Abstract
OBJECTIVES
Despite evidence from several randomized controlled trials and observational studies validating short-term safety and efficacy of off-pump coronary artery bypass grafting (CABG), ...concerns persist regarding the impact of off-pump CABG on long-term survival and freedom from reintervention. This persistent scepticism regarding off-pump CABG prompted us to review our practice of CABG over the last 20 years with a view to comparing the impact of off-pump and on-pump CABG on short-term and long-term outcomes in a high-volume off-pump coronary surgery centre.
METHODS
We retrospectively analysed prospectively collected data from the Patients Analysis and Tracking System database (Dendrite Clinical Systems, Oxford, UK) for all isolated first-time CABG procedures with at least 2 grafts performed at our institution from January 1996 to September 2017. Over the study period, 5995 off-pump CABG and 4875 on-pump CABG were performed by surgeons with exclusive off-pump and on-pump practices, respectively. Multivariable logistic regression and the Cox model were used to investigate the effect of off-pump versus on-pump procedures on short-term outcomes and long-term survival. Propensity score matching was used to compare the 2 matched groups.
RESULTS
Off-pump CABG was associated with a lower risk for 30-day mortality odds ratio (OR) 0.42, 95% confidence interval (CI) 0.32–0.55; P < 0.001, reintubation/tracheostomy (OR 0.58, 95% CI 0.47–0.72; P < 0.001) and re-exploration for bleeding (OR 0.48, 95% CI 0.37–0.62; P < 0.001). The benefit in terms of operative deaths from off-pump was significant in those with Society of Cardio-Thoracic Surgery logistic EuroSCORE >2 (interaction P = 0.04). When compared with on-pump CABG, off-pump CABG did not significantly reduce the risk of stroke (OR 0.96, 95% CI 0.88–1.12; P = 0.20) and postoperative haemofiltration (OR 0.98, 95% CI 0.86–1.20; P = 0.35). At the median follow-up of 12 years (interquartile range 6–17, max 21), off-pump CABG did not affect late survival log rank P = 0.24; hazard ratio (HR) 0.95, 95% CI 0.89–1.02 or the need for reintervention (log rank P = 0.12; HR 1.19, 95% CI 0.95–1.48).
CONCLUSIONS
This large volume, single-centre study with the longest reported follow-up confirms that off-pump CABG performed by experienced surgeons, who perform only off-pump procedures in a high-volume off-pump coronary surgery centre, is associated with lower risk of operative deaths, fewer postoperative complications and similar 20-year survival and freedom from reintervention rates compared with on-pump CABG.
Incidence and impact of silent brain lesions after coronary artery bypass grafting Tachibana, Hitoshi; Hiraoka, Arudo; Saito, Kazuya ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
February 2021, 2021-02-00, 20210201, Volume:
161, Issue:
2
Journal Article
Peer reviewed
Open access
Silent brain lesions are known to occur after coronary artery bypass grafting (CABG). The aim of this study was to seek the incidence rate, the influence of procedures, and their impact on the ...postoperative course.
From July 2016 to April 2018, 104 consecutive patients undergoing elective and isolated first-time CABG (65 off-pump and 39 on-pump) were enrolled. New brain lesions were evaluated by brain magnetic resonance imaging both before and after CABG. Postoperative outcomes, including cognitive function, were compared between patients with and without brain lesions.
The overall incidence of new brain lesions was 20.1% (21/104). Excluding one symptomatic stroke case, silent brain lesions were revealed in the remaining patients. The percentage of on-pump CABG (61.9% 13/21 vs 31.3% 26/83, P = .019) and aortic clamp (52.4% 11/21 vs 24.1% 20/83, P = .014) were significantly greater in patients with brain lesions. Brain lesions were observed in 12.3% and 15.8% of patients in the off-pump and anaortic CABG. The Katz Index of Independence in Activities of Daily Living was significantly lower in patients with brain lesions (from 5.8 ± 0.9 to 5.4 ± 1.2 vs from 5.9 ± 0.5 to 5.9 ± 0.6, P = .013). In patients with new lesions, postoperative cognitive dysfunction (POCD) was observed only in multiple lesions, and the maximum size was significantly greater in patients with POCD.
