Effects of Off-Pump and On-Pump Coronary-Artery Bypass Grafting at 1 Year

Lamy, André; Devereaux, P. J.; Prabhakaran, Dorairaj; Taggart, David P.; Hu, Shengshou; Paolasso, Ernesto; Straka, Zbyněk; Piegas, Leopoldo Soares; Akar, Ahmet; Jain, Anil; Noiseux, N.; Padmanabhan, Chandrasekar; Bahamondes, Juan-Carlos; Novick, Richard J.; Vaijyanath, Prashant; Reddy, S. Chandra Bose; Tao, Liang; Olavegogeascoecehea, Pablo A.; Airan, Balram; Sulling, Toomas-Andres; Whitlock, Richard; Ou, Yongning; Pogue, Janice; Chrolavicius, Susan; Yusuf, Salim

doi:10.1097/sa.0000000000000033

Cited by 42 publications

(54 citation statements)

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“…At 30 days, patients having OPCAB had a higher rate of repeat revascularization while at 1 year the revascularization rates remained similar. Similarly, the CORONARY trial showed fewer grafts performed in the off-pump group and higher early revascularization rate at 30 days, but at 1 year the revascularization rates were no longer different (12,19). A large meta-analysis of RCTs by Deppe et al (3) showed increased early (30 days) revascularization in the off-pump group ( Table 4).…”

Section: Number Of Grafts and Repeat Revascularizationmentioning

confidence: 99%

Current outcomes of off-pump versus on-pump coronary artery bypass grafting: evidence from randomized controlled trials

et al. 2016

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Coronary artery bypass grafting remains the standard treatment for patients with extensive coronary artery disease. Coronary surgery without use of cardiopulmonary bypass avoids the deleterious systemic inflammatory effects of the extracorporeal circuit. However there is an ongoing debate surrounding the clinical outcomes after on-pump versus off-pump coronary artery bypass (ONCAB versus OPCAB) surgery. The current review is based on evidence from randomized controlled trials (RCTs) and metaanalyses of randomized studies. It focuses on operative mortality, mid-and long-term survival, graft patency, completeness of revascularisation, neurologic and neurophysiologic outcomes, perioperative complications and outcomes in the high risk groups. Early and late survival rates for both OPCAB and ONCAB grafting are similar. Some studies suggest early poorer vein graft patency with off-pump when compared with onpump, comparable midterm arterial conduit patency with no difference in long term venous and arterial graft patency. A recent, pooled analysis of randomised trials shows a reduction in stroke rates with use offpump techniques. Furthermore, OPCAB grafting seems to reduce postoperative renal dysfunction, bleeding, transfusion requirement and respiratory complications while perioperative myocardial infarction rates are similar to ONCAB grafting. The high risk patient groups seem to benefit from off-pump coronary surgery. Developed about 40 decades ago (5-7), OPCAB reached a plateau in Europe, accounting for nearly 15-20% of all coronary operations, while in Asia 60-100% of patients are offered coronary artery bypass grafting (2). A retrospective analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database in USA revealed a decline in off-pump operations, currently being used in fewer than one out of five patients (8). The current review focuses on the main outcomes of on-pump coronary artery bypass (ONCAB) grafting versus OPCAB from randomized controlled trials (RCTs) (i.e., level I evidence). The main criticism of RCTs in this area, is the under powering because of recruitment of low risk patients but also because of the low mortality and morbidity of coronary artery bypass grafting that would require very large sample populations to detect a difference (4). Therefore, we will also be reviewing pooled data from recent, updated meta-analyses of randomized trials only. We selected in our review large sample size RCTs or large meta-analyses of RCTs to discuss the hard end-point outcomes but smaller trials were also included to discuss other outcomes. Operative mortalityThe majority of the large RCTs to date failed to show a difference in early mortality between off-pump and on-pump surgery (1,3,9-13). One small sample size RCT by Fattouch et al. showed a reduced mortality in patients with ST elevation undergoing urgent/emergent off-pump coronary surgery compared to on-pump surgery (14). Deppe et al. in meta-analysis of RCTs on almost 16,900 patients found no difference in 30-day mortality. Kow...

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Section: Number Of Grafts and Repeat Revascularizationmentioning

confidence: 99%

Current outcomes of off-pump versus on-pump coronary artery bypass grafting: evidence from randomized controlled trials

et al. 2016

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“…The technique of performing CABG without cardiopulmonary bypass (off-pump) using heart stabilizers Forcillo et al has been used more extensively in high-risk and older patients who could not tolerate on-pump CABG (2). Numerous studies have reported the safety and efficacy of off-pump CABG surgery (3)(4)(5). Despite tremendous enthusiasm from surgeons, patients, industry, and the media, skepticism exists about the impact of off-pump CABG on the completeness and quality of revascularization and clinical outcomes.…”

