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On-pump and off-pump coronary artery bypass grafting for patients needing at least two grafts: comparative outcomes at 20 years
Abstract
Objectives:
Despite evidence from several randomized controlled trials and observational studies validating short-term safety and efficacy of off-pump coronary artery bypass grafting (CABG), concerns persist regarding the impact of off-pump CABG on long-term survival and freedom from reintervention. This persistent scepticism regarding off-pump CABG prompted us to review our practice of CABG over the last 20 years with a view to comparing the impact of off-pump and on-pump CABG on short-term and long-term outcomes in a high-volume off-pump coronary surgery centre.
Methods:
We retrospectively analysed prospectively collected data from the Patients Analysis and Tracking System database (Dendrite Clinical Systems, Oxford, UK) for all isolated first-time CABG procedures with at least 2 grafts performed at our institution from January 1996 to September 2017. Over the study period, 5995 off-pump CABG and 4875 on-pump CABG were performed by surgeons with exclusive off-pump and on-pump practices, respectively. Multivariable logistic regression and the Cox model were used to investigate the effect of off-pump versus on-pump procedures on short-term outcomes and long-term survival. Propensity score matching was used to compare the 2 matched groups.
Results:
Off-pump CABG was associated with a lower risk for 30-day mortality [odds ratio (OR) 0.42, 95% confidence interval (CI) 0.32-0.55; P < 0.001], reintubation/tracheostomy (OR 0.58, 95% CI 0.47-0.72; P < 0.001) and re-exploration for bleeding (OR 0.48, 95% CI 0.37-0.62; P < 0.001). The benefit in terms of operative deaths from off-pump was significant in those with Society of Cardio-Thoracic Surgery logistic EuroSCORE >2 (interaction P = 0.04). When compared with on-pump CABG, off-pump CABG did not significantly reduce the risk of stroke (OR 0.96, 95% CI 0.88-1.12; P = 0.20) and postoperative haemofiltration (OR 0.98, 95% CI 0.86-1.20; P = 0.35). At the median follow-up of 12 years (interquartile range 6-17, max 21), off-pump CABG did not affect late survival [log rank P = 0.24; hazard ratio (HR) 0.95, 95% CI 0.89-1.02] or the need for reintervention (log rank P = 0.12; HR 1.19, 95% CI 0.95-1.48).
Conclusions:
This large volume, single-centre study with the longest reported follow-up confirms that off-pump CABG performed by experienced surgeons, who perform only off-pump procedures in a high-volume off-pump coronary surgery centre, is associated with lower risk of operative deaths, fewer postoperative complications and similar 20-year survival and freedom from reintervention rates compared with on-pump CABG.
... However, none of these two methods was found to be superior to the other, and their results are still debating the postoperative complications and major adverse cardiac and cerebrovascular events (MACCE) through various years of follow-up. This debate is especially more profound in patients with multiple coronary artery diseases [16][17][18][19]. Nonetheless, considerable diversities in the study design, main outcomes, and confounding adjustments in the literature cause severe heterogeneity and controversy among previous studies. ...
... P value = 0.0008) [32]. In addition, there are few studies with longer follow-up duration [19], and this issue demands further research. ...
Background and aim of the study:
Several studies have compared early and late outcomes of on-pump coronary artery bypass grafting (CABG) and off-pump CABG. However, there is still an ongoing debate on this matter, especially in patients with triple-vessel coronary artery disease (3VD).
Methods:
We randomly assigned 274 consecutive patients with 3VD to two equal groups to undergo on-pump CABG or off-pump CABG. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), including all-cause mortality, acute coronary syndrome, stroke or transient ischemic attack, and the need for repeat revascularization. The secondary outcomes were postoperative infection, ventilation time, ICU admission duration, hospital stay length, and renal failure after surgery.
Results:
The median follow-up duration was 31.2 months (range 24.6-35.2 months). The mean age of patients was 61.4 ± 9.3 years (range: 38-86), and 207 (78.7%) were men. There were 15 (11.2%) and 9 (7.0%) MACCE occurrences in on-pump and off-pump groups, respectively (P value = 0.23). MACCE components including all-cause death, non-fatal MI, CVA, and revascularization did not significantly differ between on-pump and off-pump groups. We observed no difference in the occurrence of MACCE between off-pump and on-pump groups in multivariable regression analysis (HR = 0.57; 95% CI 0.24-1.32; P value = 0.192). There were no statistical differences in postoperative outcomes between the off-pump and on-pump CABG groups.
