Coronary artery bypass surgery for acute coronary syndrome: A network meta‐analysis of on‐pump cardioplegic arrest, off‐pump, and on‐pump beating heart strategies

Abstract

Background Coronary artery bypass grafting (CABG) in the setting of an acute coronary syndrome is a high‐risk procedure, and the best strategy for myocardial revascularisation remains debated. This study compares the 30‐day mortality benefit of on‐pump CABG (ONCAB), off‐pump CABG (OPCAB), and on‐pump beating heart CABG (OnBHCAB) strategies. Methods A systematic search of three electronic databases was conducted for studies comparing ONCAB with OPCAB or OnBHCAB in patients with acute coronary syndrome (ACS). The primary outcome, 30‐day mortality, was compared using a Bayesian hierarchical network meta‐analysis (NMA). A random effects consistency model was applied, and direct and indirect comparisons were made to determine the relative effectiveness of each strategy on postoperative outcomes. Results One randomised controlled trial and eighteen observational studies fulfilling the inclusion criteria were identified. A total of 4320, 5559, and 1962 patients underwent ONCAB, OPCAB, and OnBHCAB respectively. NMA showed that OPCAB had the highest probability of ranking as the most effective treatment in terms of 30‐day mortality (odds ratio [OR], 0.50; 95% credible interval [CrI], 0.23−1.00), followed by OnBHCAB (OR, 0.62; 95% CrI, 0.20−1.57), however the 95% CrI crossed or included unity. A subgroup NMA of nine studies assessing only acute myocardial infarction (AMI) patients demonstrated a 72% reduction in likelihood of 30‐day mortality after OPCAB (CrI, 0.07−0.83). No significant increase in rate of stroke, renal dysfunction or length of intensive care unit stay was found for either strategy. Conclusions Although no single best surgical revascularisation approach in ACS patients was identified, the significant mortality benefit with OPCAB seen with AMI suggests high acuity patients may benefit most from avoiding further myocardial injury associated with cardiopulmonary bypass and cardioplegic arrest.

Coronary Artery Bypass Grafting in High-Risk Patients: On-Pump Beating-Heart CABG

“…The most recent metanalysis [1,6,7,24] showed that postoperative stroke rate is similar between patients who underwent off-pump CABG and OPBHC. These data [7] suggest that the only aortic cannulation procedure might not affect cerebral disease after surgery.…”

“…A low level of perfusion pressure might increase the risk of hypoperfusion in the distal and subendocardial territories, as low perfusion pressure might lead to flow competition and insufficient native coronary artery blood flow. Evidence from metanalysis [1,6,7,24] suggests that a mean pressure between 70 and 80 mmHg could be an optimal level but due to few observations within the sample, more studies should be performed on this topic.…”

Aktuelle Weiterentwicklungen und Fortschritte in der Herzchirurgie

“…Die vergleichende Betrachtung zwischen off-und on-Pump-operierten Patienten zeigt in der überwiegenden Anzahl von Metaanalysen vergleichbare Ergebnisse auf, sodass die Auswahl des operativen Verfahren in der Koronarchirurgie überwiegend nach der Expertise und den Präferenzen der durchführenden Klinik bzw. des Operateurs durchgeführt wird [16].…”

Revascularization and Left Ventricular Dysfunction for ICD Eligibility

“…Surgical revascularization has recently been shown to improve long-term outcomes, although the open-chest approach is associated with increased early hazard [ 58 ]. A network meta-analysis [ 59 ] of on-pump cardioplegic arrest, off-pump, and on-pump beating heart strategies, demonstrated a superiority of the last two approaches in terms of 30-day mortality; such conclusions indicated that critically ill subjects may benefit most from avoiding further myocardial injury associated with cardiopulmonary bypass and cardioplegic arrest. After excluding re-exploration for bleeding or tamponade, patients affected by ICM undergoing CABG surgery show continuous recovery from LVD in the first post-operative year [ 22 , 60 ].…”