Off-pump versus on-pump coronary artery bypass graft surgery: differences in short-term outcomes and in long-term mortality and need for subsequent revascularization

Selective beta-1 receptor blockade further reduces the mechanically stabilized target coronary artery motion during beating heart surgery

OBJECTIVE

Adequate stabilization of anastomosis sites during off-pump coronary artery bypass is essential to obtain excellent graft patency. We examined the effect of beta-1 adrenergic receptor blockade on the target coronary artery motion by three-dimensional (3D) digital motion capture and reconstruction technology.

METHODS

Eight pigs underwent a sternotomy. Reflection markers were attached to the surface coronary arteries, followed by a mechanical stabilizer application. Two high-speed digital cameras captured two-dimensional (2D) motion of the markers from different angles. These 2D data were reconstructed into 3D data points, representing the motion of each coronary artery. Landiolol hydrochloride, a novel selective beta-1 receptor blocker, was infused intravenously after acquisition of control data.

RESULTS

Beta-1 receptor blockade decreased heart rate (105 ± 16 vs. 90 ± 9 beat/min; P = 0.007) without decreasing arterial blood pressure. The 3D distance moved (millimeter) during one cardiac cycle was significantly reduced on the left anterior descending (9.6 ± 2.8 vs. 6.6 ± 1.9 mm; P = 0.003), left circumflex (10.5 ± 6.3 vs. 6.4 ± 2.6 mm; P = 0.038), and right coronary (8.3 ± 3.6 vs. 6.5 ± 2.1 mm; P = 0.028) arteries. Reduction in the maximal velocity, maximal acceleration, and maximal deceleration of the anastomosis site in all coronary arteries was also found in a quantitative fashion.

CONCLUSIONS

Selective beta-1 receptor blockade significantly reduces the 3D motion at anastomosis sites on the beating heart, with stable systemic blood pressure. Further quantitative investigations of pharmacological stabilization are warranted to achieve better outcome of the patients undergoing off-pump coronary artery bypass surgery.

Off-pump Coronary Artery Bypass is a Safe Option in Patients Presenting as Emergency

Introduction: The applicability of off-pump coronary-artery bypass (OPCAB) in patients who present as emergency remains controversial. Herein, we explore the efficacy and safety of OPCAB in patients who were indicated for emergency surgery. Materials and Methods: Between 2002 and 2007, a total of 282 patients underwent OPCAB, of which 68 were presented as emergency. This cohort (group A) was compared to 68 patients who had traditional on-pump coronary artery bypass grafting (CABG, group B) under emergency indications during the same period of time. Baseline demographics, intraoperative data and postoperative outcomes were analysed. Results: Preoperative demographics were comparable in both groups. Mortality during the first 30 days was comparable in both groups and no stroke occurred in the whole series. Patients in group A had significantly less pulmonary complications (4.4% vs 14.7%, P= 0.04), less ventilation time (30.3 ± 33.6 hours vs 41.5 ± 55.4 hours, P = 0.18) and were less likely to have prolonged ventilation, (19.1% vs 35.3%, P = 0.03). Similarly, OPCAB patients had less postoperative renal-failure/dysfunction (5.9% vs 8.8%, P = 0.51) and required less inotropic support (66.2% vs 88.2%, P = 0.002), bloodtransfusions (23% vs 86.8%, P <0.0001), and atrial- (17.6% vs 35.3%, P = 0.02) or ventricular-pacing (17.6% vs 41.2%, P = 0.002). Although the number of diseased vessels was comparable in both groups, patients in group A received less distal anastomoses. (2.78 ± 1.19 vs 3.41 ± 0.89, P = 0.002). Similarly, complete revascularisation was achieved less frequently in group A (76.5% vs 94.1%, P = 0.004). Conclusion: OPCAB strategy is a safe and efficient in emergency patients with reasonable good short-term postoperative outcomes. Keywords: Cardiac surgery, Coronary artery disease, Off-pump coronary-artery bypass

Off-pump coronary artery bypass surgery and acute kidney injury: a meta-analysis of randomized controlled trials

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.

