Off‐Pump Coronary Artery Bypass Grafting: 30 Years of Debate

Gaudino, Mario; Angelini, Gianni; Antoniades, Charalambos; Bakaeen, Faisal G.; Benedetto, Umberto; Calafiore, Antonio M.; Franco, Antonino Di; Mauro, Michele Di; Fremes, Stephen E.; Girardi, Leonard N.; Glineur, David; Grau, Juan B.; He, Guo‐Wei; Patrono, Carlo; Puskas, John D.; Ruel, Marc; Schwann, Thomas A.; Tam, Derrick Y.; Tatoulis, James; Tranbaugh, Robert F.; Vallely, Michael P.; Zenati, Marco A.; Mack, Michael J.; Taggart, David P.

doi:10.1161/jaha.118.009934

Cited by 96 publications

(87 citation statements)

References 128 publications

(123 reference statements)

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“…OPCAB grafting has been performed for over three decades and as a technique has evolved; OPCAB has gained widespread acceptance in clinical practice as a common approach in the cardiac surgeon's armamentarium. Avoiding the use of cardiopulmonary bypass has the theoretical benefits of reducing inflammatory trauma, global myocardial ischemic, and aortic manipulation, which proponents of the approach suggest results in lower rates of postoperative strokes, renal failure, early mortality, blood product transfusions, and earlier recruitment of hibernating myocardium 1 . These potential benefits may occur at the expense of incomplete coronary revascularization, which may increase the need for repeat revascularization and decrease longitudinal survival 2 .…”

Section: Discussionmentioning

confidence: 99%

“…The benefits of off‐pump coronary artery bypass (OPCAB) surgery have been studied in the general population for over three decades, yet the longitudinal effects on clinical outcomes when compared with on‐pump coronary artery bypass (ONCAB) surgery remain controversial 1‐6 . Several observational studies have found that OPCAB may disproportionally benefit high‐risk subpopulations such as those with reduced left ventricular ejection fraction (LVEF), who are frequently excluded from clinical trials, with reductions in early morbidity and mortality 7,8 .…”

Section: Introductionmentioning

confidence: 99%

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Off‐pump coronary artery bypass surgery lacks a longitudinal survival advantage in patients with left ventricular dysfunction

et al. 2020

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Background This study evaluates the longitudinal impacts of off‐pump coronary artery bypass (OPCAB) surgery in patients with reduced left ventricular ejection fraction (LVEF). Methods Adults with LVEF ≤ 30% undergoing coronary artery bypass grafting between 2011 and 2020 were included. Patients were stratified based on the utilization of cardiopulmonary bypass into OPCAB or on‐pump coronary artery bypass (ONCAB) groups. Primary outcomes included survival and hospital readmissions. Secondary outcomes evaluated postoperative morbidities. Multivariable regression evaluated risk‐adjusted mortality and readmission. Propensity score matching was utilized to reduce bias. Results A total of 660 low LVEF patients were included, of which 28.5% (n = 188) were OPCAB and 71.5% (n = 472) were ONCAB. The rates of complete revascularization were similar between the groups (80.3% vs 82.0%; P = .67). Early survival between the unmatched groups was similar at 1‐year follow‐up (86.2% vs 87.9%; P = .53); however, at 5 years OPCABs had significantly worse survival compared with ONCABs (71.5% vs 64.2%; P = .02). These findings persisted in the matched cohort where survival at 1 year was comparable (86.8% vs 85.7%; P = .80), but 5‐year survival was better for ONCABs (64.1% vs 69.9%; P = .03). The rates of readmission were similar between the unmatched and matched groups at all time intervals, including readmissions for cardiac‐related and heart failure‐related events (all, P > .05). Conclusions In contemporary patients with reduced LVEF, survival after OPCAB was similar at 1 year but lower at 5‐year follow‐up compared with ONCAB, despite similar rates of complete revascularization. These findings suggest that there may be other factors influencing longitudinal mortality in the low LVEF cohort, beyond the use of cardiopulmonary bypass.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Off‐pump coronary artery bypass surgery lacks a longitudinal survival advantage in patients with left ventricular dysfunction

et al. 2020

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“…In patients with severe end-organ dysfunction or failure, particularly renal disease and cirrhosis, OPCAB has been shown to reduce morbidity and mortality compared with on-pump bypass techniques. 20 Patients with a history of coronary stents on dual antiplatelet therapy may benefit from OPCAB, and decisions on perioperative antiplatelet regimens have been shown to vary based on surgeon and center preference. 21 During the preoperative evaluation, it is important to consider the degree of aortic calcification and when it is important to avoid applying a cross-clamp to the aorta, which is required to arrest the heart during on-pump CABG.…”

