The outcome of patients requiring emergency conversion from off-pump to on-pump coronary artery bypass grafting

Landoni, Giovanni; Pappalardo, Federico; Crescenzi, Giuseppe; Aletti, Giacomo; Marchetti, Chiara; Poli, D.; Franco, Annalisa; Rosica, Concetta; Zangrillo, Alberto

doi:10.1017/s0265021506001578

Cited by 19 publications

(11 citation statements)

References 24 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…The 17 selected studies [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] were published between 1998 and 2008 and contained data for 18,870 OPCAB cases, of which 920 were conversions to ONCAB. Of these conversions, 701 were defined as emergency, 178 were elective and, in the remaining 41, the conversion subtype was not specified.…”

Section: Selected Studiesmentioning

confidence: 99%

“…It is reasonable to assume that straightforward cases with favourable risk profiles will not require conversion. However, where patients present with risk factors predictive of several-fold increase in the risk of conversion, such as poor cardiac function [18,20,40], poor-quality coronary targets [20,40,41], prior myocardial infarction [22,40], redo or salvage revascularisation [18,22] or chronic obstructive pulmonary disease [23,30], informed consent should be obtained, accounting for the possibility of conversion. It is desirable, perhaps, for future research to be directed towards developing a system for predicting the individual patient's risk of conversion.…”

Section: Consent Issuesmentioning

confidence: 99%

See 1 more Smart Citation

Intra-operative conversion is a cause of masked mortality in off-pump coronary artery bypass: a meta-analysis

Mukherjee

Ashrafian

Kourliouros

et al. 2012

European Journal of Cardio-Thoracic Surgery

View full text Add to dashboard Cite

Coronary artery bypass surgery can offer excellent results when performed with cardiopulmonary bypass (on pump) or without cardiopulmonary bypass (off pump). The debate as to which technique is superior remains unanswered. Intra-operative conversion from off- to on-pump coronary surgery is a relatively unexplored phenomenon, which cannot be assessed within randomised controlled trial design. We aimed to assess the effect of off-pump conversion on patient mortality. Medline, Embase, Cochrane and Google Scholar databases were systematically reviewed for studies published between 1980 and 2010 that compared the incidence of mortality between converted and non-converted off-pump patients. Publication bias and heterogeneity were assessed and data were extracted independently by multiple observers. We undertook a meta-analysis of these studies using random effects modelling. A total of 17 studies fulfilled our inclusion criteria, containing data for 18,870 off-pump coronary artery bypass operations spanning a decade (1998-2008), involving 920 cases of conversion. Overall, conversion increased mortality by an odds ratio of 6.18 (95% confidence interval 4.65-8.20), whereas emergency conversion further raised the odds ratio of mortality to 6.99 (95% confidence interval 5.18-9.45). The conversion from off- to on-pump cardiac surgery may significantly increase the chance of an adverse outcome, whereas emergency conversion confers a significant rise in mortality. The risk of conversion should be discussed when obtaining the patient's informed consent and its prevention warrants serious consideration by cardiac surgeons and cardiac surgical training programmes.

show abstract

Section: Selected Studiesmentioning

confidence: 99%

Section: Consent Issuesmentioning

confidence: 99%

Intra-operative conversion is a cause of masked mortality in off-pump coronary artery bypass: a meta-analysis

Mukherjee

Ashrafian

Kourliouros

et al. 2012

European Journal of Cardio-Thoracic Surgery

View full text Add to dashboard Cite

show abstract

“…The reported rate of conversion is quite variable in literature. [ 1 2 3 4 5 6 ] The presence of higher conversion rates within randomized trials reporting it compared with observational studies may be due to more accurate documentation. [ 7 ] In a recent meta-analysis ( n = 18,870) of 17 studies spanning over a decade, reported conversion rate was 4.9% (920/18,870).…”

Section: Discussionmentioning

confidence: 99%

“…IOC is associated with a significantly increased risk of mortality and postoperative morbidity, which may potentially negate any benefit of OPCAB. [ 1 2 3 4 5 6 ]…”

Section: Introductionmentioning

confidence: 99%

Intraoperative conversion to on-pump coronary artery bypass grafting is independently associated with higher mortality in patients undergoing off-pump coronary artery bypass grafting: A propensity-matched analysis

