OPCAB versus early mortality and morbidity: an issue between clinical relevance and statistical significance☆

Sergeant, Paul; Wouters, Patrick; Meyns, Bart; Bert, Christophe; Hemelrijck, J. Van; Bogaerts, Chris; Sergeant, Gregory; Slabbaert, Koen

doi:10.1016/j.ejcts.2004.02.013

Cited by 63 publications

(31 citation statements)

References 21 publications

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“…La cirugía coronaria sin CEC reduce, aunque no suprime, los valores circulantes de mediadores inflamatorios 74 , y la eliminación del pinzamiento aórtico reduce el sufrimiento miocárdico. Aunque los resultados clínicos no han alcanzado aún evidencia clase I, los resultados de series amplias observacionales indican el beneficio de esta técnica en términos de supervivencia a corto y largo plazo, principalmente en pacientes con disfunción ventricular, diabéticos y ancianos [79][80][81] , incidencia de infarto de miocardio y accidente cerebrovascular 82 , y reducción de la incidencia de fibrilación auricular postoperatoria 83 . La cirugía coronaria con injertos arteriales sin CEC asociada a anestesia epidural torácica y fast track representa actualmente el patrón oro.…”

Section: Cirugía Coronaria Menos Invasivaunclassified

Cirugía coronaria. Evolución en la última década. Indicaciones y resultados actuales

Herreros

2005

Revista Española de Cardiología

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La cirugía coronaria está avalada por unos excelentes resultados, bien documentados a largo plazo como consecuencia de la revascularización completa y la utilización de una o 2 arterias mamarias. En este artículo se revisan los resultados y las indicaciones de la cirugía y se valoran los nuevos retos y las oportunidades que incluyen la cirugía más segura, menos agresiva y asociada a otros procedimientos quirúrgicos. El objetivo es desarrollar estrategias ligadas a un ciclo innovador que adapte la cirugía a las necesidades de la población, las nuevas tecnologías y a las actividades pioneras. INTRODUCCIÓNLa cirugía coronaria tiene un origen incierto, en función de la localización geográfica y las preferencias del autor: Senning en Europa (1966), Garrett (1996) Coronary artery bypass surgery is endorsed by the excellent, well-documented, long-term results that follow complete revascularization and the use of 1 or 2 mammary artery grafts. This article contains a review of the current indications for and the results of such surgery and an evaluation of new challenges and opportunities, including the implementation of safer and less aggressive surgery, and surgery associated with other operative procedures. The aim was to develop a strategy linked to a cycle of innovation that could be used to adapt surgery to the needs of the population, to new technologies, and to pioneering developments.

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Section: Cirugía Coronaria Menos Invasivaunclassified

Cirugía coronaria. Evolución en la última década. Indicaciones y resultados actuales

Herreros

2005

Revista Española de Cardiología

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“…35 The advantages of OPCAB have been observed for high-risk cases, 29,32 and it is believed that this trial targeting low-risk male subjects was unable to demonstrate the superiority of OPCAB. Sergeant et al reported a significant reduction in the risk of stroke in highrisk patients, 36 and the OPCAB technique might be associated with a reduced incidence of stroke, particularly in elderly patients. 37 Nishiyama et al 38 conducted a study of stroke, based on the CREDO-Kyoto database.…”

Section: Opcab Vs On-pump Cabgmentioning

confidence: 99%

Off-Pump Coronary Artery Bypass vs Percutaneous Coronary Intervention - Therapeutic Strategies for 3-Vessel Coronary Artery Disease: OPCAB vs PCI (OPCAB-Side) -

Nishimi

Tashiro

2010

Circ J

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Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp ebate over the use of percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) to treat ischemic heart disease has continued over several decades. The PCI procedure has shifted from balloon angioplasty into the stent era, and the development of drugeluting stents (DES), in particular, has ushered in a new era for surgeons. At the same time, in recent years stable results have been obtained using CABG procedures and we have entered the era of the less invasive, off-pump coronary artery bypass (OPCAB) procedure, the rate of use of which exceeds 60% in Japan, and good surgical results have been reported. 1 Regarding the selection of PCI or CABG, although many large-scale clinical trials have found no significant differences in actuarial survival, significant differences have been observed in major adverse cardiac and cerebrovascular events (MACCE) and repeat revascularization rates, and because of the complicated combinations of various factors, such as 3-vessel lesions, left main coronary artery disease, complex multivessel lesions, diabetes mellitus (DM), and kidney disease, debate over the selection of treatment for individual patients will continue. Here we discuss the CABG procedures, including OPCAB, based on previous clinical studies. Findings Regarding Coronary RevascularizationBased on Treatment Method Medical Treatment vs PCIIn comparisons of conservative medical treatment and PCI for treating stable coronary artery disease, meta-analyses performed in 11 randomized controlled trials (RCTs) conducted in 2005 with 2,950 subjects (wherein 1,476 received PCI and 1,474 received conservative treatment) revealed no significant differences in mortality, myocardial infarction (MI) and repeat revascularization rates between the 2 treatments. 2 In the subsequent COURAGE trial of 2007 with 2,287 subjects, an optimal medical therapy (MT) group (1,138 patients) and PCI with MT group (1,149 patients) were compared for longterm follow-up results (median: 4.6 years), and no significant differences were observed in hard endpoints such as death, MI and stroke. 3 However, it was reported that in the PCI group the improvement effects for the onset of angina pectoris were good, and single-photon-emission computed tomography (SPECT) examinations revealed significant improvement effects for patients with moderate to severe pretreatment ischemia. 4 On the other hand, in the JSAP study, 5 which was a multicenter RCT conducted in Japan with 384 subjects, an Coronary artery bypass graft (CABG) surgery is still the best therapy for patients with multivessel and left main coronary artery disease. Recently, the introduction of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in these patients has improved the restenosis rate compared with bare metal stents. Furthermore, according to the results of the SYNTAX trial, no differences were found in the frequencies of mortality or myocardial infarcti...

