Acquiring proficiency in off-pump surgery: traversing the learning curve, reproducibility, and quality control

A Beating Heart is a Happy Heart, Especially in Patients with Left Ventricular Dysfunction Undergoing Coronary Artery Bypass Grafting

Beating-heart coronary artery bypass grafting (CABG) in patients with left ventricular (LV) dysfunction can provide the best of all words by limiting myocardial injury purported by cardioplegic arrest. Complete revascularization is possible and graft numbers are not different when compared to arrested heart CABG. Furthermore, beating-heart CABG more often reduces the need for intraoperative and postoperative mechanical support reducing the complications and costs associated with these devices.

A simple signaling rule for variable life-adjusted display derived from an equivalent risk-adjusted CUSUM chart

The variable life-adjusted display (VLAD) is the first risk-adjusted graphical procedure proposed in the literature for monitoring the performance of a surgeon. It displays the cumulative sum of expected minus observed deaths. It has since become highly popular because the statistic plotted is easy to understand. But it is also easy to misinterpret a surgeon's performance by utilizing the VLAD, potentially leading to grave consequences. The problem of misinterpretation is essentially caused by the variance of the VLAD's statistic that increases with sample size. In order for the VLAD to be truly useful, a simple signaling rule is desperately needed. Various forms of signaling rules have been developed, but they are usually quite complicated. Without signaling rules, making inferences using the VLAD alone is difficult if not misleading. In this paper, we establish an equivalence between a VLAD with V-mask and a risk-adjusted cumulative sum (RA-CUSUM) chart based on the difference between the estimated probability of death and surgical outcome. Average run length analysis based on simulation shows that this particular RA-CUSUM chart has similar performance as compared to the established RA-CUSUM chart based on the log-likelihood ratio statistic obtained by testing the odds ratio of death. We provide a simple design procedure for determining the V-mask parameters based on a resampling approach. Resampling from a real data set ensures that these parameters can be estimated appropriately. Finally, we illustrate the monitoring of a real surgeon's performance using VLAD with V-mask.

Bilateral Internal Mammary Artery Use Can Be Safely Taught Without Increasing Morbidity or Mortality

BACKGROUND

Evidence shows a likely survival benefit with the use of bilateral internal mammary arteries (BIMA) compared with a single internal mammary artery (SIMA). Nonetheless, BIMA use is often not used or taught because of a perceived increase in operative time and complexity. This study aimed to evaluate operative time, morbidity, and mortality in both resident and nonresident cases using BIMA compared with SIMA.

METHODS

Consecutive patients undergoing isolated coronary artery bypass grafting (October 2012 to April 2015) at a single institution were reviewed. Cases were stratified on the basis of the use of SIMA versus BIMA and resident teaching versus nonresident teaching cases. Primary outcomes included operative time, postoperative morbidity, and mortality.

RESULTS

A total of 416 patients were identified; 335 of 416 (81%) patients received a SIMA, and 81 of 416 (19%) patients received BIMA. A total of 184 of 416 (44%) were resident cases: 143 of the 335 (43%) SIMA cases and 41 of the 81 (51%) BIMA cases. Use of BIMA in resident cases was associated with a longer operative and cardiopulmonary bypass (CPB) time than resident SIMA cases, but this increased time did not affect morbidity or mortality. Use of SIMA versus BIMA in nonresident cases had no significant difference on total operative time, CPB time, postoperative morbidity, or mortality. Overall, operative and 1-year mortality rates were similar in the SIMA and BIMA groups (SIMA: 1.2%, 1.8%, respectively; BIMA: 0%, 0%, respectively; p = NS).

CONCLUSIONS

In the hands of an experienced surgeon, BIMA use can be effectively performed without an increase in operative or CPB time. In resident teaching cases, BIMA use may increase operative time, but it can be safely taught without affecting morbidity or mortality.