Teaching off-pump coronary artery bypass surgery

Off-pump coronary artery revascularization requires a unique skill set and a different conduct of operation compared with on-pump coronary artery bypass. Not only must the surgeon perform anastomoses on the beating heart, but he/she must understand the hemodynamic consequences of cardiac positioning and stabilization, the effects of regional ischemia on hemodynamic function, contractility, and arrhythmias, and the importance of anesthesia and grafting sequence given variants of anatomy and clinical conditions. Given these differences, the ability to teach off-pump coronary artery bypass to residents and surgeons places unique demands on the teaching surgeon. In this article, we review the available literature about the safety and efficacy of teaching off-pump coronary artery bypass to residents, discuss the fundamentals for training residents, and review the future of simulation and new training paradigms and the impact this will have on current training methods.

Off-pump coronary artery bypass may increase late mortality: a meta-analysis of randomized trials

BACKGROUND

Although a lot of randomized trials of off-pump coronary artery bypass grafting (CABG) versus on-pump CABG were conducted, the majority of them reported only early outcomes. Previous meta-analyses of a few randomized trials found no differences for 1-year to 2-year mortality.

METHODS

We focused late (> or = 1 year) all-cause mortality and performed a meta-analysis of randomized controlled trials of off-pump versus on-pump CABG. The MEDLINE, the EMBASE, and the Cochrane Central Register of Controlled Trials were searched using PubMed and OVID. For each study, data regarding all-cause mortality in both the off-pump and on-pump groups were used to generate risk ratios (RRs) and 95% confidence intervals. Study-specific estimates were combined using inverse variance-weighted averages of logarithmic RRs in both fixed-effects and random-effects models.

RESULTS

Our search identified 11 results of 12 randomized trials (4,326 patients) of off-pump versus on-pump CABG. Pooled analysis demonstrated a statistically significant increase in midterm all-cause mortality by a factor of 1.37 with off-pump relative to on-pump CABG (RR, 1.373; 95% confidence interval, 1.043 to 1.808). Exclusion of any single result, except for the largest (>2,000 patients) trial, from the analysis did not substantively alter the overall result of our analysis. Eliminating the largest trial demonstrated a statistically nonsignificant benefit of on-pump over off-pump CABG for midterm all-cause mortality (RR, 1.344; 95% confidence interval, 0.952 to 1.896).

CONCLUSIONS

The results of our analysis suggest that off-pump CABG may increase late all-cause mortality by a factor of 1.37 over on-pump CABG. Longer term mortality from randomized trials of off-pump versus on-pump CABG is needed.

Increasing Long-Term Major Vascular Events and Resource Consumption in Patients Receiving Off-Pump Coronary Artery Bypass

Background— Despite its widespread use and short-term efficacy, substantial uncertainty remains about the long-term outcomes and cost-effectiveness of off-pump coronary artery bypass (OPCAB).

Methods and Results— A retrospective review of prospectively collected data was conducted of 6665 consecutive patients undergoing isolated coronary artery bypass graft (CABG) at our institution during 1999 to 2006. All patients were followed up until September 30, 2008. Short- and long-term outcomes were compared between OPCAB and conventional CABG. The 2 main long-term outcome measures were repeat revascularization and the composite outcome of major vascular events. Cost comparison at 2 years in a propensity-matched sample during follow-up was also a study interest. The overall mean baseline age was 60.3±8.6 years, and 17.0% were women. Compared with conventional CABG, patients who underwent OPCAB had lower rates of atrial fibrillation ( P =0.003) and requirements for blood transfusion ( P =0.03) and ventilation time >24 hours ( P <0.001). After an average of 4.5 years of follow-up, the rates of repeat revascularization (adjusted hazard ratio, 1.40; 95% confidence interval, 1.03 to 1.89) and major vascular events (adjusted hazard ratio, 1.23; 95% confidence interval, 1.09 to 1.39) were significantly higher in the OPCAB than the conventional CABG group. At 2 years, OPCAB was associated with increased additional direct costs per patient compared with conventional CABG and had a similar survival rate.

Conclusions— Compared with conventional CABG, OPCAB is associated with small short-term gain but increased long-term risks of repeat revascularization and major vascular events, especially among high-risk patients. Moreover, OPCAB consumes more resources and is less cost-effective in the long run.

Off-pump coronary artery revascularization in octogenarians: is it better?

PURPOSE OF REVIEW

Octogenarians are the fastest growing stratum of the population and have the highest prevalence of coronary artery disease. In the past, physicians have been reluctant to provide these patients with optimal care. Seniors are frequently excluded from large randomized trials and generally not included in published guidelines. The purpose of this review is to revisit the demography and epidemiology of coronary artery disease in this population as well as therapeutic strategies used.