Magnetic resonance imaging of the brain frequently detected postoperative silent brain lesions after CABG in off-pump and aorta non-touch groups. Multiple and larger new brain lesions were associated with the development of POCD.
The incidence of postoperative new brain lesions detected by magnetic resonance imaging was 20.2% (21/104) after coronary artery bypass grafting (CABG). Postoperative cognitive dysfunction was significantly observed in patients with multiple and larger lesions. Display omitted
La cirugía coronaria es un procedimiento quirúrgico que ha presentado un importante desarrollo a lo largo de los años, con múltiples avances y refinamientos de la técnica para tratar de reducir las ...complicaciones derivadas del procedimiento, así como aumentar la durabilidad de los injertos.
En la presente revisión trataremos algunas de las modificaciones técnicas de la cirugía de revascularización coronaria encaminadas a reducir la agresión del procedimiento (cirugía sin circulación extracorpórea), reducir el tamaño de la incisión quirúrgica (cirugía mini-invasiva) o reducir la posible aparición del ictus postoperatorio (cirugía sin manipulación de la aorta ascendente).
Coronary artery bypass grafting (CABG) is a surgical procedure which has greatly evolved during the last years, with important technical advances and improvements to try to reduce the procedural complications and prolong the durability of the coronary grafts.
In this review we will describe some of these technical modifications of the classical procedure of CABG which are indicated to reduce the aggressiveness of the procedure (off-pump CABG), reduce the size of the surgical access (minimally invasive direct coronary artery bypass grafting) or to reduce the possible occurrence of a postoperative stroke (anaortic).
Background The debate on the relative benefits of off-pump and on-pump coronary artery bypass surgery ( OPCABG and ONCABG ) is still open. We aimed to provide an updated and complete summary of the ...evidence on the differences between OPCABG and ONCABG and to explore whether the length of the follow-up and the surgeons' experience in OPCABG modify the comparative results. Methods and Results All randomized clinical trials comparing OPCABG and ONCABG were included. Primary outcome was follow-up mortality. Secondary outcomes were operative mortality, perioperative stroke, perioperative myocardial infarction, and late repeated revascularization. Subgroup analyses were performed based on the length of the follow-up and the percentage of crossover from the OPCABG group (used as a surrogate of surgeon experience with OPCABG ). One hundred four trials were included (20 627 patients, OPCABG : 10 288; ONCABG : 10 339). Weighted mean follow-up time was 3.7 years (range 1-7.5 years). OPCABG was associated with a higher risk of follow-up mortality (incidence rate ratio 1.11, 95% confidence interval 1.00-1.23, P=0.05). The difference was significant only for trials with mean follow-up of ≥3 years and for studies with a crossover rate of ≥10%. There was a trend toward lower risk of perioperative stroke and higher need for late repeated revascularization in the OPCABG arm. Conclusions OPCABG is associated with a higher incidence of incomplete revascularization, an increased need for repeated revascularization, and decreased midterm survival compared with ONCABG . Surgeon inexperience in OPCABG is associated with late mortality.
Prediction scoring systems for coronary artery bypass grafting (CABG) patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) have not yet been reported. This study was designed to ...develop a predictive score for in-hospital mortality for cardiogenic shock patients who received VA-ECMO after isolated CABG.
Retrospective cohort study of consecutive CABG patients supported with VA-ECMO (n = 166) at the Beijing Anzhen Hospital between February 2004 and March 2017.
