Off-pump surgery for the poor ventricle?

Abstract

Severely decreased ejection-fraction is an established risk-factor for worse outcome after cardiac surgery. We compare outcomes of off-pump coronary artery bypass grafting (OPCAB) and on-pump CABG (ONCABG) in patients with severely compromised EF. From 2004 to 2009, 478 patients with a decreased EF B35% underwent myocardial-revascularization. Patients received either OPCAB (n = 256) or ONCABG (n = 222). Propensity score (PS), including 50 preoperative risk-factors, was used to balance characteristics between groups. PS adjusted logistic regression analysis was performed to assess mortality and major adverse cardiac and cerebrovascular events (MACCE). A composite endpoint for major non-cardiac complications such as respiratory failure, renal failure, rethoracotomy was applied. Complete revascularization (CR) was assumed when the number of distal anastomoses was larger than that of diseased vessels. There was no difference for mortality (2.3 vs. 4.1%; PS-adjusted odds ratio (PS-OR) = 1.05; p = 0.93) and MACCE (13.7 vs. 17.6%; PS-OR = 1.22; p = 0.50) including myocardial-infarction (1.4 vs. 4.9%; PS-OR = 0.39; p = 0.26), low cardiac output (2.3 vs. 4.7%; PS-OR = 0.75; p = 0.72) and stroke (2.3 vs.2.7%; PS-OR = 0.69; p = 0.66). OPCAB patients presented with a trend to less frequent occurrence of the non-cardiac composite (12.1 vs. 22.1%; PS-OR = 0.54; p = 0.059) including renal dysfunction (PAOR = 0.77; 95% CI 0.31-1.9; p = 0.57), bleeding (PAOR = 0.42; 95% CI 0.14-1.20; p = 0.10) and respiratory failure (PAOR = 0.39; 95% CI 0.05-3.29; p = 0.39). The rate of complete revascularization was similar (92.2 vs. 92.8%; PS-OR = 0.75; p = 0.50). OPCAB in patients with severely decreased EF is safe and feasible. It may even benefit these patients in regard to non-cardiac complications and does not come at cost of less complete revascularization.

Outcomes of off-pump versus on-pump coronary artery bypass graft surgery in patients with severely dilated left ventricle

“…Some studies suggest that OPCAB reduces cardiac complications and even benefit high-risk patients in regard to stroke prevention, less postoperative morbidity and mortality (5,(10)(11)(12). Cardioplegic arrest and CPB have been the mainstays of CABG surgery for almost 30 years.…”

“…To large extent, the surgery reduces the recurrence of myocardial ischemia and the demand of revascularization (2). For elderly patients and patients with diabetes mellitus, renal insufficiency, poor left ventricular ejection fraction (LVEF) (≤35%), peripheral vascular disease, left main CAD and chronic obstructive pulmonary disease (COPD), off-pump coronary artery bypass (OPCAB) grafting is associated with lower operative combination and mortality than on-pump coronary artery bypass (ONCAB) (3)(4)(5)(6). For patients with giant left ventricle, few reports are available (7).…”

Feasibility of off‐pump coronary artery grafting for patients with impaired left ventricular ejection fraction: A retrospective cohort study from a single institutional database

“…A recent study showed that OPCAB is a safe and efficient choice for high‐risk patients with multiple organ failure 18 . Considering the advantages of the OPCAB procedure, an increasing number of surgeons are trying to extend the surgery to high‐risk patients, including women and patients with low LVEF 19,20 …”

“…18 Considering the advantages of the OPCAB procedure, an increasing number of surgeons are trying to extend the surgery to high-risk patients, including women and patients with low LVEF. 19,20 However, despite the enthusiasm for OPCAB among surgeons, its widespread adoption in China has been slower than anticipated. 21 Considering the inconsistencies among different reports, the use of OPCAB in LVD patients should be limited in real practice.…”

Feasibility of off-pump coronary artery grafting for patients with impaired left ventricular ejection fraction: a retrospective cohort study from a single institutional database

“…A recent published study shows that OPCAB is a safe and efficient choice for high risk patients with multiple organs failure [18]. Given the improvement and advantages of OPCAB procedure, more and more surgeons try to extend the suegery to high risk patients, including female and Low LVEF patient [19,20].…”