Conclusions:
Off-pump CABG is an equal option to on-pump CABG for 3VD patients with similar rates of MACCE and postoperative complications incidence when surgery is performed in the same setting by an expert surgeon in both methods. (IRCT20190120042428N1).
... However, their results are still debated, and none of these two methods was found to be superior to the other (11)(12)(13). This debate is especially more profound in patients with multiple coronary artery diseases (14)(15)(16)(17). Nonetheless, considerable diversities in the study design, main outcomes, and confounding adjustments in the literature cause severe heterogeneity and controversy among previous studies. ...
... P-value = 0.0008) (33). In addition, there are few studies with longer follow-up duration (17), and this issue demands further research. ...
background and aim of the study: Several studies have compared early and mid-term outcomes of on-pump coronary artery bypass grafting (CABG) and off-pump CABG. However, there is still an ongoing debate on this matter, especially in patients with triple-vessel coronary artery disease (3VD).
Methods: We randomly assigned 274 consecutive patients with 3VD to two equal groups to undergo on-pump CABG or off-pump CABG. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), including all-cause mortality, acute coronary syndrome, stroke or transient ischemic attack, and the need for repeat revascularization. The secondary outcomes were postoperative infection, ventilation time, duration of ICU admission, length of hospital stay, and renal failure after surgery.
Results: The mean follow-up duration was 31.1 ± 5.9 months. The mean age of patients was 61.4±9.3 years (range: 38 to 86), and 207 (78.7%) were men. There were 15 (11.2%) and 9 (7.0%) MACCE occurrence in on-pump and off-pump groups, respectively (P-value =0.23). None of the MACCE components, including CVA, non-fatal MI, and revascularization, did not significantly differ between on-pump and off-pump groups. We observed no difference in the occurrence of MACCE between off-pump and on-pump groups in multivariate regression analysis (HR=0.57; 95% CI: 0.24–1.32; P-value=0.192). There were no statistical differences in postoperative outcomes between the off-pump and on-pump CABG groups.
Conclusions: We found no significant differences between on-pump and off-pump CABG in the rate of MACCE and postoperative complications incidence when surgery is performed in the same setting by the same surgeon. (IRCT20190120042428N1)
... 6 There are data to reflect surgeon and unit volume affecting outcomes in off-pump surgery. 7 The UK National Adult Cardiac Surgery Audit Database demonstrated that off-pump surgery performed by surgeons with a preference for the technique had superior outcomes when compared to on-pump surgery performed by surgeons with a preference for it. 8 Additional analyses of RCTs have demonstrated that there are certain subpopulations nested within the cohorts that might benefit from the off-pump approach. ...
... We have previously published our detailed methodology for patient selection. 7 Briefly, the patient admission and tracking system (PATS database; Dendrite Clinical Systems, Oxford, UK) captures detailed information on a wide range of pre, intra, and post-operative variables (including complications and mortality) for all patients undergoing cardiac surgery at our institution. Reproducible cleaning algorithms were applied to the database, which are regularly updated as required. ...
Background: Octogenarians are being increasingly referred for coronary artery bypass grafting (CABG). However, there is a paucity of studies reporting impact of choice of surgical revascularization strategy on in-hospital mortality and mid-term survival of octogenarians. We evaluated our institutional experience to determine the impact of off-pump and on-pump CABG on in-hospital mortality and mid-term survival of octogenarians. Methods: We retrospectively analysed prospectively collected data from the Patients Analysis and Tracking System database (Dendrite Clinical Systems, Oxford, UK) for all isolated first-time CABG procedures with at least 2 grafts performed at our institution from January 2000 to September 2017. Over the study period, 566 octogenarians underwent either off-pump (N = 374) or on-pump CABG (N = 192). Short-term outcomes including in-hospital mortality as well as mid-term survival was compared for the two groups. Results: The two groups had similar preoperative demographics and mean number of distal anastomoses (off-pump: 2.7 ± 0.6 [median 3] vs on-pump: 2.7 ± 0.3 [median 3]; P=0.6). However, more bilateral internal mammary artery grafts were performed in the off-pump cohort compared to on-pump cohort (117 [31.3%] vs 22 [11.5%]; P <0.001). In-hospital mortality for the entire cohort was 5.7% with significantly fewer deaths in the off-pump cohort (4.3% vs 8.3%; P=0.04). The remaining in-hospital outcomes were similar. Kaplan-Meier survival at 1 year (89.7% vs 82.9%; P=0.048) and 5 year (71.1% vs 61.3%; P=0.038) was significantly better for the off-pump cohort. Conclusion: Octogenarians experience lower in-hospital mortality and improved mid-term survival after off-pump CABG compared to on-pump CABG.
