Propensity case-matched analysis of off-pump coronary artery bypass grafting in patients with atheromatous aortic disease

Early and midterm outcomes after off pump coronary artery bypass surgery

Purpose

There has been debate whether off pump coronary artery bypass surgery (OPCAB) has results comparable to conventional on pump bypass surgery. This has led to the low uptake of OPCAB in the West. In India, OPCAB is the default mode of coronary revascularization. However, there is scarce data on mid-term outcomes of OPCAB in our patients. This study aims to evaluate both short and mid-term mortality and analyze factors associated with mortality.

Methods

This is a single center study of all consecutive patients undergoing isolated OPCAB from October 2014 to December 2019. Patient data was collected from hospital records and follow-up was from the hospital electronic medical records and telephone interviews. Mortality and factors contributing to survival were analyzed.

Results

Operative mortality was 2.3%. Mid-term mortality was 5.5%. Preoperative renal dysfunction, post-operative renal failure, use of the intra-aortic balloon pump (IABP), re-exploration for bleeding, postoperative stroke, ventilation > 24 h, and postoperative atrial fibrillation were associated with operative mortality. Factors associated with mid-term mortality were age > 62 years, postoperative renal failure, IABP usage, ventilation time > 24 h, and postoperative atrial fibrillation. The mean survival time was 2343.55 + / - 15.27 days and 6-year survival was 88.7%.

Conclusion

OPCAB can safely be performed with satisfactory short and mid-term outcomes. Further corroborative studies from different regions of the country or a multi-center study will help to establish the suitability of the technique in Indian patients.

Factors affecting mortality after coronary bypass surgery: a scoping review

OBJECTIVES

Previous research reports numerous factors of post-operative mortality in patients undergoing isolated coronary artery bypass graft surgery. However, this evidence has not been mapped to the conceptual framework of care improvement. Without such mapping, interventions designed to improve care quality remain unfounded.

METHODS

We identified reported factors of in-hospital mortality post isolated coronary artery bypass graft surgery in adults over the age of 19, published in English between January 1, 2000 and December 31, 2019, indexed in PubMed, CINAHL, and EMBASE. We grouped factors and their underlying mechanism for association with in-hospital mortality according to the augmented Donabedian framework for quality of care.

RESULTS

We selected 52 factors reported in 83 articles and mapped them by case-mix, structure, process, and intermediary outcomes. The most reported factors were related to case-mix (characteristics of patients, their disease, and their preoperative health status) (37 articles, 27 factors). Factors related to care processes (27 articles, 12 factors) and structures (11 articles, 6 factors) were reported less frequently; most proposed mechanisms for their mortality effects.

CONCLUSIONS

Few papers reported on factors of in-hospital mortality related to structures and processes of care, where intervention for care quality improvement is possible. Therefore, there is limited evidence to support quality improvement efforts that will reduce variation in mortality after coronary artery bypass graft surgery.

Intimal aortic atherosclerosis in cardiac surgery: surgical strategies to prevent embolic stroke

 

OBJECTIVES

Although the incidence of perioperative stroke after cardiac surgery gradually decreased over the last decades, there is much variation between centres. This review aimed to create a concise overview of the evidence on possible surgical strategies to prevent embolic stroke in patients with intimal aortic atherosclerosis.

METHODS

The PubMed and EMBASE databases were searched for studies on surgical management of aortic atherosclerosis and the association with perioperative stroke in cardiac surgery, including specific searches on the most common types of surgery. Articles were screened with emphasis on studies comparing multiple strategies and studies reporting on the patients’ severity of aortic atherosclerosis. The main findings were summarized in a figure, with a grade of the corresponding level of evidence.