Section: Patient Selectionmentioning

confidence: 99%

Off-Pump Coronary Artery Bypass Grafting: Closing the Communication Gap Across the Ether Screen

Bianco

Kilic

Gelzinis

et al. 2020

Journal of Cardiothoracic and Vascular Anesthesia

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“…1,2 The use of cardiopulmonary bypass (CPB) and cardioplegic arrest could be responsible for cardiac and systemic complications, therefore off-pump CABG has been gradually developed as an alternative technique especially in case of markedly calcified ascending aorta. [3][4][5][6] Beside the concerns related to higher incidence of incomplete revascularization and potentially inferior long-term outcomes in off-pump surgery, 7 transitory haemodynamic instability caused by surgical manipulation, especially in case of severe coronary disease, might require emergent conversion to on-pump conventional CABG, increasing enormously the operative risk. 1,2 Patients at high risk of complications, such as those with recent myocardial infarction (MI), impaired left ventricular ejection fraction (LVEF) or poor hemodynamics might benefit from on-pump beating-heart CABG (OPBHC, also known as ONBEAT in some studies).This CPB-assisted approach was introduced by Perrault et al 8 more than 20 years ago and immediately fueled great interest in the treatment of high-risk patients.…”

Section: Introductionmentioning

confidence: 99%

On‐pump beating‐heart coronary artery bypass grafting in high‐risk patients: A systematic review and meta‐analysis

et al. 2020

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Background Operative technique for surgical myocardial revascularization in high‐risk patients remains an argument of debate. On‐pump coronary artery bypass graft (CABG) with cardioplegic arrest and off‐pump CABG have intrinsic limitations. The hybrid approach of on‐pump beating‐heart CABG (OPBHC) has been proposed over the years with conflicting results. This systematic review and meta‐analysis intends to summarize the contemporary literature. Methods A literature search was conducted through major electronic databases. The systematic review provided a total of 279 articles, of those 17 studies were included in the present study. Results Compared with on‐pump CABG, OPBHC patients showed a preoperative higher risk profile but had reduced early mortality (risk ratio [RR], 0.59, 95% CI, 0.36‐0.97) and reduced postoperative stroke (RR, 0.60, 95% CI, 0.39‐0.91). Also, interesting trends towards reduced postoperative intra‐aortic balloon pump use (RR, 0.56, 95% CI, 0.31‐1.01) and myocardial infarction (RR, 0.48, 95% CI, 0.22‐1.07) were observed. Baseline characteristics and postoperative complications were similar between OPBHC and off‐pump CABG, but limited data are available. The risk of incomplete revascularization in OPBHC is lower than off‐pump CABG (RR, 0.53, 95% CI, 0.33‐0.87) but higher than conventional on‐pump CABG (RR, 1.71, 95% CI, 1.23‐2.39). Conclusion OPBHC is an effective technique to perform surgical revascularization in high‐risk patients as preventing haemodynamic deterioration and guaranteeing adequate end‐organ perfusion. OPBHC represents an alternative technique to on‐pump and off‐pump CABG, in those cases in which complications deriving from cardioplegic arrest or manipulation of the heart are more likely. For these reasons, OPBHC might be useful in patients with recent myocardial infarction or with left ventricular dysfunction.

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Off‐Pump Coronary Artery Bypass Grafting: 30 Years of Debate

Cited by 96 publications

References 128 publications

Off‐pump coronary artery bypass surgery lacks a longitudinal survival advantage in patients with left ventricular dysfunction

Off‐pump coronary artery bypass surgery lacks a longitudinal survival advantage in patients with left ventricular dysfunction

Off-Pump Coronary Artery Bypass Grafting: Closing the Communication Gap Across the Ether Screen

On‐pump beating‐heart coronary artery bypass grafting in high‐risk patients: A systematic review and meta‐analysis

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