... Current presentation confirms the trend of satisfactory results in welltrained centers and may indicate the necessity for center specialization into either on-or off-pump technique. Raja et al. [19] proved that off-pump CABG, performed by experienced surgeons, is associated with both low perioperative risk and satisfactory 20-year survival not affected by the surgical technique. ...
Introduction
Left main (LM) coronary disease is believed to represent a complex, advanced, and potentially life-threatening atherosclerotic syndrome that can be treated by either percutaneous or surgical interventions. Despite its satisfactory results, the declined number of off-pump coronary artery bypass grafting (OPCAB) is observed.
Aim
To compare 10-year survival and point out possible mortality risk factors in patients referred for left main and multivessel OPCAB surgery followed by transit time bypass measurements.
Material and methods
There were 159 patients (128 (81%) men and 31 (19%) women) in a median age of 66 (60–70) years enrolled in retrospective analysis who were referred to surgical intervention due to left main (51, 32%) and multivessel (108, 68%) disease. The regression analysis for long-term mortality risk and the Kaplan-Meyer survival curve were analyzed.
Results
Multivariable analysis pointed female sex (HR = 1.08, 95% CI: 1.03–1.14, p = 0.001) and diabetes mellitus (HR = 6.33, 95% CI: 1.86–21.52, p = 0.003) as possible risk factors for 10-year mortality risk. There was no significant difference in Kaplan-Meyer 10-year mortality comparison between left main and multivessel disease patients treated by off-pump surgical revascularization (HR = 0.93, 95% CI: 0.40–2.13, p = 0.86).
Conclusions
Off-pump surgery in the left main disease, compared to multivessel disease, represents a safe surgical technique with satisfactory long-term results. The female sex and diabetes mellitus were found as possible risk factors for 10-year mortality risk in multivariable analysis.
... First, OPCAB has failed to demonstrate short and long-term survival benefits compared with ONCAB in RCTs. No differences were [12]. In fact, OPCAB was often associated with a lower number of graft and increased risk of incomplete revascularization. ...
Objectives:
The popularity of off pump coronary artery bypass grafting varies across the world, ranging from 20% in Europe and USA to 56% in Asia. We present the trend and early clinical outcomes in off pump in the United Kingdom.
Method:
All patients who underwent elective or urgent isolated CABG from 1996 to 2019 were extracted from the National Adult Cardiac Surgery Audit database. The trend in operating surgeons and units volume and training in off pump were analysed. Early clinical outcomes between off- and on pump Coronary Artery Bypass grafting were compared using propensity score matching.
Results:
A total 351422 patients were included. The overall off pump rate during the study period was 15.17%, it peaked in 2008 (19.8%), followed by a steady decreased to 2018 (7.63%). Its adoption varied across centres and surgeons, ranging from <1% to 48.36% and <1% to 85.5% respectively of total cases performed.After propensity score matching for the period 1996-2019, off pump, when compared to on pump, was associated with a lower in-hospital/30 day mortality (1.2% vs 1.5%, p < 0.001), return to theatre (3.7% vs 4.5%, p < 0.001), cerebrovascular accident (Transient Ischaemic Attack: 0.3% vs 0.6%, Stroke: 0.3% vs 0.6%, p < 0.001) and deep sternal wound infection (0.8% vs 1.2%, p = <0.001). In a sub analysis from the introduction of Euroscore II (2012-2019) there was no differences in-hospital/30 day mortality [1.0% vs 1.0%, p = 0.71]. However, on pump, had a higher return to theatre [4.2% vs 2.7%, p < 0.001], cerebrovascular accident [Transient Ischaemic Attack: 0.4% vs 0.2%, Stroke: 0.5% vs 0.3%, p = 0.003] and deep sternal wound infection [1.0% vs 0.6%, p = 0.004].
Conclusion:
Our data show a decreasing trend in the use of off pump in the UK since 2008. This is likely to be multifactorial and raises the question on whether it should be a specialized revascularisation technique.