RESULTS

Regarding embolic stroke risk, aortic atherosclerosis of the tunica intima is most relevant. Although several strategies in general cardiac surgery seem to be beneficial in severe disease, none have conclusively been proven most effective. Off-pump surgery in coronary artery bypass grafting should be preferred with severe atherosclerosis, if the required expertise is present. Although transcatheter aortic valve replacement is used as an alternative to surgery in patients with a porcelain aorta, the risk profile concerning intimal atherosclerosis remains poorly defined.

CONCLUSIONS

A tailored approach that uses the discussed alternative strategies in carefully selected patients is best suited to reduce the risk of perioperative stroke without compromising other outcomes. More research is needed, especially on the perioperative stroke risk in patients with moderate aortic atherosclerosis.

Toward stroke-free coronary surgery: The role of the anaortic off-pump bypass technique

Surgical coronary revascularization remains the preferred strategy in a significant portion of patients with coronary artery disease due to superior long-term outcomes. However, there is a significant risk of perioperative neurologic injury that has influenced guideline recommendations. These complications occur in 1%-5% of patients, ranging from overt neurologic deficits with permanent disability, to subtle cerebral defects noted on neuroimaging that may result in slow cognitive and functional decline. The primary mechanism by which these events occur is thromboembolism from manipulation of the ascending aorta. This occurs during cardiopulmonary bypass, aortic cross-clamping, and partial occlusion clamping (side clamp). Elderly patients and patients with aortic atheroma are, therefore, at significantly increased risk. Initial surgical techniques addressed this by aggressively debriding or replacing the ascending aorta during coronary artery bypass grafting (CABG). Strategies then moved toward minimizing aortic manipulation through pump-assisted beating heart surgery and off-pump surgery with partial occlusion clamping or proximal anastomosis devices. Finally, anaortic off-pump CABG aims to avoid all manipulation of the ascending aorta through advanced off-pump grafting techniques combined with in situ and composite grafts. This has been demonstrated to result in the greatest reduction in risk. Establishing successful anaortic off-pump CABG programs requires subspecialization and focused interest groups dedicated to advancing CABG outcomes.

Off-Pump versus Conventional Coronary Artery Bypass Grafting: A Meta-Analysis and Consensus Statement from the 2004 ISMICS Consensus Conference

Background

The purpose of this evidence-based consensus statement is to systematically review and meta-analyze the randomized and nonrandomized evidence comparing off-pump (OPCAB) to conventional coronary artery bypass (CCAB) surgery and to provide consensus on the role of OPCAB in low- and high-risk surgical patients.

Methods and Results

This consensus conference was conducted according to the American College of Cardiology (ACC)/American Heart Association (AHA) standards for development of clinical practice guidelines. The Steering Committee collated all published studies of OPCAB versus CCAB through May 2004 and developed six questions central to controversies surrounding OPCAB surgery in mortality, morbidity, and resource utilization. For mixed-risk patient populations, meta-analysis of 37 randomized clinical trials (3,369 patients, Level A) reported across a total of 53 papers, and two meta-analyses of nonrandomized trials (Level B) comparing OPCAB versus CCAB were identified. For high-risk patient populations, we performed a meta-analysis of 3 randomized and 42 nonrandomized trials (26,349 patients, Level B).

Conclusion

Meta-analysis of Level A and B evidence provided the basis for the following consensus statements in patients undergoing surgical myocardial revascularization: (1) OPCAB should be considered a safe alternative to CCAB with respect to risk of mortality [Class I, Level A]; (2) With appropriate use of modern stabilizers, heart positioning devices, and adequate surgeon experience, similar completeness of revascularization and graft patency can be achieved [Class IIa, Level A]; (3) OPCAB is recommended to reduce perioperative morbidity [Class I, Level A]; (4) OPCAB may be recommended to minimize midterm cognitive dysfunction [Class IIa, Level A]; (5) OPCAB should be considered as an equivalent alternative to CCAB in regard to quality of life [Class I, Level A]; (6) OPCAB is recommended to reduce the duration of ventilation, ICU and hospital stay, and resource utilization [Class I, Level A]; (7) OPCAB should be considered in high-risk patients to reduce perioperative mortality, morbidity, and resource utilization [Class IIa, Level B].