Section: Introductionmentioning

confidence: 99%

“…Off-pump CABG surgery may be associated with a higher incidence of incomplete revascularization, recurrent angina, and graft occlusion, suggesting poorer graft quality and anastomotic accuracy in some series (6). Whether this is related to the technical expertise of the surgeon for off-pump CABG surgery in these trials is a matter of debate (3)(4)(5). The transit time flowmetry (TTF) method is a non-invasive Doppler-based technology generating real-time graft flow waveforms measurements (7).…”

Section: Introductionmentioning

confidence: 99%

Intra-operative Graft Blood Flow Measurements for Composite and Sequential Coronary Artery Bypass Grafting

et al. 2014

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Objectives Intraoperative assessment of coronary artery bypass grafts (CABG) anastomotic quality can be performed using transit-time flowmetry (TTF). The aim of this study was to compare on- versus off-pump coronary graft TTF and early postoperative outcomes. Materials and methods Between January 2009 and January 2010, 521 distal graft flows were assessed using TTF measurements in 253 consecutive patients undergoing primary isolated CABG surgery. Data were analyzed using multilevel models accounting for clustering among surgeons and grafts performed in the same patient. Results Mean age was 66 ± 10 years and 22% were female (n = 55) with 34% diabetics (n = 86) and 40% pre-operative myocardial infarction (MI) (n = 101). The surgeries were performed off-pump in 67% (n = 170) with sequential vein grafts in 57% (n = 144) of patients. Off-pump patients had higher pre-operative left ventricular ejection fractions (LVEF), fewer urgent surgeries, fewer distal anastomoses, and fewer sequential vein grafts (all p<0.001). Intra-operative coronary graft TTF measurements were lower in sequential vein grafts performed off-pump versus on-pump. More patients in the on-pump group needed milrinone or dobutamine 24-48 h postoperatively (p = 0.005). Independent predictors of lower TTF included female gender and off-pump surgery, whereas predictors of better TTF were pre-operative MI, larger coronary diameter at the site of the distal anastomosis, and sequential vein grafting. Conclusions Lower intra-operative TTF measurements were found in sequential vein grafts in offpump CABG. However, off-pump patients experienced similar short-term outcomes compared to on-pump patients.

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“…The CABG Off or On Pump Revascularization Study (CORONARY) trial included surgeons with greater experience in OPCAB technique but similarly, did not find differences in primary endpoints of mortality, MI and stroke at 1 year. However, there was a trend towards benefit with OPCAB for higher EuroSCORE patient cohorts (6). Regarding repeat revascularization, there was a trend towards higher incidence with OPCAB in the CORONARY trial.…”

Section: Overview Of the Opcab Randomized Controlled Trial (Rct) Litementioning

confidence: 98%

The future of off-pump coronary artery bypass grafting: a North American perspective

2016

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Off-pump coronary artery bypass graft (OPCAB) is currently performed routinely in a minority of specialized centers and in many more centers, utilized only when a porcelain aorta mandates a no-touch aortic technique. The OPCAB literature can be summarized as follows: (I) large-scale randomized trials in relatively low risk patients that include surgeons with a range of experience demonstrating no consistent beneficial differences in major cardiovascular and cerebrovascular outcomes but lower transfusion rates and shorter length of stay, tempered by some reports of higher rates of incomplete revascularization and lower rates of long term graft patency; (II) smaller randomized controlled trials (RCTs) from highly specialized programs demonstrating equivalent or superior outcomes with OPCAB and similar completeness of revascularization and graft patency; and (III) observational data from large databases demonstrating a consistent benefit of OPCAB, especially in higher-risk patient subsets. Our rationale for OPCAB remains that if complete and precise revascularization can be safely and routinely accomplished, then the patient should benefit by avoiding the morbidities that can be attributed to aortic cannulation/clamping, cardiopulmonary bypass (CPB), hemodilution, hypothermia and global myocardial ischemia/cardioplegia.We further believe that OPCAB procedures should emphasize the use of arterial grafts to optimize long term patency and minimize aortic manipulation to limit the risk of stroke. Moving forward, the off-pump surgical community and specialty societies must address the challenge of training surgeons and their teams to master this technically demanding procedure. Furthermore, OPCAB opens the door to minimally-invasive surgical revascularization via hybrid coronary revascularization (HCR). A large NIH-funded RCT is currently underway to determine whether hybrid revascularization can offer a superior alternative to multi-vessel percutaneous coronary intervention for patients with low SYNTAX score and proximal LAD disease.

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Effects of Off-Pump and On-Pump Coronary-Artery Bypass Grafting at 1 Year

Cited by 42 publications

References 10 publications

Current outcomes of off-pump versus on-pump coronary artery bypass grafting: evidence from randomized controlled trials

Current outcomes of off-pump versus on-pump coronary artery bypass grafting: evidence from randomized controlled trials

Intra-operative Graft Blood Flow Measurements for Composite and Sequential Coronary Artery Bypass Grafting

The future of off-pump coronary artery bypass grafting: a North American perspective

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