... Another finding of this study is that ID patients who received on-pump surgery were more likely to experience a reduction in EF during follow-up in the subgroup analyses. CPB can exacerbate oxidative stress injury [20], although its impact on prognosis is still uncertain [41,42]. Therefore, the increased oxidative stress caused by the CPB and coexisting ID might be a possible explanation for the observed reduction in EF, in T2DM patients. ...
Background
Iron deficiency (ID) is one of the most common micronutrient deficiencies affecting public health. Studies show that ID affects the prognosis of patients with heart disease, including heart failure, coronary artery disease and myocardial infarction. However, there is limited information regarding the impact of ID on patients undergoing cardiac surgery. This study aimed to evaluate the influence of preoperative ID on the prognosis of type 2 diabetes mellitus (T2DM) patients undergoing coronary artery bypass grafting (CABG).
Methods
In the Glycemic control using mobile-based intervention in patients with diabetes undergoing coronary artery bypass to promote self-management (GUIDEME) study, patients with T2DM undergoing CABG were prospectively recruited. In this study, only those patients with preoperative iron metabolism results were enrolled. Patients were grouped based on the presence of preoperative ID. The primary endpoint was defined as the significant improvement of follow-up ejection fraction (EF) compared to postoperative levels (classified according to the 75th percentile of the change, and defined as an improvement of greater than or equal to 5%). Univariable logistic regression was performed to explore the potential confounders, followed by multiple adjustment.
Results
A total of 302 patients were enrolled. No deaths were observed during the study period. A higher incidence of the primary endpoint was observed in the ID group (25.4% vs 12.9%, p = 0.015). The postoperative and follow-up EF were similar beween the two groups. In the regression analysis, ID was noticed to be a strong predictor against the significant improvement of EF in both univariable (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.22–0.86, p = 0.017) and multivariable (OR: 0.43, 95% CI: 0.24–0.98, p = 0.043) logistic regression. In the subgroup analysis, ID was a predictor of significant improvement of EF in age ≤60 years, male, EF ≤60%, and on-pump CABG patients.
Conclusions
In T2DM patients undergoing CABG, ID might negatively affect the early recovery of left ventricular systolic function in terms of recovery of EF 3–6 months after surgery, especially in patients age ≤60 years, males, EF ≤60% and in those undergoing on-pump CABG.
... However, ONCABG patients received more often red blood [13]. The current main view, however, seems to be that the surgeon's experience contributes to a successful outcome at OPCABG [5,6], and a similar survival profile in both types of surgery can be seen in a follow-up of up to 20 years [14]. In our study, the OPCABG surgeons had several years of experience and they used principally OPCABG technique for all their CABG patients. ...
Objectives
To determine whether surgical technique has an effect on prognosis in coronary artery bypass grafting (CABG).
Design
Retrospective observational.
Setting
Single center.
Participants
All the off-pump (OPCABG) and on-pump (ONCABG) patients at Turku University Central Hospital in 2018.
Interventions
None.
Measurements and main results
After propensity score matching, perioperative, 1-year and 3-year mortality did not differ between the groups. The ONCABG patients received more allogenic red blood cells (1.3 vs. 0.6 units, p = 0.020), autologous red blood cells (564 vs. 285 ml, p < 0.001) and crystalloids (3388 vs. 2808 ml, p < 0.001), and had higher postoperative values of troponin T (581 vs. 222, p = 0.001) and lactate (1.69 vs. 1.23, p < 0.001) than the OPCABG patients.
Conclusions
The both techniques seem equally safe. However, there may be some benefits to avoiding using a heart-lung machine, such as lower infused fluid volumes. Myocardial damage may also be milder and postoperative hemodynamics more balanced in OPCABG patients, based on lower levels of troponin T and lactate.
... early complications, and length of hospital stay while providing equivalent longterm outcomes compared with standard CABG decades after surgery. 22,26,[28][29][30][31] Furthermore, OPCAB reduces operative blood loss and thus need for transfusion of blood products which are associated with adverse outcomes. 32 Furthermore, OPCAB has been shown to benefit elderly patients, especially those with high calcific load, diabetes, and COPD, reducing their risk of death, stroke, and MI. ...