RECENT FINDINGS

Recent publications have shown significant advancement in medical and invasive treatment of coronary artery disease in elderly, with special focus on the potential benefit of off-pump coronary artery bypass (OPCAB) surgery.

SUMMARY

Although OPCAB surgery has gained popularity over the past 15 years, its benefit regarding operative mortality and major complications has not been clearly defined in the general population. There is a body of literature supporting its benefit in the elderly population. OPCAB surgery has the potential of decreasing operative mortality and major postoperative complications such as stroke, delirium, atrial fibrillation, and decline in neurocognitive functions in these patients. Off-pump surgery is technically more demanding and has been blamed for providing less complete revascularization and lower graft patency rate, especially in less experienced hands. However, with the upcoming demographic explosion of senior citizens in western societies, OPCAB surgery has definitely to be a part of the armamentarium of modern cardiac surgeons.

Off-pump coronary artery surgery with the Coronéo Cor-Vasc stabilizing device: clinical experience of 141 patients

OBJECTIVES

Numerous devices have been successfully introduced in off-pump coronary artery bypass graft (OPCABG) surgery, most of them being disposable tools based on suction stabilization. Coronéo Cor-Vasc is a reusable system combining suction positioning with compression stabilization. The purpose of this study was to analyze our experience in OPCABG with the Cor-Vasc system.

METHODS

Between March 2001 and May 2008, 141 patients (age = 71.1 +/- 7.5 years) underwent OPCABG surgery using the Cor-Vasc system, representing 6.3% of the case volume of isolated coronary artery bypass graft surgery in the same period. Eighty-eight patients (62.4%) underwent surgery on an urgent basis. In 95 patients (67.4%), the OPCABG option was selected after finding a diseased ascending aorta at intraoperative epiaortic ultrasound.

RESULTS

Among 334 anastomoses (mean = 2.4 +/- 1 per patient), 242 (95 patients) were fashioned with bilateral and 54 (46 patients) with single internal thoracic artery, respectively. In 89.4 and 73% of patients, a complete and a total arterial myocardial revascularization was achieved, respectively. There were two strokes (1.4%) and two myocardial infarctions (1.4%). Two patients died in the hospital (1.4%). Median ICU and in-hospital length of stay were 31.2 h and 10 days, respectively.

CONCLUSION

In our experience, the use of the Cor-Vasc system, including the device-learning curve, was associated with low mortality and morbidity indexes in an aged population with a high risk of stroke. The system appeared to be sufficiently versatile and potentially cost-effective when compared with disposable devices.

High OPCAB surgical volume improves midterm event-free survival

BACKGROUND

The aim of this study was to evaluate the midterm results of the initial phase of off-pump coronary artery bypass (OPCAB) surgery adoption in a single surgical unit, assessing the impact of procedural volume.

METHODS

Study participants were 312 patients who underwent OPCAB during the period between August 2000 and January 2005 at S. Croce Hospital. Of these patients, 126 patients with an indication selected for comorbidities or 1-vessel disease underwent OPCAB performed by 4 low-volume surgeons, and 186 unselected patients underwent OPCAB performed by a single high-volume surgeon.

RESULTS

OPCAB performed by low-volume surgeons was associated with less complete revascularization and less arterial conduit use. Early result analysis showed a low rate of in-hospital or 30-day adverse events. The 5-year survival was 0.88 (0.02 SE). OPCAB performance by a high-volume surgeon and complete revascularization were shown have a protective effect for midterm major adverse cardiac events (respectively, hazard ratio = 0.28, 95% confidence interval 0.11-0.74 and hazard ratio = 0.33, 95% confidence interval 0.15-0.73).

CONCLUSION

Our study on the initial phase of OPCAB adoption suggests a benefit on midterm outcome from surgery performed by a high-volume surgeon.

Off-pump coronary artery bypass: techniques, pitfalls, and results

In an attempt to advance the surgical treatment of coronary artery disease, surgeons sought a way to offer the proven benefits of coronary revascularization and avoid the side effects of cardiopulmonary bypass by performing revascularization in the beating heart (off-pump coronary artery bypass). This review will describe the development and refinement of the technique, pitfalls to its widespread adoption, and an up-to-date assessment of current results.

