Off-Pump Coronary Artery Surgery for Reducing Mortality and Morbidity

Wijeysundera, Duminda N.; Beattie, W. Scott; Djaiani, George; Rao, Vivek; Borger, Michael A.; Karkouti, Keyvan; Cusimano, Robert J.

doi:10.1016/j.jacc.2005.05.064

Cited by 265 publications

(177 citation statements)

References 75 publications

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“…However, our results support the findings of a recent meta-analysis of risk adjusted observational studies 23 favouring the OPCAB technique for stroke reduction. To assess patient consciousness status we utilized the NEECHAM confusion scale which has been shown to reflect clinical impact of cerebral embolic load and new DW-MRI lesions after ONCAB surgery.…”

Section: Discussionsupporting

confidence: 90%

“…However, the OPCAB technique was associated with significant reduction in stroke in a meta-analysis of 22 risk-adjusted observational studies evaluating patients at high risk for neurological injury. 23 It was likely that lower stroke rates after OPCAB surgery were secondary to less aortic manipulation and reduced cerebral embolic load in patients with atheromatous aorta. [24][25][26] The discrepancies between the RCTs and risk-adjusted observational studies may be attributed to different patient populations being studied, i.e., the RCTs are usually associated with recruitment of low-risk patients whilst the observational studies better reflect patient diversity similar to that of clinical practice.…”

Section: Discussionmentioning

confidence: 99%

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Off-pump coronary bypass surgery: risk of ischemic brain lesions in patients with atheromatous thoracic aorta

Djaiani

Fedorko

Cusimano

et al. 2006

Can J Anesth/J Can Anesth

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Purpose:The purpose of this study was to determine if there is an association between the proximal thoracic aortic (ascending aorta and aortic arch) atheroma and ischemic brain lesions on diffusion-weighted magnetic resonance imaging (DW-MRI) after on-pump (ONCAB) and off-pump (OPCAB) coronary artery bypass surgery. Methods:Patients who underwent ONCAB surgery (n = 13) and who had aortic atheroma > 2 mm were compared to a risk-adjusted prospective cohort of patients (n = 13) undergoing OPCAB surgery. Transesophageal echocardiography and epiaortic scanning were performed to assess the proximal thoracic aorta. Patients were evaluated for new ischemic brain lesions utilizing DW-MRI three to seven days after surgery. The NEECHAM confusion scale was used to evaluate patient consciousness. Results:The groups were comparable with respect to demographic data, and prevalence of preoperative risk factors. The extent and severity of aortic atheroma was similar in the two groups. The average maximum height of atheroma was 5.0 ± 2.0 mm in the OPCAB and 4.8 ± 1.9 in the ONCAB groups, respectively. The prevalence of new ischemic brain lesions on DW-MRI was 0% in the OPCAB group and 61% in the ONCAB group (P = 0.001). Patients in the OPCAB group were less confused during the first two postoperative days. Conclusion:Patients with aortic atheroma > 2 mm may have a lower risk of new ischemic brain lesions as identified by DW-MRI after OPCAB surgery. Patient stratification based upon aortic atheroma burden should be addressed in future trials designed to tailor treatment strategies to improve short-and long-term neurological outcomes in patients undergoing cardiac surgery. Objectif : Déterminer s'il y a une association entre l'athérome de l'aorte thoracique proximale (aorte ascendante et crosse de l'aorte) et les lésions cérébrales ischémiques à l'examen d'imagerie par résonance magnétique pondérée par diffusion (IRM-PD) à la suite du pontage aortocoronarien avec circulation extracorporelle (PACCE) et un PAC à coeur battant (PACCB). Méthode : Des patients subissant un PACCE (n = 13) et ayant de l'athérome aortique > 2 mm ont été comparés à une cohorte prospective de patients à risque ajusté (n = 13) subissant un PACCB. L'échocardiographie transoesophagienne et le balayage épiaortique ont permis d'évaluer l'aorte thoracique proximale. La présence de nouvelles lésions cérébrales ischémiques a été vérifiée avec l'IRM-PD trois à sept jours après l'opération. La conscience des patients a été évaluée par l'échelle de confusion NEECHAM. Résultats