One hundred and six patients (64%) could be weaned from VA-ECMO, and 74 patients (45%) survived to hospital discharge. On the basis of multivariable logistic regression analyses, the pRedicting mortality in patients undergoing veno-arterial Extracorporeal MEMBrane oxygenation after coronary artEry bypass gRafting (REMEMBER) score was created with six pre-ECMO parameters: older age, left main coronary artery disease, inotropic score > 75, CK-MB > 130 IU/L, serum creatinine > 150 umol/L, and platelet count < 100 × 10
/L. Four risk classes, namely class I (REMEMBER score 0-13), class II (14-19), class III (20-25), and class IV (> 25) with their corresponding mortality (13%, 55%, 70%, and 94%, respectively), were identified. The area under the receiver operating characteristic curve 0.85(95% CI 0.79-0.91) for the REMEMBER score was better than those for the SOFA, SAVE, EuroSCORE, and ENCOURAGE scores in this population.
The REMEMBER score might help clinicians at bedside to predict in-hospital mortality for patients receiving VA-ECMO after isolated CABG for refractory cardiogenic shock. Prospective studies are needed to externally validate this scoring system.
Background:We compared postoperative outcomes in hemodialysis (HD) patients who underwent isolated coronary artery bypass grafting (CABG) for multivessel disease using either bilateral or single ...skeletonized internal thoracic artery.Methods and Results:Among 1,486 patients who underwent isolated CABG between 2002 and 2020, 145 HD patients were retrospectively analyzed. After inverse probability of treatment weighting, there were no significant differences in the preoperative characteristics. No significant differences in 30-day mortality (P=0.551) or postoperative deep sternal wound infection (P=0.778) were observed. However, the bilateral internal thoracic artery grafting group had a lower postoperative stroke rate (0% vs. 4.0%, P=0.019). No significant differences in freedom from all-cause death (P=0.760) and cardiac death (P=0.863) were found. In the multivariate Cox proportional hazards models, bilateral internal thoracic artery grafting was not associated with all-cause death (P=0.246) or cardiac death (P=0.435).Conclusions:Bilateral internal thoracic artery grafting in HD patients did not improve mid-term outcomes, but it was also not associated with worse postoperative outcomes. Use of the bilateral internal thoracic artery may be an important option in patients with limited conduits to prevent postoperative complications.
Pneumonia, the most common infection following cardiac surgery, is associated with major morbidity and mortality. While prior work has identified preoperative risk factors for pneumonia, the present ...study evaluates the role and associated impact of intra- and postoperative risk factors on pneumonia after cardiac surgery.
This observational cohort study evaluated 71,165 patients undergoing coronary and/or aortic valve surgery across 33 institutions between 2011 and 2021. Terciles of estimated pneumonia risk were compared between a validated preoperative model (Model One) and a model additionally accounting for significant intra- (e.g., bypass duration) and postoperative (e.g., extubation time) factors (Model Two). Logistic regression was used to develop and validate Model Two.
Postoperative pneumonia occurred among 2.62% of patients. A total of nine significant intra- and early postoperative risk factors were identified. The absolute risk of pneumonia increased across Model One terciles: low (≤ 1.04%), medium (1.04%-2.40%), and high (>2.40%). Model Two performed well (C-statistic: 0.771). Most patients (60.1%) had no change in their pre- versus intra-/postoperative risk tercile. The 19.6% of patients who increased their risk tercile with Model Two accounted for 18.6% of all pneumonia events.
This study identified nine significant perioperative risk factors for pneumonia. Nearly one out of every five patients moved into a higher pneumonia risk category based on their intra- and postoperative course. These findings may serve as the focus of future quality improvement efforts to reduce a patient’s risk of postoperative pneumonia.
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Surgical coronary artery bypass grafting (CABG) is the standard of care for revascularization of left main or three-vessel coronary artery disease. The off-pump coronary artery bypass graft (OPCAB) ...procedure avoids the use of cardiopulmonary bypass. Theoretically, OPCAB may improve long-term outcomes by reducing the rates of perioperative myocardial injury, stroke, neurocognitive impairment, and cardiac-related mortality. Several high-quality clinical trials have been conducted since OPCAB became popular in the 1990s and have demonstrated no benefit of OPCAB over traditional CABG with respect to these outcomes despite favorable short-term reductions in transfusion requirements and other postoperative complications. Ultimately, OPCAB is associated with less effective myocardial revascularization and does not entirely prevent complications traditionally associated with cardiopulmonary bypass. This article reviews major high-quality trials of OPCAB versus traditional CABG with respect to both short- and long-term clinical outcomes.