Perioperative Vision Loss after Non-Ocular Surgery

Perioperative vision loss (POVL) may cause devastating visual morbidity. A prompt anatomical and etiologic diagnosis is paramount to guide management and assess prognosis. Where possible, steps should be undertaken to minimize risk of POVL for vulnerable patients undergoing high-risk procedures. We review the specific risk factors, pathophysiology, and management and prevention strategies for various etiologies of POVL.

Aortic Arch Atheroma: Stroke Reduction in Cardiac Surgical Patients

Cardiac surgery is increasingly performed on elderly patients with extensive coronary artery abnormalities who have impaired left ventricular function, decreased physiologic reserve, and multiple comorbid conditions. Considerable numbers of these patients develop perioperative neurologic complications ranging from subtle cognitive dysfunction to more evident postoperative confusion, delirium, and, less commonly, clinically apparent stroke. Magnetic resonance imaging studies have elucidated that a considerable number of patients have new ischemic brain infarcts, particularly after conventional coronary artery bypass graft surgery. Mechanisms of cerebral injury during and after cardiac surgery are discussed. Intraoperative transesophageal echocardiography and epiaortic scanning for detection of atheromatous disease of the proximal thoracic aorta is paramount in identifying patients at high risk from neurologic injury. It is important to recognize that our efforts to minimize neurologic injury should not be limited to the intraoperative period. Particular efforts should be directed to temperature management, glycemia control, and pharmacologic neuroprotection extending into the postoperative period. Preoperative magnetic resonance angiography may be of value for screening patients with significant atheroma of the proximal thoracic aorta. It is likely that for patients with no significant atheromatous disease, conventional coronary artery revascularization is the most effective long-term strategy, whereas patients with atheromatous thoracic aorta may be better managed with beating heart surgery, hybrid techniques, or medical therapy alone. Patient stratification based on the aortic atheromatic burden should be addressed in future trials designed to tailor treatment strategies to improve long-term outcomes of coronary heart disease and reduce the risks of perioperative neurologic injury.

The preoperative neurological evaluation

Neurological diseases are prevalent in the general population, and the neurohospitalist has an important role to play in the preoperative planning for patients with and at risk for developing neurological disease. The neurohospitalist can provide patients and their families as well as anesthesiologists, surgeons, hospitalists, and other providers guidance in particular to the patient's neurological disease and those he or she is at risk for. Here we present considerations and guidance for the neurohospitalist providing preoperative consultation for the neurological patient with or at risk of disturbances of consciousness, cerebrovascular and carotid disease, epilepsy, neuromuscular disease, and Parkinson disease.

On pump coronary artery bypass graft surgery versus off pump coronary artery bypass graft surgery: a review

There are two basic ways of performing coronary artery bypass graft surgery (CABG): on pump CABG and off pump CABG. Off pump CABG is relatively a newer procedure to on-pump CABG and does not require the use of the cardiopulmonary bypass machine. On pump CABG is the more traditional method of performing bypass surgery. However its resultant inflammatory effects cause renal dysfunction, gastrointestinal distress and cardiac abnormalities which have forced the surgeons to look for alternatives to the procedure. An extensive literature search revealed that on pump CABG causes better revascularization as compared to off pump CABG while off pump CABG has a much lower post operative morbidity and mortality especially in high risk patients. We suggest that the technique used should depend on the ease of the surgeon doing the operation as both the methods seem almost equally efficient according to the review.

Replacement of the ascending aorta for severe atherosclerosis during coronary artery bypass surgery

BACKGROUND AND AIM

In the present study, we investigated the benefit of ascending aorta replacement in patients with severe aortic atherosclerosis who undergo coronary artery bypass surgery (CABG).