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Off-pump coronary bypass surgery: risk of ischemic brain lesions in patients with atheromatous thoracic aorta

Djaiani

Fedorko

Cusimano

et al. 2006

Can J Anesth/J Can Anesth

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“…A larger observational study by Williams et al (27) also demonstrated an increased risk for repeat revascularization with OPCAB surgery (RR 1.29, P=0.02). Other studies (23,27,28) have reported similar increased need for early revascularization following OPCAB. The increased need for repeat revascularization may outweigh any potential economic benefits of earlier intensive care unit and hospital discharge.…”

Section: Discussionmentioning

confidence: 65%

“…Ascione and Angelini (5) discussed the dilemma faced by many cardiac surgeons who perform CABG. On one hand, the literature is replete with studies that emphasize the potential for reducing postoperative morbidity and length of stay with OPCAB surgery (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24); on the other hand, there is continued concern regarding intraoperative myocardial ischemia, inadequate revascularization and the need for early revascularization (5,8,23,(25)(26)(27)(28)(29).…”

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Mid-term outcomes of off-pump versus on-pump coronary artery bypass graft surgery

Ivanov

Borger

et al. 2008

Canadian Journal of Cardiology

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C oronary artery disease is associated with more death and disabilities than any other disease in industrialized nations. Coronary artery bypass graft surgery (CABG) is one of the most effective methods of treating symptomatic coronary artery disease and is performed in approximately 10,000 patients annually in Ontario.The majority of cardiac operations require the establishment of cardiopulmonary bypass and cardioplegic arrest. However, cardiopulmonary bypass is a well-recognized factor for generating a whole-body inflammatory response, which can contribute to postoperative morbidity including renal, pulmonary, neurological and bleeding complications (1,2). Benetti et al (3) and Buffolo et al (4) reintroduced beating heart surgery almost 20 years ago as a strategy to prevent complications in high-risk patients. Since that time, off-pump coronary artery bypass (OPCAB) surgery has gained increasing popularity and is challenging conventional on-pump coronary artery bypass (CCAB) as the standard of therapy for multivessel disease in many cardiac centres (2).The benefits of OPCAB remain controversial, despite the publication of numerous studies reporting equivalent or improved hospital outcomes and significantly shorter lengths of hospital stay. Ascione and Angelini (5) discussed the dilemma faced by many cardiac surgeons who perform CABG. On one hand, the literature is replete with studies that emphasize the potential for reducing postoperative morbidity and length of stay with OPCAB surgery (6-24); on the other hand, there is continued concern regarding intraoperative myocardial ischemia, inadequate revascularization and the need for early revascularization (5,8,23,(25)(26)(27)(28)(29).Therefore, the purpose of the present study was to evaluate midterm outcomes of OPCAB versus conventional CCAB in two wellmatched cohorts. CLINICAL STUDIES©2008 Pulsus Group Inc. All rights reserved OBJECTIVE: To evaluate survival and readmissions to hospital for cardiac events or coronary revascularization (REVASC) in patients having off-pump (OPCAB) versus conventional on-pump (CCAB) coronary artery bypass graft surgery (CABG). METHODS: Of 11,368 consecutive patients undergoing isolated CABG between 1996 and 2002, 514 had OPCAB surgery. Using propensity scores, 503 CCAB patients were randomly matched to 503 OPCAB patients. RESULTS: There were no clinical or statistical differences between the two groups for any prognostic variable. However, OPCAB patients received significantly fewer distal anastomoses than the CCAB group (2.6±1.0 versus 3.1±1.0; P<0.001). There was no difference in operative mortality (OPCAB 1.0%, CCAB 1.4%; P=0.6), but the OPCAB group had significantly fewer operative strokes (0.2% versus 1.8%; P=0.01). Follow-up was 99.7% complete at 2.2±1.2 years (range 0 to 6 years). Twice as many OPCAB patients (n=24) required REVASC compared with the CCAB (n=11) group. The following five-year actuarial outcomes are presented for CCAB and OPCAB, respectively: survival: 77±6%, 76±8%, P=0.8; freedom from REVASC: 95±3%, 92±2%, ...