Background
Combined on‐pump coronary artery bypass (ONCAB) and surgical aortic valve replacement (SAVR) is the treatment of choice for concomitant severe aortic stenosis and coronary artery disease not amenable to percutaneous coronary intervention. Extensive aortic calcification and atheromatous disease may prohibit cardiopulmonary bypass and aortic cross‐clamping. In these cases, anaortic off‐pump coronary artery bypass (OPCAB) is a Class I (EACTS 2018) and Class IIA (AHA 2021) indication for surgical coronary revascularization. Transcatheter aortic valve replacement (TAVR) has similar benefits when compared with SAVR for this population (Partner 2 & 3). Herewith we describe a case series of concomitant Anaortic OPCAB and TAVR via the transfemoral approach for patients with coronary artery and valve disease considered too high risk for traditional coronary artery bypass grafting and SAVR due to severe aortic disease.
Methods/Results
Eight patients underwent anaortic OPCAB and transfemoral TAVR during the same anesthetic in a hybrid operating room. Seven patients with multivessel disease had anaortic OPCAB via a sternotomy using composite grafts, one patient with LAD disease had anaortic OPCAB using a Da Vinci‐assisted MIDCAB approach. All patients then had an Edwards Sapien 3 TAVR placed percutaneously via the common femoral artery. There was no 30 mortality or CVA in the series and all patients were discharged to home or a rehabilitation facility on Day 4–13.
Conclusions
Combined anaortic OPCAB and transfemoral TAVR is a safe and feasible approach to treating concomitant extensive coronary artery disease and severe aortic stenosis. The aortic no‐touch technique provides benefits in the elderly high‐risk patients by reducing the risk of postoperative myocardial infarction and cerebrovascular stroke.
... Raja et al. compared the impact of OPCAB and ONCAB on shortterm and long-term outcomes in a high-volume off-pump coronary surgery center in isolated first-time CABG procedures with at least two grafts; 5,995 OPCAB and 4,875 ONCAB were performed by surgeons with exclusive off-pump and on-pump practices. OPCAB performed by experienced surgeons, who perform only off-pump procedures in a high-volume off-pump coronary surgery center, was associated with a lower risk of operative deaths, fewer postoperative complications, and similar 20-year survival and freedom from reintervention rates compared with ONCAB [62] . ...
Coronary artery bypass grafting (CABG) has consolidated its role as the most effective procedure for treating patients with advanced atherosclerotic coronary artery disease, reducing the long-term risk of myocardial infarction and death compared to other therapies and relieving angina. Despite the recognized benefits afforded by surgical myocardial revascularization, a subset of higher-risk patients bears a more elevated risk of perioperative stroke. Stroke remains the drawback of conventional CABG and has been strongly linked to aortic manipulation (cannulation, cross-clamping, and side-biting clamping for the performance of proximal aortic anastomoses) and the use of cardiopulmonary bypass. Adoption of off-pump CABG (OPCAB) is demonstrated to lower the risk of perioperative stroke, as well as reducing the risk of short-term mortality, renal failure, atrial fibrillation, bleeding, and length of intensive care unit stay. However, increased risk persists owing to the need for the tangential ascending aorta clamping to construct the proximal anastomosis. The concept of anaortic (aorta no-touch) OPCAB (anOPCAB) stems from eliminating ascending aorta manipulation, virtually abolishing the risk of embolism caused by aortic wall debris into the brain circulation. The adoption of anOPCAB has been shown to further decrease the risk of postoperative stroke, especially in higher-risk patients, entailing a step forward and a refinement of outcomes provided by the primeval OPCAB technique. Therefore, anOPCAB has been the recommended technique in patients with cerebrovascular disease and/or calcification or atheromatous plaque in the ascending aorta and should be preferred in patients with high-risk factors for neurological damage and stroke.
... Previous studies show that postoperative sedation is important for prognosis. Therefore, the ideal sedative treatment is beneficial to reduce stress response in patients after cardiac surgery, reduce man-machine confrontation, reduce oxygen consumption, stabilize hemodynamics and reduce delirium or restlessness, to ensure the completion of the invasive operation [11][12][13][14] . ...
