Off-pump coronary artery bypass grafting improves short-term outcomes in high-risk patients compared with on-pump coronary artery bypass grafting: Meta-analysis

Kowalewski, Mariusz; Pawliszak, Wojciech; Malvindi, Pietro Giorgio; Bokszanski, Marek Pawel; P, Damian; Raffa, Giuseppe Maria; Kowalkowska, Magdalena Ewa; Zaborowska, Katarzyna; Navarese, Eliano Pio; Kołodziejczak, Michalina; Kowalewski, Janusz; Tarelli, Giuseppe; Taggart, David P.; Anisimowicz, Lech

doi:10.1016/j.jtcvs.2015.08.042

Cited by 183 publications

(152 citation statements)

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“…A further effort in minimizing the occurrence of some complications related to conventional CABG has led to the development of the off‐pump (OPCAB) technique in which the anastomoses are performed on the beating heart 4. Observational studies have suggested that, by avoiding the negative effects of CBP, OPCAB may substantially reduce the rate of mortality and morbidity when compared with conventional CABG 30, 31 and in particular in high‐risk patients 5, 32. Standard OPCAB, however, still requires application of a side biting clamp to complete proximal anastomoses, thus increasing the risk of dislodging fragile material from the aortic wall.…”

Section: Discussionmentioning

confidence: 99%

Cerebrovascular Events After No‐Touch Off‐Pump Coronary Artery Bypass Grafting, Conventional Side‐Clamp Off‐Pump Coronary Artery Bypass, and Proximal Anastomotic Devices: A Meta‐Analysis

Pawliszak

Kowalewski

Raffa

et al. 2016

JAHA

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BackgroundOff‐pump coronary artery bypass (OPCAB) has been shown to reduce the risk of neurologic complications as compared to coronary artery bypass grafting performed with cardiopulmonary bypass. Side‐clamping of the aorta while constructing proximal anastomoses, however, still carries substantial risk of cerebral embolization. We aimed to perform a comprehensive meta‐analysis of studies assessing 2 clampless techniques: aortic “no‐touch” and proximal anastomosis devices (PAD) for OPCAB.Methods and ResultsPubMed, CINAHL, CENTRAL, and Google Scholar databases were screened for randomized controlled trials and observational studies comparing “no‐touch” and/or PAD with side‐clamp OPCAB and reporting short‐term (≤30 days) outcomes: cerebrovascular accident and all‐cause mortality. A total of 18 studies (3 randomized controlled trials) enrolling 25 163 patients were included. Aortic “no‐touch” was associated with statistically lower risk of cerebrovascular accident as compared to side‐clamp OPCAB: risk ratio 95% CI: 0.41 (0.27–0.61); P<0.01; I2=0%. Event rates were 0.36% and 1.28% for “no‐touch” and side‐clamp OPCAB, respectively. No difference was seen between PAD and side‐clamp OPCAB: 0.71 (0.33–1.55); P=0.39; I2=39%. A trend towards increased 30‐day all‐cause mortality with PAD and no difference with “no‐touch” were observed when compared to side‐clamp OPCAB. In a subset analysis, “no‐touch” consistently reduced the risk of cerebrovascular accident regardless of patients’ baseline risk characteristics. A benefit with PAD was observed in low‐risk patients.ConclusionsAortic “no‐touch” technique was associated with nearly 60% lower risk of postoperative cerebrovascular events as compared to conventional side‐clamp OPCAB with effect consistent across patients at different risk.

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Section: Discussionmentioning

confidence: 99%

Cerebrovascular Events After No‐Touch Off‐Pump Coronary Artery Bypass Grafting, Conventional Side‐Clamp Off‐Pump Coronary Artery Bypass, and Proximal Anastomotic Devices: A Meta‐Analysis

Pawliszak

Kowalewski

Raffa

et al. 2016

JAHA

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“…Deppe et al in meta-analysis of RCTs on almost 16,900 patients found no difference in 30-day mortality. Kowalewski et al in meta-analysis of over 19,000 patients demonstrated no significant difference in short term mortality (1). The evidence is summarised in Table 1.…”

Section: Operative Mortalitymentioning

confidence: 97%

“…OPCAB, off-pump coronary artery bypass; ONCAB, on-pump coronary artery bypass; RCT, randomized controlled trial; CI, confidence interval; RR, relative risk. (1,3) found no difference in myocardial infraction rates between ONCAB or OPCAB. In the meta-analysis by Deppe et al (3), the incidence of low cardiac output and infection were reduced with use off-pump.…”

Section: Postoperative Renal Dysfunctionmentioning

confidence: 97%

“…The 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)(10)(11)(12)(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).…”

Section: Operative Mortalitymentioning

confidence: 99%

“…This intense debate is held between three schools of thought: the "pure", off-pump surgeons, the onpump surgeons and the "selectivists" group that reserves off-pump surgery for selected cases only. Historically, the shift towards off-pump coronary artery bypass (OPCAB) grafting was proposed both to reduce the operation cost in developing countries but also to avoid the deleterious effects of the contact of blood with the artificial extracorporeal circuit (i.e., mainly the systemic inflammatory response and coagulopathy) (1)(2)(3). Furthermore, avoidance of aortic cannulation and minimisation of aortic manipulation would theoretically translate into reduced cerebral stroke, hence reduced morbidity and perioperative mortality (4).…”

Section: Introductionmentioning

confidence: 99%

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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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Epidural analgesia for adults undergoing cardiac surgery with or without cardiopulmonary bypass

Guay

Kopp

2019

Cochrane Database of Systematic Reviews

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Off-pump coronary artery bypass grafting improves short-term outcomes in high-risk patients compared with on-pump coronary artery bypass grafting: Meta-analysis

Cited by 183 publications

References 129 publications

Cerebrovascular Events After No‐Touch Off‐Pump Coronary Artery Bypass Grafting, Conventional Side‐Clamp Off‐Pump Coronary Artery Bypass, and Proximal Anastomotic Devices: A Meta‐Analysis

Cerebrovascular Events After No‐Touch Off‐Pump Coronary Artery Bypass Grafting, Conventional Side‐Clamp Off‐Pump Coronary Artery Bypass, and Proximal Anastomotic Devices: A Meta‐Analysis

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

Epidural analgesia for adults undergoing cardiac surgery with or without cardiopulmonary bypass

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