Survival of patients on dialysis having off-pump versus on-pump coronary artery bypass surgery in the United States

BACKGROUND

Patients on dialysis sustain at least a threefold higher in-hospital mortality rate and markedly higher long-term mortality following coronary artery bypass graft surgery than the general population. Smaller studies have suggested that dialysis patients have superior outcomes with off-pump compared with on-pump coronary artery bypass surgery.

METHODS

From the United States Renal Data System database, 13,085 patients on dialysis having first coronary artery bypass surgery between 2001 and 2006 were identified. Of these, 2335 (17.8%) had off-pump coronary artery bypass surgery. The Kaplan-Meier method was used to estimate survival of patients having off-pump coronary artery bypass and patients having on-pump coronary artery bypass. A Cox proportional hazards model was used to assess effects of off-pump coronary artery bypass on mortality with adjustment for baseline patient characteristics.

RESULTS

Off-pump coronary artery bypass surgery was associated with significantly reduced all-cause mortality compared with on-pump coronary artery bypass surgery (hazard ratio 0.92, 95% confidence interval 0.86-0.99, P = .02). The observed survival benefit was most notable in the first year after surgery (70.3% vs 68.7%) and was lost 2 years after surgery (55.4% vs 55.2%). No difference was noted in the in-hospital mortality rate with off-pump coronary artery bypass surgery versus on-pump coronary artery bypass surgery (9.7% vs 11.0%, P = .06). Cardiac mortality during the follow-up period was similar (23.6% vs 23.8%; adjusted hazard ratio 0.95, 95% confidence interval 0.86-1.04, P = .26). Use of internal thoracic grafts was independently associated with improved survival after coronary artery bypass surgery (hazard ratio, 0.92; 95% confidence interval, 0.87-0.98, P = .0057).

CONCLUSIONS

Patients on dialysis sustain high in-hospital and 2-year mortality rates after coronary artery bypass surgery. Off-pump coronary artery bypass is associated with modestly increased survival compared with on-pump coronary artery bypass, a benefit most marked early after off-pump coronary artery bypass.

Randomized clinical trials and observational studies: guidelines for assessing respective strengths and limitations

The 2 primary types of studies that are used to test new drugs or procedures or compare competing drugs or types of procedures are randomized clinical trials (RCTs) and observational studies (OS). Although it would appear that RCTs always trump OS because they eliminate selection bias, there are many possible limitations to both types of studies, and these limitations must be carefully assessed when comparing the results of RCTs and OS. This state-of-the art review describes these limitations and discusses how to assess the validity of RCTs and OS that yield different conclusions regarding the relative merit of competing treatments/interventions.

Temporal pattern of strokes after on-pump and off-pump coronary artery bypass graft surgery

BACKGROUND

The incidence of strokes has not decreased after coronary artery bypass graft surgery (CABG). The purpose of this study is to identify incidence, risk factors, and temporal pattern of strokes after on-pump and off-pump CABG.

METHODS

We analyzed 2,516 consecutive patients who underwent first elective isolated CABG. The primary endpoint was strokes within 30 days. The temporal onset of the deficits was classified by consensus as either an "early stroke," which is present just after emergence from anesthesia, or a "delayed stroke," which is present after first awaking from surgery without a neurologic deficit.

RESULTS

More than half of strokes (29 of 46; 63%) were delayed strokes. Patients undergoing off-pump CABG had significantly lower risk of early stroke (0.1% versus 1.1%, p = 0.0009), whereas the incidence of delayed strokes was not different significantly (0.9% versus 1.4%, p = 0.3484) between patients undergoing on-pump and off-pump CABG. In multivariate analyses, undergoing off-pump CABG was an independent protective factor for all strokes (relative risk 0.29, 95% confidence interval: 0.14 to 0.56, p = 0.0005) and early strokes (relative risk 0.05, 95% confidence interval: 0.003 to 0.24, p < 0.0001), but it was not an independent protective factor for delayed strokes (relative risk 0.54, 95% confidence interval: 0.24 to 1.17, p = 0.1210).

CONCLUSIONS

Undergoing off-pump CABG reduces the incidence of perioperative stroke mainly by minimizing early strokes; however, the risk of delayed strokes is not different between patients undergoing on-pump and off-pump CABG.

