On-pump and off-pump coronary artery bypass grafting in patients with left main stem disease: A propensity score analysis
This study compared safety and efficacy between off-pump coronary artery bypass grafting (OPCAB), a relatively new technique, and conventional on-pump coronary artery bypass grafting (CCAB) in patients with left main stem disease.
In a retrospective, observational, cohort study of prospectively collected data on 2375 consecutive patients with left main stem disease undergoing isolated CABG (1297 OPCAB, 1078 CCAB) between April 1996 and December 2009 at the Bristol Heart Institute, 548 patients undergoing OPCAB were matched with 548 patients undergoing CCAB by propensity score.
After propensity matching, groups were comparable in preoperative characteristics. Relative to CCAB, OPCAB was associated with lower in-hospital mortality (0.5% vs 2.9%; P = .001), incidence of stroke (0% vs 0.9%; P = .02), postoperative renal dysfunction (4.9% vs 10.8%; P = .001), pulmonary complications (10.2% vs 16.6%; P = .002), and infectious complications (3.5% vs 6.2%; P = .03). The OPCAB group received fewer grafts than did the CCAB group (2.7 ± 0.7 vs 3 ± 0.7; P = .001) and had a lower rate of complete revascularization (88.3% vs 92%; P = .04). In multivariable analysis, cardiopulmonary bypass was confirmed to be an independent predictor of in-hospital mortality (odds ratio, 5.74; P = .001). Survivals at 1, 5, and 10 years were similar between groups (OPCAB, 96.8%, 87.3%, and 71.7%; CCAB, 96.8%, 88.6%, and 69.8%).
OPCAB in patients with left main stem disease is a safe procedure with reduced early morbidity and mortality and similar long-term survival to conventional on-pump revascularization.
Available from: Michał Zembala
- "Moreover, early mortality, length of hospital stay, blood loss and inotropic requirements were significantly favoured by OPCAB surgery. Similar findings were noted by Murzi et al. , where 2375 consecutive patients with LMD were operated on using off-and on-pump techniques. "
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ABSTRACT: OBJECTIVES: Left main disease (LMD), combined with carotid artery stenosis (CAS), constitutes a high-risk patient population. Priority is often given to coronary revascularization, due to the severity of the angina. However, the choice of revascularization strategy [off-pump coronary artery bypass (OPCAB) vs. coronary artery bypass grafting (CABG)] remains elusive. METHODS: A total of 1340 patients with LMD were non-randomly assigned to either on-pump (CABG group, n = 680) or off-pump (OPCAB group, n = 634) revascularization between 1 January 2006 and 21 September 2010. Multivariable regression was used to determine the risk-adjusted impact of a revascularization strategy on a composite in-hospital outcome (MACCE), and proportional hazards regression was used to define the variables affecting long-term survival. RESULTS: Significant CAS was found in 130 patients: 84 (13.1%) patients underwent OPCAB, while 46 patients (6.8%) underwent CABG (P < 0.05). Patients with a history of stroke/transient ischaemic attack were also more likely to receive OPCAB (7.1 vs. 4.7%; P = 0.08). OPCAB patients were older, in a higher New York Heart Association (NYHA) class, with a lower LVEF and higher EuroSCORE. A calcified aorta was found in 79 patients [OPCAB-CABG: 49 (7.73%) vs. 30 (4.41%); P = 0.016] and resulted in a less complex revascularization (OPCAB-CABG: 2.3 ± 0.71 vs. 3.19 ± 0.82; P < 0.05), and 30-day mortality was insignificantly higher in the CABG (2.7 vs. 2.8%) as well as MACCE (11.2 vs.12.2%; P = NS). This trend reversed when late mortality was evaluated; however, it did not reach significance at 60 months. Preoperative renal impairment requiring dialysis was found to be a technique-independent predictor of MACCE. The number of arterial conduits also influenced MACCE. CONCLUSIONS: Off-pump coronary revascularization may offer risk reduction of neurological complications in patients with a significant carotid artery disease and a history of previous stroke, but a larger study population is needed to support this thesis. The growing discrepancy in long-term survival should draw attention to a more complete revascularization in OPCAB patients.
Available from: Jacques Scherman
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Surgical revascularization is the most appropriate therapy for patients with significant left main coronary-artery disease (LMD). An incidence of perioperative stroke remains an issue when compared to the early outcomes to percutaneous coronary intervention (PCI). This study evaluates the safety and impact of standardized "clampless" OPCAB techniques, composed of either complete in situ grafting or "clampless" device enabled techniques for stroke reduction in patients undergoing surgical revascularization for LMD.
Between 1999 and 2009, 1031 patients with LMD underwent myocardial-revascularization at our institution. Of these, 507 patients underwent "clampless" OPCAB and 524 patients underwent conventional on-pump CABG (ONCABG). Data-collection was performed prospectively and a propensity-adjusted regression-analysis was applied to balance patient characteristics. LMD was defined as a stenosis >50% and endpoints were mortality, stroke, a cardiac-composite (including death, stroke and myocardial-infarction); a non-cardiac composite and complete-revascularization.
In OPCAB patients, the cardiac composite (3.0% vs. 7.8%; propensity-adjusted (PA)OR=0.27; CI95% 0.12-0.65; p=0.003) as well as the occurrence of stroke (0.4% vs. 2.9%; PAOR=0.04; CI95% 0.003-0.48; p=0.012) were significantly lower while the mortality-rate was well comparable between groups (1.8% vs. 2.5%; PAOR=0.44; CI95% 0.11-1.71; p=0.24). The non-cardiac composite was also significantly decreased after OPCAB (8.9% vs. 19.7%; PAOR=0.55; CI95% 0.34-0.89; p=0.014) and complete revascularization was achieved for similar proportions in both groups (95.1% vs. 93.7%; p=0.35).
This study shows the superiority of OPCAB for patients with LMD with regards to risk-adjusted outcomes other than mortality. A "clampless OPCAB strategy", effectively reduces stroke yielding similar early outcomes as PCI.
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ABSTRACT: The aim of this article is to review the current revascularization strategies in patients presenting with unprotected left main coronary artery disease (LMCAD).
Coronary artery bypass grafting (CABG) is the current standard of treatment for patients with LMCAD. The development and refinement of techniques increased the number of percutaneous coronary interventions (PCI) in LMCAD patients.
Although several observational studies show comparable results of CABG and/or PCI in patients with LMCAD, there is currently no convincing randomized evidence that either one of the two is associated with better long-term survival. Recent meta-analyses of four small randomized trials revealed a similar rate of 1-year major adverse cardiovascular and cerebrovascular events, higher rates of target vessel revascularization and lower stroke rates for PCI. Pooling randomized patients studies stratified by lesion complexity strengthened the hypothesis that CABG is better in more complex LMCAD patients. However, the randomized comparisons are affected by methodological limitations and lack power to be conclusive. The ongoing Evaluation of XIENCE V Everolimus Eluting Stent System Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial is expected to provide a better answer on the optimal treatment strategy for LMCAD patients. In the meantime, risk models need to be improved and the most appropriate revascularization strategy for the individual LMCAD patient should be chosen using a multidisciplinary heart team that considers not only risk models but also other clinical and economic facets.
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