On- and off-pump coronary surgery and perioperative myocardial infarction: an issue between incomplete and extensive revascularization

Combined Minimally Invasive Mitral Valve Surgery and Percutaneous Coronary Intervention: A Hybrid Concept for Patients with Mitral Valve and Coronary Pathologies

We evaluated the feasibility of hybrid percutaneous coronary intervention (PCI) and minimally invasive mitral valve surgery (MIMVS) in patients with concomitant coronary and mitral disease. Of 534 patients who underwent MIMVS at our institution between 2012 and 2018, those with combined mitral and single vessel coronary pathologies who underwent MIMVS and PCI were included. Patients were excluded if they had endocarditis or required emergency procedures. Preprocedural, procedural, and postprocedural data were retrospectively analyzed. In total, 10 patients (median age, 75 years; 7 males) with a median ejection fraction (EF) of 60% were included. Nine patients underwent PCI before and one after MIMVS. The success rate was 100% in both procedures. There were no postoperative myocardial infarctions or strokes. Two patients developed delirium and one required re-thoracotomy for bleeding. The median stay in intensive care and the hospital was 3 and 8 days, respectively. The 30-day survival rate was 100%. A hybrid PCI and MIMVS approach is feasible in patients with mitral valve and single vessel coronary disease. In combined pathologies, the revascularization strategy should be evaluated independent from the mitral valve pathology in the presence of MIMVS expertise. Extension of this recommendation to multivessel disease should be evaluated in future studies.

Myocardial revascularization without extracorporeal circulation; Why hasn't it convinced yet?

Extracorporeal circulation has led to a great development in cardiovascular surgery during the last five decades. Its time-proven efficacy and safety have made on-pump coronary artery bypass grafting (CABG) the gold standard method of surgical revascularization. However, coronary revascularization on cardiopulmonary bypass and the accompanying aortic manipulation are related to plenty of deleterious complications. Therefore, off-pump CABG surgery was established to avoid complications. Nevertheless, despite the initial enthusiasm on this technique, only 20% of myocardial revascularization procedures worldwide are performed off-pump. Not only are off-pump cardiac procedures more technically difficult but also they do not provide better results in terms of graft patency, completeness of revascularization, repeat revascularization requirement, cost, and quality of life. Completeness of revascularization and anastomotic quality should not be compromised to avoid cardiopulmonary bypass.

Incidence of postoperative atrial fibrillation in patients undergoing on-pump and off-pump coronary artery bypass grafting

OBJECTIVE

To determine the incidence of postoperative atrial fibrillation in patients undergoing on-pump and off-pump coronary artery bypass grafting.

METHODS

A retrospective study with analysis of 230 medical records between January 2011 and October 2013 was conducted.

RESULTS

Fifty-six (24.3%) out of the 230 patients were female. The average age of patients undergoing on-pump coronary artery bypass grafting was 59.91±8.62 years old, and off-pump was 57.16±9.01 years old (P=0.0213). The average EuroSCORE for the on-pump group was 3.37%±3.08% and for the off-pump group was 3.13%±3% (P=0.5468). Eighteen (13.43%) patients who underwent off-pump coronary artery bypass grafting developed postoperative atrial fibrillation, whereas for the onpump group, 19 (19.79%) developed this arrhythmia, with no significant difference between the groups (P=0.1955).

CONCLUSION

Off-pump coronary artery bypass grafting did not reduce the incidence of atrial fibrillation in the postoperative period. Important predictors of risk for the development of this arrhythmia were identified as: patients older than 70 years old and presence of atrial fibrillation in perioperative period in both groups, and non-use of beta-blockers drugs postoperatively in the on-pump group.

Coronary artery bypass grafting: Part 1--the evolution over the first 50 years

Surgical treatment for angina pectoris was first proposed in 1899. Decades of experimental surgery for coronary artery disease finally led to the introduction of coronary artery bypass grafting (CABG) in 1964. Now that we are approaching 50 years of CABG experience, it is appropriate to summarize the advancement of CABG into a procedure that is safe and efficient. This review provides a historical recapitulation of experimental surgery, the evolution of the surgical techniques and the utilization of CABG. Furthermore, data on contemporary clinical outcomes are discussed.

Less invasive coronary artery revascularization with a minimized extracorporeal circulation system: preliminary results of a comparative study with off-pump-procedures

BACKGROUND

Coronary-artery-bypass-grafting (CABG) with conventional extracorporeal circulation (CECC) is associated with adverse effects such as systemic inflammatory response leading to a decrease in systemic vascular resistance and hemodynamic instability. Modern "less invasive" procedures have been established recently which potentially avoid negative side effects of CECC. The aim of this study was to compare perioperative outcome following coronary revascularization using either a minimized extracorporeal circuit (Mini-HLM) or off-pump technique (OPCAB).

METHODS

In this prospective ethics-approved trial, 120 patients referred for CABG were randomly assigned either to off-pump coronary artery bypass (OPCAB) or to a Mini-HLM procedure. Patient demographics, preoperative characteristics and extensive postoperative outcome were analyzed for both groups. Hemodynamic data were measured at seven time points perioperatively.

RESULTS

Operation-time was longer in the Mini-HLM group (178,3 ± 32,9 min) compared to OPCAB (133,2 ± 32,7 min, p < 0,001) with higher graft numbers in Mini-HLM group (3,11 ± 0,7 vs. 1,78 ± 0,7, p < 0.001). There were no significant differences in perioperative hemodynamic criteria, catecholaminergic support, hospital (p = 0,534) and intensive care unit stay (p = 0,880), ventilation time (p = 0,113), blood loss (p = 0,570), transfusion requirements, postoperative atrial fibrillation rate (p = 0,706) and neurocognitive disturbance (p = 0,297). No deaths and no myocardial infarctions were observed.

CONCLUSIONS

Coronary revascularisation with Mini-HLM represents a suitable and "less invasive" procedure which achieves all benefits of OPCAB but may allow for less demanding revascularisation than OPCAB in special patients with complex coronary anatomy and can therefore be used both on a routine basis and in all "conversion" cases of OPCAB.

Off-pump coronary artery bypass grafting--the current state

The optimal strategy for coronary revascularization remains controversial. Currently, most surgical revascularizations are performed with the use of cardiopulmonary bypass (ONCAB), yet over the past 20 years off-pump coronary artery bypass grafting (OPCAB) has been increasingly used because of the increased awareness of the deleterious effects of cardiopulmonary bypass (CPB) and aortic manipulation. Small, prospective, randomized controlled trials have lacked sufficient sample size to demonstrate differences in early and long-term outcomes. Larger observational studies that are better powered to statistically compare outcomes have shown more favorable in-hospital outcomes and equivalent long-term outcomes with OPCAB and ONCAB. The benefits of OPCAB techniques may be more apparent for patients at high risk for complications associated with CPB and aortic manipulation. Recent studies have demonstrated improved outcomes in higher-risk patients undergoing OPCAB, as well as improved neurological outcomes. The purpose of this review is to outline the recent literature comparing OPCAB with ONCAB, and to demonstrate efficacy of OPCAB as a useful technique for coronary revascularization.

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.

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.