Objective To determine the predictive value of surgical Apgar score on delirium postoperatively following OPCABG. Method Intraoperative anesthesia data of patients underwent OPCABG during the period of January 2012 and December 2019 were reviewed and SAS score of each patient was calculated. Relationship between SAS score and postoperative occurrence of delirium were analyzed to determine the underlying mechanism. Results There are a total of 436 patients included with a mean age of 62.8±13.8 and 61.2±16.8 in each group. Patients in Delirium group had significantly higher incidence of heart failure (P=0.043) preoperatively in the Delirium group. No significant difference was observed referring to ASA PS III (P=0.102) and no significant difference was observed in duration of the surgery and anesthesia. Also no significant differences was observed as to dexmedetomidine and propofol use (P=0.256, P=0.278). The mean SAS score was in 4.2±0.8, 7.8±1.2 in two groups respectively (P＜0.001) and 96(22.02%) postoperative delirium events were recorded. Patients in Delirium group had much more EBL (P＜0.001) while LHR (P=102) showed no significant statistical difference between two groups. Univariate and multivariate regression analysis showed that the intraoperative SAS score was significant predictors of delirium following OPCABG (P＜0.001; P＜0.001). After adjustment for other clinical predictors, the addition of SAS also improved and the area under the curve to predict delirium was 0.934 (95%CI, 0.907-0.960, P＜0.001). Conclusions Intraoperative SAS score is associated with postoperatively following OPCABG and SAS score may be a valuable component to improve preoperative risk stratification of delirium among patient under OPCABG.
... Coronary artery bypass grafting (CABG) surgery and percutaneous coronary intervention (PCI) are both well-established revascularization methods to treat CAD. CABG is associated with the reduction of mortality, and remains a standard therapy in patients with extensive CAD when compared with PCI and pharmacological treatment alone [1]. ...
Coronary artery bypass grafting may be associated with several cardiac complications, including ischemia, acute myocardial infarction, arrhythmias, or hemodynamic instability. Accumulating evidence suggests that well-developed coronary collateral circulation may protect against adverse effects, including myocardial ischemia. Assessment of myocardial microvascular perfusion is, therefore, of great clinical interest in beating heart surgery. In this paper, myocardial microvascular perfusion is continuously assessed on the beating heart using laser Doppler flowmetry in consecutive patients who underwent coronary artery bypass grafting procedures. No significant (p = 0.110) differences were found between the averaged perfusion signal (n = 42) at the baseline, during artery occlusion, or after reperfusion (732.4 ± 148.0 vs. 711.4 ± 144.1 vs. 737.0 ± 141.2, respectively). In contrast, significantly different (p < 0.001) mean perfusion signals (n = 12) were found (805.4 ± 200.1 vs. 577.2 ± 212.8 vs. 649.3 ± 220.8) in a subset of patients who presented with hemodynamic instability and myocardial ischemia. Additionally, a strong positive correlation between the plasma levels of high-sensitivity troponin I and perfusion decrease level after artery occlusion was found (r = 0.854, p < 0.001). This study argues that myocardial microvascular perfusion remains constant during coronary artery bypass grafting on the beating heart in advanced coronary artery disease. This phenomenon is most likely due to an extensive coronary collateral circulation.
Multivessel coronary artery disease is present in ∼50% of patients with acute coronary syndrome and, compared with single-vessel disease, entails a higher risk of new ischaemic events and a worse prognosis. Randomized controlled trials have shown the superiority of ‘complete revascularization’ over culprit lesion-only treatment. Trials, however, only included patients treated with percutaneous coronary intervention (PCI), and evidence regarding complete revascularization with coronary artery bypass graft (CABG) surgery after culprit lesion-only PCI (‘hybrid revascularization’) is lacking. The CABG after PCI is an open, non-negligible therapeutic option, for patients with non-culprit left main and/or left anterior descending coronary artery disease where evidence in chronic coronary syndrome patients points in several cases to a preference of CABG over PCI.
This valuable but poorly studied ‘PCI first-CABG later’ option presents, however, relevant challenges, mostly in the need of interrupting post-stenting dual antiplatelet therapy (DAPT) for surgery to prevent excess bleeding. Depending on patients’ clinical characteristics and coronary anatomical features, either deferring surgery after a safe interruption of DAPT or bridging DAPT interruption with intravenous short-acting antithrombotic agents appears to be a suitable option. Off-pump minimally invasive surgical revascularization, associated with less operative bleeding than open-chest surgery, may be an adjunctive strategy when revascularization cannot be safely deferred and DAPT is not interrupted.
Here, the rationale, patient selection, optimal timing, and adjunctive strategies are reviewed for an ideal approach to hybrid revascularization in post-acute coronary syndrome patients to support physicians’ choices in a case-by-case patient-tailored approach.