Survival, clinical status and quality of life five years after coronary surgery. The ARCA study

INTRODUCTION AND OBJECTIVES

Little is known about the long-term outcomes of coronary surgery and their determinants in Spain. The objectives of this study were to evaluate clinical outcomes, quality of life and survival in a cohort of patients 5 years after undergoing a first aortocoronary bypass operation without any other associated procedure.

METHODS

Patients who survived the operation and whose pre- and postoperative data had been collected prospectively were followed up by telephone interview after 5 years.

RESULTS

Information was available after 5 years on 1,300 (85.2%) of the 1,525 patients who survived until hospital discharge. Of these, 13.6% had died, while 24% had either died, undergone revascularization or were readmitted because of a cardiac complaint. The cumulative survival rate (excluding the period of hospitalization) was 0.87 (95% confidence interval, 0.85-0.89). Mortality varied significantly with the level of preoperative risk (i.e. the EuroSCORE), to the extent that mortality in the low-risk group was equivalent to that in the general reference population.

CONCLUSIONS

Three-quarters of patients who survived until hospital discharge after coronary surgery did not experience a major cardiac event within 5 years and their level of functioning and quality of life were good. The survival rate after the immediate postoperative period varied according to the patient's preoperative risk profile and, in low-risk patients, was equivalent to that in the general reference population.

Fewer grafts performed in off-pump bypass surgery: patient selection or incomplete revascularization?

BACKGROUND

Comparisons of off-pump (OPCAB) versus conventional on-pump coronary artery bypass (CCAB) consistently report fewer grafts per patient with OPCAB. Performing fewer grafts than indicated based on angiographic assessment could result in incomplete revascularization. We questioned whether OPCAB influenced surgeons to perform fewer grafts than needed.

METHODS

Preoperative angiographic and surgical data were collected prospectively on 945 patients undergoing coronary artery bypass grafting (370 OPCAB, 575 CCAB) at 8 hospitals between February 1, 2004, and July 31, 2004. The number of grafts needed per patient was determined from the reported number of vessels with angiographic stenoses of 50% or greater, and compared with the number received per patient, stratified by coronary artery bypass grafting technique.

RESULTS

The OPCAB and CCAB groups were demographically similar. The mean number of grafts needed per patient was significantly less in the OPCAB group (2.95 versus 3.48), accounting for fewer grafts received in that group (2.75 versus 3.36). The ratio of grafts (received/needed) was the same in both groups. Patients receiving more than three grafts were more likely to have CCAB (71.2%), whereas those receiving fewer than three grafts were almost as likely to have OPCAB as CCAB (55.5%). The rate of 1-year major adverse events (death, myocardial infarction, repeat revascularization) was the same in OPCAB and CCAB (15.5% versus 14.1%; p = 0.57).

CONCLUSIONS

Completeness of revascularization, determined by comparing the number of grafts performed to the number needed, was equivalent in OPCAB and CCAB patients, and 18-month clinical outcomes were equivalent. Preferential selection of patients needing more bypass grafts to CCAB results in the lower mean number of grafts per patient with OPCAB.

Minimal extracorporeal circulation: an alternative for on-pump and off-pump coronary revascularization

BACKGROUND

Coronary artery bypass surgery employing minimal extracorporeal circulation (MECC) was compared with standard extracorporeal circulation (ECC) and off-pump coronary artery bypass graft surgery (OPCABG) with regard to the perioperative course.

METHODS

From January 2004 to December 2007, 1,674 patients (n = 558 MECC, n = 558 ECC, n = 558 OPCABG) who underwent coronary bypass surgery were studied. The primary end point was in-hospital mortality; secondary end points were perioperative variables, intensive care, and in-hospital course.

RESULTS

Demographic data, comorbidity, and the European System for Cardiac Operative Risk Evaluation score (MECC 3.0%, ECC 3.5%, OPCABG 3.2%) were similar among the groups, but in-hospital mortality for elective and urgent/emergent patients was lower in the MECC and OPCABG groups (MECC 3.2%, OPCABG 3.7%, ECC 6.9%; p < 0.05). The number of distal anastomoses was lowest in the OPCABG group, but comparable for MECC and ECC patients. Postoperative ventilation time, release of creatinine kinase, catecholamine therapy, drainage loss, and transfusion requirements were lower in the MECC and OPCABG groups, whereas stay in the intensive care unit was shorter only in the latter (p < 0.05).

