karlsruhe, Karlsruhe (P.V.), Universität Bochum, Bochum (A.A.), and Universitätsklinik Regensburg, Regensburg (M.H.) - all in Germany. New England Journal of Medicine
(Impact Factor: 55.87).
03/2013; DOI: 10.1056/NEJMoa1211666
Background The benefits of coronary-artery bypass grafting (CABG) without cardiopulmonary bypass in the elderly are still undetermined. Methods We randomly assigned patients 75 years of age or older who were scheduled for elective first-time CABG to undergo the procedure either without cardiopulmonary bypass (off-pump CABG) or with it (on-pump CABG). The primary end point was a composite of death, stroke, myocardial infarction, repeat revascularization, or new renal-replacement therapy at 30 days and at 12 months after surgery. Results A total of 2539 patients underwent randomization. At 30 days after surgery, there was no significant difference between patients who underwent off-pump surgery and those who underwent on-pump surgery in terms of the composite outcome (7.8% vs. 8.2%; odds ratio, 0.95; 95% confidence interval [CI], 0.71 to 1.28; P=0.74) or four of the components (death, stroke, myocardial infarction, or new renal-replacement therapy). Repeat revascularization occurred more frequently after off-pump CABG than after on-pump CABG (1.3% vs. 0.4%; odds ratio, 2.42; 95% CI, 1.03 to 5.72; P=0.04). At 12 months, there was no significant between-group difference in the composite end point (13.1% vs. 14.0%; hazard ratio, 0.93; 95% CI, 0.76 to 1.16; P=0.48) or in any of the individual components. Similar results were obtained in a per-protocol analysis that excluded the 177 patients who crossed over from the assigned treatment to the other treatment. Conclusions In patients 75 years of age or older, there was no significant difference between on-pump and off-pump CABG with regard to the composite outcome of death, stroke, myocardial infarction, repeat revascularization, or new renal-replacement therapy within 30 days and within 12 months after surgery. (Funded by Maquet; GOPCABE ClinicalTrials.gov number, NCT00719667 .).
Available from: Miklos Lipcsey
- "In particular, CPB itself has been implicated as trigger of inflammatory cascade activation (Hall et al., 1997; Raja & Berg, 2007) and kidney injury (Fischer et al., 2002). Cardiac surgery without CPB (off-pump surgery), therefore, is believed to induce less inflammation than on-pump surgery and to lead to a lesser risk of postoperative AKI (Diegeler et al., 2013; Houlind et al., 2012; Lamy et al., 2012, 2013). One possible mechanism of kidney protection during off-pump cardiac surgery is decreased inflammation and tubular damage (Gude & Jha, 2012). "
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ABSTRACT: Abstract Context: Cardiac surgery. Objective: To compare plasma and urinary neutrophil gelatinase-associated lipocalin (P-/U-NGAL) in on-pump (n = 43) versus off-pump (n = 40) surgery. Materials and methods: We obtained perioperative P-/U-NGAL and outcome data. Results: P-/U-NGAL increased after surgery. P-NGAL was higher post-surgery in on pump patients (139 versus 67 µg L(-1); p < 0.001), but not at 24 h. There were no differences in U-NGAL. Correlation between P-/U-NGAL and plasma creatinine was weak. Discussion: P-NGAL acts like a neutrophil activation biomarker and U-NGAL like a tubular injury marker. Conclusion: On-pump patients had greater neutrophil activation. On- versus off-pump surgery had similar impact on tubular cells.
Available from: Marion Hofmann Bowman
- "Two randomized large clinical trials examining the benefits of CABG without cardiopulmonary bypass were recently reported. The study by Diegeler et al. found no difference in composite outcome of death, stroke, myocardial infarction , repeat revascularization, or new renal-replacement therapy within 30 days and within 12 month after surgery in 2539 patients 75 years and older randomized to either off-pump CABG or on-pump CABG . A second large multicenter randomized clinical trial examined the quality of life, neurocognitive function and clinical outcome 1 year after randomization of 4752 patients undergoing CABG on pump or off pump, and found no significant difference in the rate of the primary or composite outcome . "
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ABSTRACT: Study's purpose: Plasma levels of soluble receptor for advanced glycation endproducts (sRAGE) and S100A12 are increased in young children after cardiac surgery and correlate with the time spent on cardiopulmonary bypass (CPB). This study was performed to investigate whether plasma levels of sRAGE and S100A12 are affected by the use of CPB. Levels of S100A12 and sRAGE, along with of interleukin-6, tumor necrosis factor-α, myeloperoxidase, and C-reactive protein were measured in 25 adults undergoing non-urgent coronary artery bypass grafting with and without the use of CPB. Significant finding: Plasma levels of S100A12, sRAGE, IL-6, TNF-α and MPO 4h after cardiac surgery were elevated compared to baseline; this increase was equally observed in patients undergoing traditional coronary artery bypass grafting on cardiopulmonary bypass (n = 16), and in patients undergoing robot-assisted coronary artery bypass grafting off pump (OPCAB, n = 9). Patients with prolonged hospitalization of 7 days or longer had significantly higher S100A12 and sRAGE 4 hours post surgery compared to patients hospitalized ≤ 6 days.
Increased sRAGE and S100A12 after cardiac surgery is associated with prolonged length of hospitalization in patients after coronary artery bypass grafting; however, we did not observe an intrinsic effect of cardiopulmonary bypass on S100A12 or sRAGE plasma levels in our small pilot study. Further studies are required to confirm the value of sRAGE and S100A12 in predicting postoperative complications after cardiac surgery in a larger study.
Available from: Jacques Scherman
- "older than 75 years to undergo either OPCAB or on-pump, concluded that no significant difference in regard to neurological outcomes was seen The stroke rate of 2.2% in the OPCAB is, however, very high, but no information on aortic techniques was provided to the reader . "
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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.
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