Abstract
Aims
Coronary computed tomography angiography (CTA) has emerged as a non-invasive diagnostic method for patients with suspected coronary artery disease, but its usefulness in patients with ...complex coronary artery disease remains to be investigated. The present study sought to determine the agreement between separate heart teams on treatment decision-making based on either coronary CTA or conventional angiography.
Methods and results
Separate heart teams composed of an interventional cardiologist, a cardiac surgeon, and a radiologist were randomized to assess the coronary artery disease with either coronary CTA or conventional angiography in patients with de novo left main or three-vessel coronary artery disease. Each heart team, blinded for the other imaging modality, quantified the anatomical complexity using the SYNTAX score and integrated clinical information using the SYNTAX Score II to provide a treatment recommendations based on mortality prediction at 4 years: coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or equipoise between CABG and PCI. The primary endpoint was the agreement between heart teams on the revascularization strategy. The secondary endpoint was the impact of fractional flow reserve derived from coronary CTA (FFRCT) on treatment decision and procedural planning. Overall, 223 patients were included. A treatment recommendation of CABG was made in 28% of the cases with coronary CTA and in 26% with conventional angiography. The agreement concerning treatment decision between coronary CTA and conventional angiography was high (Cohen’s kappa 0.82, 95% confidence interval 0.74–0.91). The heart teams agreed on the coronary segments to be revascularized in 80% of the cases. FFRCT was available for 869/1108 lesions (196/223 patients). Fractional flow reserve derived from coronary CTA changed the treatment decision in 7% of the patients.
Conclusion
In patients with left main or three-vessel coronary artery disease, a heart team treatment decision-making based on coronary CTA showed high agreement with the decision derived from conventional coronary angiography suggesting the potential feasibility of a treatment decision-making and planning based solely on this non-invasive imaging modality and clinical information.
Trial registration number
NCT02813473.
Intraoperative conversion to cardiopulmonary bypass with its subsequent high mortality is a major concern associated with off-pump coronary artery bypass grafting (OPCAB). The impact of procedure ...volume on the incidence of intraoperative conversion, however, is poorly defined. This study therefore evaluated the effect of procedure volume on the incidence of conversion in OPCAB using nationwide data. We analyzed 31,361 patients who underwent primary, nonemergent, isolated OPCAB during 2013–2016 reported in the Japan Cardiovascular Surgery Database. Hospitals (n = 548) and surgeons (n = 1315) were divided into tertile categories (low-, medium-, and high volumes) based on the total number of isolated coronary artery bypass grafting (CABG). Hierarchical logistic regression analysis, including 22 preoperative factors and hospital and surgeon CABG volumes, was used to assess the relation between procedure volume and the risk of conversion due to bleeding/hemodynamic instability. There were 797 (2.5%) intraoperative conversions due to bleeding/hemodynamic instability. Risk-adjusted odds ratios for conversion were significantly lower in some combined hospital/surgeon CABG volume categories than in the reference category. Hospital/surgeon volumes and their odds ratio (95% confidence interval) were as follows: low/low 1.00 (reference); medium/low 0.62 (0.39–0.96); high/low 0.47 (0.27–0.81); high/high 0.58 (0.38–0.89). There was a lower risk of conversion in medium- and high-volume than low-volume hospitals, especially among low-volume surgeons. Procedure volume is associated with the incidence of conversion during OPCAB. Among low-volume surgeons, hospital CABG volume significantly reduces conversion in a volume-dependent manner. These findings will be useful for safety training of OPCAB surgeons.
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