CONCLUSIONS

Minimal extracorporeal circulation is an easy and safe procedure for coronary artery bypass graft surgery. In selected patients, the advantages of MECC equal those of OPCABG. MECC should be considered as an alternative to OPCABG and standard ECC procedures.

Off-pump coronary bypass surgery for high-risk patients: only in expert centers?

PURPOSE OF REVIEW

Off-pump coronary artery bypass (OPCAB) grafting has been increasingly adopted in an effort to prevent deleterious effects of cardiopulmonary bypass, including the associated inflammatory response, global myocardial ischemia and the risks of aortic manipulation. In many studies, the greatest benefit of OPCAB has been in high-risk patients. This review will summarize the recent literature examining outcomes of OPCAB versus on-pump coronary artery bypass in high-risk subgroups, and will examine the safety of routine application of OPCAB in these patients.

RECENT FINDINGS

Prospective randomized trials have shown that in comparison to on-pump coronary artery bypass, OPCAB reduces perioperative morbidity, but have failed to show a mortality benefit, owing to small sample sizes. However, numerous large retrospective series and meta-analyses have demonstrated a reduction in risk-adjusted mortality and morbidity with respect to the following outcomes: stroke, pulmonary function, renal function, atrial fibrillation, need for early reoperation, blood transfusion requirements, length of ICU and hospital stay, and hospital costs. An even greater benefit has been seen in the following high-risk patients: those with acute myocardial infarction, left ventricular dysfunction, previous history of stroke, renal insufficiency, women, elderly patients, and those undergoing reoperations.

SUMMARY

Risk-adjusted outcomes are superior after OPCAB versus on-pump coronary artery bypass for mortality and numerous morbidity endpoints. This benefit is most easily demonstrated in high-risk patient populations.

Off-pump coronary artery bypass graft surgery in California, 2003 to 2005

BACKGROUND

The impact of off-pump coronary artery bypass graft surgery (OPCAB) on operative mortality compared to conventional coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass (CCB) has not been clarified.

METHOD

Patient clinical characteristics were compared between OPCAB and CCB for isolated CABG surgeries in 2003 to 2005 using data from the California CABG outcomes reporting program. A propensity score method and logistic regression models were used to compute propensity-adjusted operative mortality for patients undergoing OPCAB or CCB.

RESULTS

Of 57,284 isolated CABGs, 13,515 (22.9%) were OPCAB. Compared to CCB, OPCAB patients were older, more females/nonwhite, and had a higher prevalence of certain noncardiac risk factors but were fewer with diabetes, acute myocardial infarction, New York Heart Association class IV heart failure or angina, cardiogenic shock, prior cardiac surgery, left main coronary disease, or > or =3-vessel coronary disease (all P < .01). Overall, the propensity-adjusted operative mortalities (PAOMRs) were significantly lower in OPCAB patients compared to CCB patients (OPCAB 2.59% [95% CI 2.52%-2.67%] vs CCB 3.22% [95% CI 3.17%-3.27%]). Off-pump CABG had a protective advantage for all quintile subgroups (all P < .05). However, within the OPCAB cohort, those who converted to CCB intraoperately had higher PAOMR (converters 3.47% [95% CI 3.16%-3.77%] vs nonconverters 2.53% [95% CI 2.46%-2.61%]). Age, female sex, nonwhite race, diabetes, congestive heart failure, prior cadiac surgery, left main disease, and with > or =3 diseased coronary arteries were associated with a higher risk of intraoperative conversion from OPCAB to CCB (all <0.05).

CONCLUSION

OPCAB and CCB patients had significantly different preoperative risk profiles, and OPCAB was associated with lower operative mortality compared to CCB.

Late and very late stent thrombosis following drug-eluting stent implantation in unprotected left main coronary artery: a multicentre registry

AIMS

To evaluate the occurrence of late and very late stent thrombosis (ST) following elective drug-eluting stent (DES) implantation in unprotected left main coronary artery (LMCA) stenosis in a large multicentre registry.