et al. 2016

View full text Add to dashboard Cite

Context:One of the main limitations of off-pump coronary artery bypass grafting (OPCAB) is the occasional need for intraoperative conversion (IOC) to on-pump coronary artery bypass grafting. IOC is associated with a significantly increased risk of mortality and postoperative morbidity. The impact of IOC on outcome cannot be assessed by a randomized control design.Aims:The objective of this study was to analyze the incidence, risk factors, and impact of IOC on the outcome in patients undergoing OPCAB.Settings and Design:Three tertiary care level hospitals; retrospective observational study.Subjects and Methods:This retrospective observational study included 1971 consecutive patients undergoing OPCAB from January 2012 to October 2015 at three tertiary care level hospitals by four surgeons. The incidence, patient characteristics, cause of IOC, and its impact on outcome were studied.Statistical Analysis Used:The cohort was divided into two groups according to IOC. Univariate logistic regression was performed to describe the predictors of IOC. Variables that were found to be significant in univariate analysis were introduced into multivariate model, and adjusted odds ratio (OR) was calculated. To further assess the independent effect of IOC on mortality, propensity score matching with a 5:1 ratio of non-IOC to IOC was performed.Results:The overall all-cause in-hospital mortality was 2.6%. IOC was needed in 128 (6.49%) patients. The mortality in the IOC group was significantly higher than non-IOC group (21 of 128 [16.4%] vs. 31 of 1843 [1.7%], P = 0.0001). The most common cause for IOC was hemodynamic disturbances during grafting to the obtuse marginal artery (51/128; 40%). On multivariate logistic regression analysis, left main disease, pulmonary hypertension, and mitral regurgitation independently predicted IOC. We obtained a propensity-matched sample of 692 patients (No IOC 570; IOC 122), and IOC had OR of 16.26 (confidence interval 6.3–41; P < 0.0001) for mortality in matched population.Conclusions:Emergency IOC increases odds for mortality by 16-fold. Hence, identification of patients at higher risk of IOC may improve the outcome.

show abstract

“…It has been shown that conversions are associated with a high rate of complications and mortality [21]. Therefore avoidance of conversion in off-pump coronary bypass surgery is of crucial importance and requires strict adherence to a standardized protocol: After positioning of the stabilizer, no arrhythmias are tolerated.…”

Section: End-diastolic Volume MLmentioning

confidence: 99%

Off-pump multi-vessel revascularization in patients with poor left ventricular function*

et al. 2011

View full text Add to dashboard Cite

Zusammenfassung. Grundlagen: Welche Patientengruppe am ehesten von der Off-Pump-Chirurgie profitiert, wird sehr kontrovers diskutiert. Diese prospektive, randomisierte Studie untersucht diese Operationsmethode an Patienten mit deutlich herabgesetzter linksventrikulärer Auswurffraktion (EF).Methodik: Von 51 Patienten mit einer EF < 35 % wurden 26 mit der Off-Pump-Methode und 25 konventionell operiert. Untersucht wurden neben der Zeit bis zur Extubation vor allem auch ein kombinierter Endpunkt (verschiedene Spitalmorbiditäten) sowie die Sterblichkeit.Ergebnisse: EF, Euro-Score, Anzahl der distalen Anastomosen sowie der postoperative Katecholaminbedarf waren gleich. Im Gegensatz dazu war die Zeit bis zur Extubation mit 11,2 ± 3,8 Stunden in der Off-Pump-Gruppe deutlich kü rzer als in den konventionell operierten Patienten (16,4 ± 2,7; p < 0,05). Auch die Anzahl der Spitalsmorbiditäten war höher (2 gegen 5 Patienten), die Sterblichkeit lag in beiden Gruppen bei 0 %.Schlussfolgerungen: In diesen Hochrisikopatienten vermindert die Off-Pump-Methode die Intubationsdauer und die Morbidität.Schlüsselwörter: Off-pump, on-pump, Koronarbypass, Herzinsuffizienz.Summary. Background: The subset of patients that benefit most from off-pump CABG remains controversial. This study randomly compared off-with on-pump CABG in patients with poor EF.Methods: Fifty-one patients were included in this study and randomized to undergo off-(n ¼ 26) or onpump (n ¼ 25) CABG. Inclusion criteria were EF < 35% and multi-vessel disease. The primary end-points were the time to extubation, a composite end-point and mortality.Results: EF, Euro-score, the number of grafts and inotropic support were similar between groups. In contrast time to extubation was 11.2 ± 3.8 hours in the offpump versus 16.4 ± 2.7 hours in the on-pump group (p < 0.05). There were no hospital deaths in both groups. However, 2 off-pump (8%) compared to 5 on-pump (20%) patients presented a composite end-point.Conclusions: In this high-risk cohort off-pump CABG reduces time to extubation and in-hospital morbidity.

show abstract

The outcome of patients requiring emergency conversion from off-pump to on-pump coronary artery bypass grafting

Abstract: Patients who are emergently converted to CPB during attempted off-pump procedures are at higher risk of death and prolonged hospital stay; this population should be included in comparative studies as "intention to treat" in the off-pump group.

Cited by 19 publications

References 24 publications

Intra-operative conversion is a cause of masked mortality in off-pump coronary artery bypass: a meta-analysis

Intra-operative conversion is a cause of masked mortality in off-pump coronary artery bypass: a meta-analysis

Intraoperative conversion to on-pump coronary artery bypass grafting is independently associated with higher mortality in patients undergoing off-pump coronary artery bypass grafting: A propensity-matched analysis

Off-pump multi-vessel revascularization in patients with poor left ventricular function*

Contact Info

Product

Resources

About