Incomplete revascularization reduces survival benefit of coronary artery bypass grafting: Role of off-pump surgery

Synnergren, Mats; Ekroth, Rolf; Odén, Anders; Rexius, Helena; Wiklund, Lars

doi:10.1016/j.jtcvs.2007.07.059

Cited by 74 publications

(35 citation statements)

References 22 publications

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“…19 Good evidence is available that incomplete revascularization at CABG can lead to poor long-term prognosis. 13,20 Consistent with the above reports, the present study suggested that incomplete revascularization contributes significantly to long-term MVE ( Figures II and III of the online-only Data Supplement). Two-year follow-up for 2088 off-pump and 2088 on-pump patients' cost data.…”

supporting

confidence: 92%

Increasing Long-Term Major Vascular Events and Resource Consumption in Patients Receiving Off-Pump Coronary Artery Bypass

Zheng

Yuan

et al. 2010

Circulation

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Background-Despite its widespread use and short-term efficacy, substantial uncertainty remains about the long-term outcomes and cost-effectiveness of off-pump coronary artery bypass (OPCAB). Methods and Results-A retrospective review of prospectively collected data was conducted of 6665 consecutive patients undergoing isolated coronary artery bypass graft (CABG) at our institution during 1999 to 2006. All patients were followed up until September 30, 2008. Short-and long-term outcomes were compared between OPCAB and conventional CABG. The 2 main long-term outcome measures were repeat revascularization and the composite outcome of major vascular events. Cost comparison at 2 years in a propensity-matched sample during follow-up was also a study interest. The overall mean baseline age was 60.3Ϯ8.6 years, and 17.0% were women. Compared with conventional CABG, patients who underwent OPCAB had lower rates of atrial fibrillation (Pϭ0.003) and requirements for blood transfusion (Pϭ0.03) and ventilation time Ͼ24 hours (PϽ0.001). After an average of 4.5 years of follow-up, the rates of repeat revascularization (adjusted hazard ratio, 1.40; 95% confidence interval, 1.03 to 1.89) and major vascular events (adjusted hazard ratio, 1.23; 95% confidence interval, 1.09 to 1.39) were significantly higher in the OPCAB than the conventional CABG group. At 2 years, OPCAB was associated with increased additional direct costs per patient compared with conventional CABG and had a similar survival rate. Conclusions-Compared with conventional CABG, OPCAB is associated with small short-term gain but increased long-term risks of repeat revascularization and major vascular events, especially among high-risk patients. Moreover, OPCAB consumes more resources and is less cost-effective in the long run. (Circulation. 2010;121:1800-1808.)Key Words: coronary artery bypass grafting Ⅲ coronary disease Ⅲ coronary artery bypass, off-pump Ⅲ surgery C urrently, increasing volume of off-pump coronary artery bypass (OPCAB) has been noted not only in Western countries but also in developing countries such as China and India. OPCAB was first introduced in China in 1996, 1 and Ͼ50 major cardiovascular centers across the country have routinely used the technique. On the basis of a large registration study involving Ϸ10 000 patients from 35 centers across China, 2 OPCAB accounts for Ͼ70% of all coronary artery bypass graft (CABG) surgeries done in these centers, a proportion that was Ϸ3 times as high as that reported in other populations such as the United States. 3 Unfortunately, when confronted with the growing volume, we seldom have adequate evidence from the literature. Several randomized controlled trials were reported but tended either to be small or to have short follow-up (seldom Ͼ5 years). 4 -6 A recent randomized controlled trial involving 18 centers and 2203 patients was released, but the patients included were mostly male. 5 Studies with long-term follow-up exist but tend to emphasize primarily all-cause mortalities, 7 and data on long-term adver...

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confidence: 92%

Increasing Long-Term Major Vascular Events and Resource Consumption in Patients Receiving Off-Pump Coronary Artery Bypass

Zheng

Yuan

et al. 2010

Circulation

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“…Despite advances in stabilizers and other equipment, it may be difficult to graft inferior and posterolateral vessels because of right ventricular and left ventricular distension and hemodynamic changes. Synnergren and coworkers 28 examined the effect of incomplete revascularization over a 5-year period in a nonrandomized cohort of 9408 patients. Leaving 1 diseased vascular segment without a bypass graft resulted in no increased risk of death.…”

Section: Opcab and Incomplete Revascularizationmentioning

confidence: 99%

Should Off-Pump Coronary Artery Bypass Grafting Be Abandoned?