Impact of off-pump coronary artery bypass grafting on survival: current best available evidence

The superiority of either off-pump (OPCAB) or on-pump (ONCAB) coronary artery bypass grafting (CABG) remains unclear despite a large body of literature evidence comparing the two approaches. The potential advantages of avoiding cardiopulmonary bypass (CPB), minimizing aortic manipulation and maintaining pulsatile flow may be associated with reduced inflammatory responses and embolic events. Numerous studies compared OPCAB with ONCAB and the cumulative data have been presented in meta-analyses of both randomized and observational studies. Although there is an abundance of data with respect to the operative morbidity and mortality and the short-term outcomes associated with these two strategies, not much is known about how they impact long-term survival and recurrence of myocardial ischaemic events. Recent studies and meta-analyses have focused on long-term survival and major secondary outcomes in OPCAB vs. ONCAB within the general population. Significant limitations in methodology, however, have raised concerns about the strength of several randomized trials with restrictive inclusion criteria that reduced the populations to those at low risk only, thus creating result bias. Here, we present a review of the best available evidence with a focus on long-term outcomes.

Long-term follow-up of off-pump and on-pump coronary artery bypass grafting

OBJECTIVE

Despite increasing recognition of the benefits of off-pump coronary artery bypass grafting (CABG), concerns persist regarding its impact on long-term mortality and freedom from reintervention. In this study, we assessed the impact of off-pump CABG on long-term outcomes.

METHODS

From January 2002 to December 2002, a total of 307 consecutive patients who underwent isolated multivessel off-pump CABG at our institution were compared with a control group of 397 patients who underwent multivessel on-pump CABG during the same period. Perioperative data were prospectively collected and compared. In addition, univariate and risk-adjusted comparisons between the two groups were performed at 10 years.

RESULTS

After adjusting for clinical covariates, off-pump CABG did not emerge as a significant independent predictor of long-term mortality [hazard ratio (HR), 0.91; 95% confidence interval (CI), 0.70-1.12], readmission to hospital for cardiac cause (HR, 0.96; 95% CI, 0.78-1.10), or the need for reintervention (HR, 0.93; 95% CI, 0.87-1.05).

CONCLUSIONS

At long-term follow-up, off-pump CABG remains a safe and effective myocardial revascularization strategy with no adverse impact on survival or freedom from reintervention.

Does off-pump coronary artery bypass grafting negatively impact long-term survival and freedom from reintervention?

Recently published evidence has raised concerns about worse late mortality and increasing need for reintervention after off-pump coronary artery bypass grafting. We undertook this study to assess the impact of off-pump coronary artery bypass grafting on survival and freedom from reintervention at 10 years. From January 2002 to December 2002, 307 consecutive patients who had isolated multivessel off-pump coronary artery bypass grafting at our institution were compared to a control group of 397 patients that underwent multivessel on-pump coronary artery bypass grafting during the same period. In addition, univariate and risk-adjusted comparisons between the two groups were performed at 10 years. Kaplan-Meier survival was similar for the two cohorts. After adjusting for clinical covariates, off-pump coronary artery bypass grafting did not emerge as a significant independent predictor of long-term mortality (Hazard Ratio 0.91; 95% Confidence Interval 0.70-1.12), readmission to hospital for cardiac cause (Hazard Ratio 0.96; 95% Confidence Interval 0.78-1.10), or the need for reintervention (Hazard Ratio 0.93; 95% Confidence Interval 0.87-1.05). Off-pump coronary artery bypass grafting compared with on-pump coronary artery bypass grafting does not adversely impact survival or freedom from reintervention at a 10-year follow-up.

Anaortic, total-arterial, off-pump coronary artery bypass surgery: why bother?

Coronary artery bypass grafting (CABG) remains the standard of care for multi-vessel coronary disease. However, the increased rate of peri-operative stroke reported after surgery compared to percutaneous coronary intervention (PCI) remains of concern. Anaortic, total-arterial, off-pump coronary artery bypass (OPCAB) grafting is a technique that offers the main advantages of surgical revascularisation with a rate of stroke that is equivalent to that of PCI. Some recent trials comparing conventional on-pump CABG with OPCAB have questioned the efficacy of the off-pump technique - these are most often performed with manipulation of the ascending aorta. We review the potential benefits of the anaortic, total-arterial OPCAB technique to explain why it is being employed by an increasing number of surgeons.

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.

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.

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.