Objective:
To evaluate the clinical effectiveness of bilateral internal mammary artery grafting over long-term (15 years) postoperative period.
Material and methods:
There were 276 patients divided into two groups: 135 patients (group A) underwent bilateral internal mammary artery grafting and 141 patients (group B) underwent unilateral internal mammary artery grafting together with venous bypass grafts. On-pump surgeries and cardioplegia, parallel CPB and on-pump procedures were performed in equal proportions. Mean age of patients was 57.3±7.6 years. Diabetes mellitus was detected in 21 (15.5%) and 24 (19.1%) patients, respectively (p>0.05). Mean LV ejection fraction was 55.4±9.9%, revascularization index - 3.1±0.8 and 3.0±0.7, respectively. In the 1st group, 43 patients underwent bilateral internal mammary artery grafting alone. Autovenous grafts were additionally used in other 84 patients.
Results:
Ten-year survival exceeded 90% in both groups. Freedom from adverse cardiac events after 15 years was significantly higher in group A (77.3% vs. 59.3%, p=0.018). In group A, 16 patients died throughout this period due to cancer (50%), myocardial infarction (12.5%), stroke (18.8%) and complications of diabetes mellitus (6.3%). In group B, 22 patients died mainly from cardiac causes (myocardial infarction - 40.9%, cancer - 27.3%).
Conclusion:
Bilateral internal mammary artery grafting has obvious advantages over traditional coronary artery bypass grafting. If we take into account higher proportion of cardiac causes in structure of mortality in group B, we can talk about positive impact of bilateral internal mammary artery grafting not only on the quality of life, but also on life expectancy in long-term postoperative period.
There are some discrepancies about the superiority of the off-pump coronary artery bypass grafting (CABG) surgery over the conventional cardiopulmonary bypass (on-pump). The aim of this study was estimating risk ratio of mortality in the off-pump coronary bypass compared with the on-pump using a causal model known as collaborative targeted maximum likelihood estimation (C-TMLE). The data of the Tehran Heart Cohort study from 2007 to 2020 was used. A collaborative targeted maximum likelihood estimation and targeted maximum likelihood estimation, and propensity score (PS) adjustment methods were used to estimate causal risk ratio adjusting for the minimum sufficient set of confounders, and the results were compared. Among 24,883 participants (73.6% male), 5566 patients died during an average of 8.2 years of follow-up. The risk ratio estimates (95% confidence intervals) by unadjusted log-binomial regression model, PS adjustment, TMLE, and C-TMLE methods were 0.86 (0.78–0.95), 0.88 (0.80–0.97), 0.88 (0.80–0.97), and 0.87(0.85–0.89), respectively. This study provides evidence for a protective effect of off-pump surgery on mortality risk for up to 8 years in diabetic and non-diabetic patients.
In 2018, 34.2 million or 10.5% of the US population were affected by diabetes, and 88 million Americans aged 18 and older had prediabetes [1]. These individuals carry up to eight times the risk of cardiovascular events compared to nondiabetic individuals, making cardiovascular disease the largest cause of mortality in this population [2]. The prevalence of coronary artery disease (CAD) has been estimated to be as high as 55% in the diabetic population [3]. It has been shown that diabetes is a major independent risk factor for cardiovascular disease after adjustment for other risk factors such as age, hypertension, hypercholesterolemia, and tobacco abuse [4]. Patients with diabetes appear to develop accelerated and more severe CAD and also exhibit a diminished angiogenic response to myocardial ischemia as shown angiographically [5] and in autopsy studies [6]. This diminished angiogenic response is associated with coronary microvascular and endothelial dysfunction as well as the presence of an overall anti-angiogenic milieu leading to fewer collateral blood vessels [7, 8]. Hyperglycemia, hyperinsulinemia, and insulin resistance further add to the development of CAD, cardiomyopathy, and heart failure (Fig. 24.1). This culminates in a greater tendency toward more frequent and more severe adverse cardiovascular events. The relative risk of myocardial infarction is 50% greater in diabetic men and 150% greater in diabetic women [9]. Approximately, 20–30% of patients who have undergone coronary artery bypass grafting (CABG) have diabetes mellitus [10]. Thus, diabetic patients undergoing surgical coronary revascularization represent a large and complex patient population. There continue to be advancements in both percutaneous coronary interventions (PCI), primarily the use of drug-eluting stents, and surgical techniques, such as off-pump CABG and the use of multiple arterial grafts, that have continued to improve methods of coronary revascularization. While there is evidence to suggest that these new techniques have improved outcomes in diabetic patients [11], the optimal treatment for multivessel CAD continues to evolve for the diabetic patient population, which still suffers from worse long-term outcomes compared to the nondiabetic population.KeywordsCardiac surgeryDiabetes mellitusCoronary artery bypassCardiopulmonary bypass
Background
Obesity rates globally continue to rise and in turn the body mass index (BMI) of patients undergoing cardiac surgery is set to mirror this. Patients who are Class III obese (BMI ≥ 40) pose significant challenges to the surgical teams responsible for their care and are also at high risk of complications from surgery and even death. To improve outcomes in this population, interventions carried out in the preoperative, operative, and postoperative periods have shown promise. Despite this, there are no defined best practice national guidelines for perioperative management of obese patients undergoing cardiac surgery.