METHODS AND RESULTS

All 731 consecutive patients who had sirolimus- or paclitaxel-eluting stent electively implanted in de novo lesions on unprotected LMCA in five centres were included. ST was defined according to Academic Research Consortium definitions. Four (0.5%) patients had a definite ST: three early (two acute and one subacute) and one late ST, no cases of very late definite ST were recorded. All patients survived from the event. Three patients had a probable ST. Therefore, 7/731 (0.95%) patients had a definite or a probable ST and all were on dual antiplatelet therapy at the time of the event. Possible (eight late and 12 very late) ST occurred in 20 (2.7%) patients. At 29.5 ± 13.7 months follow-up, a total of 45 (6.2%) patients had died; 31 (4.2%) of cardiac death. Ninety five (12.9%) patients had a target-vessel and 76 (10.4%) a target-lesion revascularization. Angiographic follow-up was performed in 548 patients (75%): restenosis occurred in 77 (14.1%) patients.

CONCLUSION

Elective treatment of LMCA stenosis with DES appears safe with a 0.9% incidence of definite and probable ST at 29.5 ± 13.7 months.

A randomized comparative study of patients undergoing myocardial revascularization with or without cardiopulmonary bypass surgery: The MASS III Trial

The MASS III Trial is a large project from a single institution, The Heart Institute of the University of Sao Paulo, Brazil (InCor), enrolling patients with coronary artery disease and preserved ventricular function. The aim of the MASS III Trial is to compare medical effectiveness, cerebral injury, quality of life, and the cost-effectiveness of coronary surgery with and without of cardiopulmonary bypass in patients with multivessel coronary disease referred for both strategies. The primary endpoint should be a composite of cardiovascular mortality, cerebrovascular accident, nonfatal myocardial infarction, and refractory angina requiring revascularization. The secondary end points in this trial include noncardiac mortality, presence and severity of angina, quality of life based on the SF-36 Questionnaire, and cost-effectiveness at discharge and at 5-year follow-up. In this scenario, we will analyze the cost of the initial procedure, hospital length of stay, resource utilization, repeat hospitalization, and repeat revascularization events during the follow-up. Exercise capacity will be assessed at 6-months, 12-months, and the end of follow-up. A neurocognitive evaluation will be assessed in a subset of subjects using the Brain Resource Center computerized neurocognitive battery. Furthermore, magnetic resonance imaging will be made to detect any cerebral injury before and after procedures in patients who undergo coronary artery surgery with and without cardiopulmonary bypass.

TRIALS REGISTRATION

Clinical Trial registration information ISRCTN59539154 Off-pump vs. on-pump surgery in patients with Stable CAD MASS III.

A randomized comparative study of patients undergoing myocardial revascularization with or without cardiopulmonary bypass surgery: The MASS III Trial

The MASS III Trial is a large project from a single institution, The Heart Institute of the University of Sao Paulo, Brazil (InCor), enrolling patients with coronary artery disease and preserved ventricular function. The aim of the MASS III Trial is to compare medical effectiveness, cerebral injury, quality of life, and the cost-effectiveness of coronary surgery with and without of cardiopulmonary bypass in patients with multivessel coronary disease referred for both strategies. The primary endpoint should be a composite of cardiovascular mortality, cerebrovascular accident, nonfatal myocardial infarction, and refractory angina requiring revascularization. The secondary end points in this trial include noncardiac mortality, presence and severity of angina, quality of life based on the SF-36 Questionnaire, and cost-effectiveness at discharge and at 5-year follow-up. In this scenario, we will analyze the cost of the initial procedure, hospital length of stay, resource utilization, repeat hospitalization, and repeat revascularization events during the follow-up. Exercise capacity will be assessed at 6-months, 12-months, and the end of follow-up. A neurocognitive evaluation will be assessed in a subset of subjects using the Brain Resource Center computerized neurocognitive battery. Furthermore, magnetic resonance imaging will be made to detect any cerebral injury before and after procedures in patients who undergo coronary artery surgery with and without cardiopulmonary bypass.

TRIALS REGISTRATION

Clinical Trial registration information ISRCTN59539154 Off-pump vs. on-pump surgery in patients with Stable CAD MASS III.

Does off-pump coronary surgery endanger long term survival?

In this issue Ibrahim and co-authors report on technical hazards of off-pump (without heart lung machine) coronary surgery 1. Their findings are in line with meta-analyses of randomized trials which indicate that under-grafting and graft-failures are more common after off-pump than after standard operations. The risk that the objectives of coronary bypass surgery are endangered is discussed in relation to evidence based medicine. A moratorium is suggested until conclusive data are available.