Lazar

2013

Circulation

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406O ne of the most controversial areas of cardiac surgery has been whether off-pump coronary artery bypass graft (OPCAB) surgery is superior to traditional on-pump coronary artery bypass graft (CABG) surgery. On-pump CABG surgery has been an effective, safe, and time-proven technique and is the gold standard with which all other surgical revascularization methods have been compared. However, performing coronary revascularization on cardiopulmonary bypass (CPB) can result in myocardial ischemic injury, neurocognitive deficits, and strokes and activate inflammatory pathways that contribute to pulmonary, renal, and hematologic complications. OPCAB offered a promising alternative strategy that had the potential to decrease perioperative morbidity, mortality, and cost by eliminating CPB. In fact, throughout Asia and particularly in India, 95% of CABG surgery is performed offpump. In North America, OPCAB procedures peaked at 25% in 2004 and have declined steadily since that time.1 It is a more technically demanding procedure and results in less complete revascularization. There is growing concern that OPCAB is associated with reduced long-term graft patency and increased need for revascularization procedures and results in inferior long-term survival compared with traditional on-pump CABG surgery.In view of these concerns, should OPCAB be abandoned? The purpose of this review is to examine clinical data that most accurately compare the advantages and disadvantages of OPCAB to determine what, if any, role it should have in the practice of surgical coronary artery revascularization. To reach these conclusions, retrospective nonrandomized, prospective randomized, and meta-analyses trials will be reviewed. The effect of incomplete revascularization and conversion to conventional CABG will be examined. The relationship between OPCAB and the inflammatory response, neurological and cognitive changes, and quality of life will be studied, and the impact of OPCAB on sex, renal transplant recipients, and elderly patients will be determined. Retrospective StudiesRetrospective studies were largely single center and lacked randomization. Surgeons who were more skilled in OPCAB were more likely to perform these procedures. Hence, there was a significant selection bias. In most studies, the intentionto-treat principle was not honored. Therefore, if a patient was converted to an on-pump CABG, an adverse outcome associated with this patient would be attributed to the on-pump CABG and not the originally planned OPCAB. Earlier studies may have lacked proper stabilizing equipment and intracoronary perfusion devices. Many trials reported only short-term outcomes. The retrospective studies discussed in this section generally involve >1 surgeon, had larger sample sizes to detect statistically significant differences in clinical outcomes, and contained long-term data.One of the largest databases used to compare outcomes between OPCAB and on-pump CABG techniques involved the New York State Registry for CABG Surgery. Racz and coworkers 2 first...

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“…Regarding the effect of CR on CABG, a Swedish hospital registry reported that IR in >1 diseased vessel was associated with an increased risk of 5-year mortality (HR, 1.82; 95% CI, 1.15-2.85). 13 However, the vast majority of registries showed that anatomical CR was not associated with long-term adverse outcomes in patients undergoing CABG. 5,8, 12 In a substudy of the SYNTAX (Synergy between PCI with TAXUS and Cardiac Surgery) trial, which compared the outcomes of PCI with DES vs. CABG for patients with multivessel or left main disease, patients with CR by PCI had lower rates of MACCE (66.5% vs. 76.2%, P<0.001), composite safety endpoints (83.4% vs. 87.9%, P=0.05) and…”

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confidence: 99%

Ischemia-Guided Percutaneous Coronary Intervention for Patients With Stable Coronary Artery Disease

Kim

Park

2013

Circ J

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Incomplete revascularization reduces survival benefit of coronary artery bypass grafting: Role of off-pump surgery

Cited by 74 publications

References 22 publications

Increasing Long-Term Major Vascular Events and Resource Consumption in Patients Receiving Off-Pump Coronary Artery Bypass

Increasing Long-Term Major Vascular Events and Resource Consumption in Patients Receiving Off-Pump Coronary Artery Bypass

Should Off-Pump Coronary Artery Bypass Grafting Be Abandoned?

Ischemia-Guided Percutaneous Coronary Intervention for Patients With Stable Coronary Artery Disease

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