Off-Pump Techniques Disproportionately Benefit Women and Narrow the Gender Disparity in Outcomes After Coronary Artery Bypass Surgery

Puskas, John D.; Kilgo, Patrick D.; Kutner, Michael; Pusca, Sorin V.; Lattouf, Omar M.; Guyton, Robert A.

doi:10.1161/circulationaha.106.678979

Cited by 90 publications

(64 citation statements)

References 34 publications

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“…(14) while the late mortality did not differ compared to conventional surgery (42). Several retrospective studies found a benefit in using off-pump techniques in other high risk groups such as: females (43) or reoperative coronary artery bypass grafting (44). Overall, the weight of randomized data for the high risk patient undergoing coronary surgery shows a clear benefit from OPCAB as demonstrated by other landmark retrospective studies (45) or large meta-analyses of nonrandomized trials (46) ( Table 9).…”

Section: Postoperative Renal Dysfunctionmentioning

confidence: 86%

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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Section: Postoperative Renal Dysfunctionmentioning

confidence: 86%

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

et al. 2016

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“…Disagreements were resolved through consensus. Eleven authors were contacted by e-mail (up to three attempts per author) for additional information, including confirmation that there were no duplicate data and clarification of the AKI definition used in trials (25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35). Five authors provided additional information (25,29,30,32,33).…”

Section: Data Abstractionmentioning

confidence: 99%

Off-Pump Coronary Artery Bypass Surgery and Acute Kidney Injury

Seabra

Alobaidi

Balk

et al. 2010

Clinical Journal of the American Society of Nephrology

121

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Background and objectives: Off-pump coronary artery bypass grafting (CABG) has been advocated to cause less inflammation, morbidity, and mortality than the more traditional on-pump technique. This meta-analysis compares these two surgical techniques with respect to causing acute kidney injury (AKI).Design, setting, participants, & measurements: This study searched for randomized controlled trials in MEDLINE and abstracts from the proceedings of scientific meetings through February 2010. Included were trials comparing off-pump to on-pump CABG that reported the incidence of AKI, as defined by a mixture of criteria including biochemical parameter/urine output/dialysis requirement. Mortality was evaluated among the studies that reported kidney-related outcomes. For primary and subgroup analyses, fixed-effect meta-analyses of odds ratios (OR) were performed.Results: In 22 identified trials (4819 patients), the weighted incidence of AKI in the on-pump CABG group was 4.0% (95% confidence interval [CI] 1.8%, 8.5%), dialysis requirement 2.4% (95% CI 1.6%, 3.7%), and mortality 2.6% (95% CI 1.6%, 4.0%). By meta-analysis, off-pump CABG was associated with a 40% lower odds of postoperative AKI (OR 0.60; 95% CI 0.43, 0.84; P ‫؍‬ 0.003) and a nonsignificant 33% lower odds for dialysis requirement (OR 0.67; 95% CI 0.40, 1.12; P ‫؍‬ 0.12). Within the selected trials, off-pump CABG was not associated with a significant decrease in mortality.Conclusions: Off-pump CABG may be associated with a lower incidence of postoperative AKI but may not affect dialysis requirement, a serious complication of cardiac surgery. However, the different definitions of AKI used in individual trials and methodological concerns preclude definitive conclusions.

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“…10 OPCAB has been shown to be beneficial for patients at increased risk of stroke, diabetic patients, and women. [11][12][13][14][15] In particular, we have previously demonstrated a significant early mortality and morbidity advantages for women and equal 10-year survival compared with men. 12 Specifically, among OPCAB patients, we have previously reported the mitigation of adverse events and equalization of outcomes in women compared with men.…”

mentioning

confidence: 96%

“…12 Specifically, among OPCAB patients, we have previously reported the mitigation of adverse events and equalization of outcomes in women compared with men. 14 The present study seeks to determine whether the disproportionate advantage of OPCAB observed in 1 high-risk demographic group (women) may also be present for another identifiable high-risk demographic group (blacks).…”

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confidence: 99%

Racial Disparity Persists After On-Pump and Off-Pump Coronary Artery Bypass Grafting

et al. 2009

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Off-Pump Techniques Disproportionately Benefit Women and Narrow the Gender Disparity in Outcomes After Coronary Artery Bypass Surgery

Abstract: Background-Women experience greater morbidity and mortality than men after conventional coronary artery bypass grafting (CABG) on cardiopulmonary bypass (CPB). The objective of this study was to determine whether off-pump CABG (OPCAB) alters this gender-based disparity.

Cited by 90 publications

References 34 publications

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

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

Off-Pump Coronary Artery Bypass Surgery and Acute Kidney Injury

Racial Disparity Persists After On-Pump and Off-Pump Coronary Artery Bypass Grafting

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