METHODS

From January 2001 to April 2011, 3842 patients underwent CABG and in 36 of these patients (31 male, 5 female) the ascending aorta was replaced due to severe atherosclerosis. Total circulatory arrest was used in 22 patients (61%). The patients were followed for 69 ± 36 months (1-133 months) and compared to a control group of patients. The control group consisted of patients who underwent CABG with or without a concomitant procedure (n = 3806).

RESULTS

For the study group, the mean additive and logistic Euroscores of the patients were nine and 20, respectively. One stroke (2.8%) was observed and this patient died in the early postoperative period. There were a total of four confirmed deaths (12%) at any time point over the length of the follow-up among the patients who were discharged from the hospital. Two of them died of malignancy (lung and gastric tumors) and the other two from cardiac reasons. No patients had a stroke during follow-up. For the control group the mean age was 61 ± 1, the stroke rate was 0.6%, and the mortality rate was 0.96%, and the mean logistic and additive Euroscores were 3.7 ± 4.4, and 3.5 ± 2.5, respectively.

CONCLUSIONS

Replacement of highly calcified ascending aortas during CABG can be safely performed in selected patients with good long-term outcomes.

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.

Complete revascularization is compromised in off-pump coronary artery bypass grafting

OBJECTIVE

Patients who undergo off-pump coronary artery bypass grafting (OPCAB) commonly receive fewer bypass grafts and are more often incompletely revascularized compared with those receiving conventional coronary artery bypass (CCAB) recipients. Because this can compromise survival, we sought to determine whether patients undergoing OPCAB are incompletely revascularized and whether this affects long-term survival and freedom from cardiac events.

METHODS

OPCAB cases (n = 411) performed from January 1, 1997 to June 30, 2003 were considered for inclusion and matching with 874 randomly selected, contemporary CCAB cases. After propensity matching, 308 OPCAB cases and 308 CCAB cases were included in the final analysis. We compared the number of bypass grafts and the completeness of revascularization by coronary territory. Survival and readmission for cardiac causes were monitored for up to 10 years postoperatively, with a median follow-up period of 5.9 years.

RESULTS

On average, the patients undergoing OPCAB received significantly fewer distal anastomoses than did those undergoing CCAB (mean ± standard deviation, 2.6 ± 0.9 vs 3.0 ± 1.0, P < .0001). The circumflex territory was the most likely territory to be ungrafted during OPCAB in patients with angiographically significant obstruction (P = .0006). The frequency of complete revascularization was significantly different between the 2 groups (OPCAB, 79.2% vs CCAB, 88.3%; P = .0.002). The OPCAB group had a significantly greater rate of total arterial grafting (OPCAB, 66.6% vs CCAB, 49.7%; P = .0001). No difference was seen in 8-year survival or freedom from cardiac cause hospital readmission between the 2 groups.

CONCLUSIONS

Despite receiving fewer distal anastomoses and the decreased frequency of complete revascularization, OPCAB and CCAB techniques produced comparable results.

Surgical considerations in off-pump coronary artery bypass grafting

Off pump coronary artery bypass grafting remains an important technique particularly in the care of high-risk patients. Consistently successful adoption of this technique requires a cooperative team approach and standardization across all phases of patient care. This review describes our approach to off pump coronary surgery.

Improve morbidity and mortality in coronary artery bypass graft surgery for severe atherosclerosis

OBJECTIVES

Atherosclerosis has been identified as a risk factor for both morbidity and mortality in patients undergoing coronary artery bypass grafting (CABG). To investigate outcomes following CABG for severe atherosclerosis, and to determine whether different surgical techniques can reduce the risk of neurologic events in these patients.

METHODS

We studied 225 consecutive patients who underwent elective isolated CABG. Routine preoperative and intraoperative examinations identified patients with severe atherosclerosis. We compared the outcomes between patients with (group A; 42 ceses) and those without (group N; 183 cases) severe atherosclerosis.