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“…Two meta-analyses demonstrated a reduction in mortality at 30 days, in off-pump surgery technique, but also there were less grafts, and more late reinterventions were required [3][4][5][6] . The difference between offpump surgery and traditional technique in the number of grafts and late patency rates, which had been observed in previous studies, was not confirmed by subsequent studies, since no statistically significant difference was demonstrated 7 .…”

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confidence: 99%

A cirurgia de revascularização miocárdica com e sem circulação extracorpórea: o impacto do custo no sistema de saúde

Gomes¹,

Braile²

2008

Arq. Bras. Cardiol.

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Myocardial revascularization; extracorporeal circulation; health care costs.Currently, the increase in health care costs is undeniable, and that is a reason for concern to all third-part payers in the world. Since health care budgets in most countries are considerably limited, cost-benefit and cost-effectiveness analyses of several medical interventions are essential, not only for physicians, but also for public and private health care systems, inasmuch as they are equally relevant for both.Therefore, new procedures which provide quality, efficiency and clinical results similar or superior to those provided by ordinary therapies, with better cost-benefit and cost-effectiveness ratios, are needed and beneficial.Consonant with this reality, the study by Girardi et al. 1 , published in this issue, which analyzes comparatively the cost of on-pump and off-pump coronary bypass surgery, is extremely relevant and pertinent. Although this issue has already been analyzed by international studies, there were no specific data concerning the Brazilian reality; therefore, this study is particularly important to clarify the issue of comparative costs of on-pump and off-pump revascularization techniques in our country.Off-pump coronary artery bypass surgery (OPCAB) is gaining great acceptance and has become a widely used procedure in the treatment of coronary artery disease, as an effort to reduce the morbity attributed to and related to cardiopulmonary bypass (CPB) 2 . This trend has been guided by scientific evidences, randomized controlled studies, systematic reviews, meta-analyses and retrospective registries of large data bases, which have shown that off-pump surgery is associated with an incidence of perioperative complications lower than that of conventional myocardial revascularization surgery.Since the early 90s, there has been a gradual change in the demographic and risk profiles of patients referred for myocardial revascularization surgery, mostly related to old age and the presence of more serious comorbities which increase the incidence of complications that may lead to a greater operative mortality. It was demonstrated that offpump surgery reduces the systemic inflammatory response and the neurological alterations associated with the use of on-pump surgery which contribute to the incidence of perioperative complications.Up to now, 41 randomized controlled trials involving 3,996 patients were published, and four recent meta-analyses compared the results of on-pump versus off-pump coronary artery bypass surgery.The results of the meta-analyses demonstrated that offpump surgery, in comparison to traditional technique, was associated with a reduction in the incidence of cerebrovascular accidents (CVA), respiratory infections, atrial fibrilation, blood transfusions and the use of inotropic agents, as well as a reduction in the duration of mechanical ventilation and hospitalization, and lower direct costs. Two meta-analyses demonstrated a reduction in mortality at 30 days, in off-pump surgery technique, but also there w...

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Off-Pump Coronary Artery Surgery for Reducing Mortality and Morbidity

Cited by 265 publications

References 75 publications

Off-pump coronary bypass surgery: risk of ischemic brain lesions in patients with atheromatous thoracic aorta

Off-pump coronary bypass surgery: risk of ischemic brain lesions in patients with atheromatous thoracic aorta

Mid-term outcomes of off-pump versus on-pump coronary artery bypass graft surgery

A cirurgia de revascularização miocárdica com e sem circulação extracorpórea: o impacto do custo no sistema de saúde

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