Aim
This review is aimed at clinicians and researchers in the field of cardiac surgery and aims to form a basis for the future development of clinical guidelines for the management of obese cardiac surgery patients.
Methods
The PubMed database was utilized to identify relevant literature and strategies employed at various stages of the surgical journey were analyzed.
Conclusions
Data presented identified the benefits of preoperative respiratory muscle training, off‐pump coronary artery bypass grafting where possible, and early extubation. Further randomized controlled trials are required to identify optimal operative and perioperative management strategies before the introduction of such guidance into clinical practice.
Aim:
Comparison of short and mid-term outcomes between off-pump CABG (OPCAB) and on-pump CABG (ONCAB) in patients older than 65 throughout a meta-analysis of randomized clinical trials (RCTs).
Evidence acquisition:
A literature search was conducted using 3 databases. RCTs reporting mortality outcomes of OPCAB versus ONCAB among the elderly were included. Data on myocardial infarction, stroke, re-revascularization, renal failure and composite endpoints after CABG were also collected. Random effects models were used to compute statistical combined measures and 95% confidence intervals (CI).
Evidence synthesis:
Five RCTs encompassing 6221 patients were included (3105 OPCAB and 3116 ONCAB). There were no significant differences on mid-term mortality (pooled HR: 1.02, 95%CI: 0.89-1.17, p=0.80) and composite endpoint incidence (pooled HR: 0.98, 95%CI: 0.88-1.09, p=0.72) between OPCAB and ONCAB. At 30-day, there were no differences in mortality, myocardial infarction, stroke and renal complications. The need for early re-revascularization was significantly higher in OPCAB (pooled OR: 3.22, 95%CI: 1.28-8.09, p=0.01), with a higher percentage of incomplete revascularization being reported for OPCAB in trials included in this pooled result (34% in OPCAB vs 29% in ONCAB, p<0.01).
Conclusions:
Data from RCTs in elderly patients showed that OPCAB and ONCAB provide similar mid-term results. OPCAB was associated with a higher risk of early rerevascularization. As CABG on the elderly is still insufficiently explored, further RCTs, specifically designed targeting this population, are needed to establish a better CABG strategy for these patients.
Objective:
To evaluate safety of coronary artery bypass surgery using bilateral internal mammary artery and effectiveness of this procedure in long-term postoperative period.
Material and methods:
The study involved 129 patients who underwent CABG for the period 2006-2007. There were 2 groups of patients depending on surgical strategy: group 1 (n=61) - double IMA harvesting, group 2 (n=68) - CABG using single IMA. Short-term results were compared using standard statistical methods. Long-term survival was compared using Kaplan-Meyer method.
Results:
Revascularization index was 3.014±0.76 in the 1st group and 3.1±0.73 in the 2nd group (p>0.05). In-hospital mortality was 0% and 1.47%, respectively (p> 0.05). A 10-year survival was 95.1% and 91.2%, respectively (p>0.05). Freedom from cardiac events (mortality, myocardial infarction, recurrent angina pectoris) was significantly different (95% vs. 81%, p<0.05).
Conclusion:
Significantly lower rate of adverse cardiac events in long-term postoperative period in comparison with conventional CABG clearly demonstrates high quality of life after coronary artery bypass surgery using bilateral internal mammary artery for a long time. Therefore, this procedure is preferred in patients with coronary artery disease.
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