RESULTS

36 patients (85.7%) in group A and 176 (96.2%) in group N underwent off-pump coronary artery bypass (OPCAB); 6 (14.3%) in group A and 7 (3.8%) in group N underwent on-pump beating CABG. Three patients in group A suffered deep sternal infection (7.1%), and one suffered stroke (2.4%) compared with none in group N. No cerebral infarction or neurologic events occurred in patients who underwent OPCAB (n = 212, 94.2%).

CONCLUSIONS

Prevalence of complications was significantly greater among patients with severe atherosclerotic disease who underwent OPCAB than in those without atherosclerotic disease. Careful selection of surgical strategies can prevent perioperative stroke and reduce mortality.

Central Nervous System Protection in Cardiac Surgery

Neurological dysfunction and stroke following cardiac surgery and thoracic surgery requiring hypothermic circulatory arrest is a well-defined problem. The original studies in CABG patients identified risk factors, such as prior stroke and lower educational level. There is older evidence suggesting that higher perfusion pressures during cardiopulmonary bypass are helpful. Hyperthermia during rewarming on cardiopulmonary bypass and postoperative hyperthermia have been associated with adverse cognitive outcomes. Glucose management intraoperatively remains controversial, but most now advocate for moderate glucose control using insulin, if required. The subset of patients having thoracic aortic surgery requiring periods of aortic discontinuity are particularly problematic. A cerebral protection strategy should be determined, and this may include hypothermic circulatory arrest, selective cerebral perfusion, or retrograde cerebral perfusion. All of these techniques have been associated with good surgical outcomes, but there is little information on cognitive outcomes of thoracic aortic surgery.

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.

Current role and outcomes of ascending aortic replacement for severe nonaneurysmal aortic atherosclerosis

BACKGROUND

Severe atherosclerosis of the ascending aorta is a challenging issue potentially affecting indications for surgery, operative choices, and patients' outcome. No standard treatment has emerged to date, and uncertainties persist about criteria for selecting patients and procedures.

METHODS

Replacement of the atherosclerotic ascending aorta was performed in 64 patients at time of either aortic (n = 49), mitral (n = 21), or tricuspid (n = 7) valve surgery. Coronary artery bypass grafting was performed in 53 patients, and the majority of patients underwent combined procedures (n = 49). Mean age was 72.0 +/- 7.6 years. The expected operative mortality, by logistic European System for Cardiac Operative Risk Evaluation, was 29.0% accounting for ascending aortic replacement and 13.1% disregarding it. Circulatory arrest under deep hypothermia, eventually combined with either retrograde or antegrade brain perfusion, was required in 61 cases.

RESULTS

Early death, stroke, and myocardial infarction rates were 10.9%, 6.3%, and 7.8%, respectively. Factors univariately associated with early deaths were preoperative renal failure requiring dialysis (p = 0.001) and longer cardiopulmonary bypass (p = 0.001) and cardioplegia (p = 0.008) times. Cumulative survival at 1, 3, and 5 years was 86% +/- 4%, 74% +/- 6%, and 68% +/- 8%, respectively.

CONCLUSIONS

Replacement of the atherosclerotic ascending aorta can be carried out at acceptable mortality rates despite the high rates of preoperative comorbidity and the significant incidence of postoperative complications.

Cerebral Emboli Generation during Off-Pump Coronary Artery Bypass Grafting with a Clampless Device versus Partial Clamping of the Ascending Aorta

Objective

It is not known whether use of a clampless facilitating device during proximal graft anastamosis decreases intraoperative cerebral emboli in patients with mild atherosclerotic ascending aorta (AAA) having off-pump coronary artery bypass.