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“…An alternative approach is to adopt the technique wholesale after a period of intense training or "re-engineering" as pursued by Sergeant and colleagues. 16 Mack and colleagues 17 recently reported a large retrospective study encompassing four centers over a 3-year period. The study examined 17,401 isolated coronary artery bypass procedures, of which 7,283 (41.9%) were off-pump and 10,118 (58.1%) were on-pump.…”

Section: Clinical Outcomementioning

confidence: 99%

“…Sergeant and colleagues 16 analyzed a consecutive series of 3,333 patients undergoing coronary artery surgery (1,593 on-pump and 1,740 off-pump). They found a trend towards a 60% reduction of stroke, which after risk adjustment, fell below the level of significance for the total population, but the benefit persisted for patients with severe stenosis of the internal carotid artery.…”

Section: Risk Of Cerebral Injurymentioning

confidence: 99%

Controversies in Off-pump Coronary Artery Surgery

Pepper¹

2005

Clinical Medicine & Research

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Motivated by a desire to reduce the morbidity of a well-established and effective procedure for coronary artery disease, up to 25% of coronary artery bypass operations are being performed without the use of a heart-lung pump. Concerns remain about the quality of the coronary anastomoses and the completeness of revascularization. Randomized trials have not revealed the significant reduction in morbidity or mortality that the early enthusiasts had hoped for. Yet a number of non-randomized studies have shown clinical benefit from the avoidance of an extracorporeal circulation, but these have been criticized for potential bias in patient selection and management. A majority of surgeons have not yet adopted this technique and are waiting for the accumulation of more evidence. Although the mortality rate of coronary artery surgery is low, at approximately 2%, 1 it is age related and rises to over 6% in those over 75 years of age. This benefit is offset by a complication rate of 20% to 30%. In addition, there is a 2 to 3 month period of recovery from the fatigue that usually follows any major operation. The recent observation of neurocognitive impairment in up to 42% of patients 5 years after surgery has aroused additional concern. 3,4 The functional significance of the neurocognitive findings and the relative contribution of aging, atherosclerotic disease, and surgical procedures to the measured impairment remain unknown.Patients and their physicians desire a low morbidity procedure, preferably without general anesthesia and in an outpatient setting. These factors together with the avoidance of the adverse consequences of cardiopulmonary bypass have been the driving force behind the development of percutaneous coronary intervention (PCI). Recurrent angina and the need for subsequent re-intervention are more frequent after PCI than after conventional coronary artery bypass surgery, a performance gap that is likely to be narrowed by the emergence of drug-eluting stents.PCI has had a dramatic effect on coronary artery bypass surgery, arresting the dramatic growth of surgery in the 1980s and shifting the attention of surgeons to patients with more advanced coronary disease and extensive coexisting conditions. This has motivated surgeons to refine coronary revascularization techniques in order to maximize clinical effectiveness, limit costs, and reduce invasiveness.In contrast to the small incision approaches, off-pump coronary artery bypass surgery through a median sternotomy has gained clinical acceptance and in many centers constitutes 20% to 30% of the total volume of coronary surgery. Creation of the distal anastomoses is facilitated by the use of stabilizers that reduce the motion of the heart in an

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OPCAB versus early mortality and morbidity: an issue between clinical relevance and statistical significance☆

Cited by 63 publications

References 21 publications

Cirugía coronaria. Evolución en la última década. Indicaciones y resultados actuales

Cirugía coronaria. Evolución en la última década. Indicaciones y resultados actuales

Off-Pump Coronary Artery Bypass vs Percutaneous Coronary Intervention - Therapeutic Strategies for 3-Vessel Coronary Artery Disease: OPCAB vs PCI (OPCAB-Side) -

Controversies in Off-pump Coronary Artery Surgery

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