Methods

After intraoperative epiaortic ultrasound showed no more than mild (grade I–II) atherosclerotic ascending aorta, 20 patients were randomized to receive either partial clamping (PC, n = 10) or the HEARTSTRING clampless device (HS, n = 9) for proximal graft construction on the ascending aorta. Continuous transcranial Doppler monitoring, with capability to discern gaseous from solid particulates, was used intraoperatively to monitor high-intensity transient signals (HITS) in the middle cerebral arteries. Postoperative diffusion-weighted brain magnetic resonance imaging documented old and new ischemic brain lesions.

Results

There were no significant differences between the groups in the number of proximals (P = 0.14), distals (P = 0.4), or intraoperative cell saver transfusions (P = 0.69). The total number of HITS was not significantly different between the PC and HS groups (P = 0.2). However, the number of solid HITS was significantly lower in the HS than in the PC group (2.7 ± 2.6 versus 14.0 ± 8.1; P < 0.001). The number of gaseous emboli in the HS group was fourfold greater when a mister-blower rather than a suction device was used to clear blood away from the HS site. Postoperatively, there were no deaths, myocardial infarctions, or clinical strokes observed in either group. Diffusion-weighted cerebral magnetic resonance imaging revealed no statistical difference between groups for new infarct lesions.

Conclusions

Use of the HS device during off-pump coronary artery bypass was associated with significantly fewer intraoperative solid emboli in the middle cerebral artery than PC of the ascending aorta.

Hydrodynamics of aortic cannulae during extracorporeal circulation in a mock aortic arch aneurysm model

This study was designed to analyze flow pattern, velocity, and strain on the aortic wall of a glass aortic arch aneurysm model during the extracorporeal circulation, and to elucidate the characteristics of flow pattern in three different aortic cannulae. Different patterns of large vortices and helical flow were made by each cannula. With the curved end-hole cannula, the high velocity flow (approximately 0.6-0.8 m/s) was blowing to the aneurismal wall without attenuating the strain rate tensor (approximately 0.2-0.25/s). With the dispersion cannula and the Soft-Flow cannula, cannular jet was attenuated in the ascending aorta creating a large vortex at a velocity less than 0.5 m/s, and the strain rate tensor on the aneurismal wall was small (less than 0.15/s). In conclusion, end-hole cannula should not be used in the operation of aortic arch aneurysm. Dispersion-type aortic cannulae were less invasive on the aortic arch aneurismal wall, but particular attention to alternative cannulation sites should be paid in cases with severe atherosclerosis on the ascending aortic wall.

Comparison of two-year outcomes in patients undergoing isolated coronary artery bypass grafting with and without peripheral artery disease

We aimed to evaluate the long-term clinical outcomes among patients with peripheral arterial disease (PAD) after coronary artery bypass grafting. We studied 589 consecutive patients who had undergone isolated coronary artery bypass grafting from January 2003 to June 2005 at our university hospital. The effect of PAD was assessed by comparing the 2-year follow-up data from 2 groups of patients: 243 patients with and 346 without PAD. A large systematic atherosclerosis screening was performed, including cerebrovascular disease, lower extremity artery disease, and abdominal aorta disease and its branches. PAD was defined as a history of treated atherosclerotic disease and significant atherosclerotic stenosis on screening. Patients with PAD were significantly older (70 +/- 9 vs 64 +/- 11 years, p <0.001) and were more often men (p = 0.04) than those without PAD. They had a greater incidence of hypertension (p = 0.002), chronic renal dysfunction (p <0.01), chronic pulmonary disease (p = 0.005), and a history of coronary artery disease (p = 0.03). No significant difference was noted between the 2 groups with regard to the left ventricular ejection fraction. The 2-year cumulative survival rate was 76.6% for patients with PAD and 94.1% for those with isolated coronary disease (p <0.001). In conclusion, after adjusting all significant variables, the presence of PAD appeared as an independent predictive factor for all-cause mortality (adjusted hazard ratio 3.2, 95% confidence interval 1.8 to 5.7, p = 0.001).

Results and predictors of early and late outcome of coronary artery bypass grafting in patients with severely depressed left ventricular function

BACKGROUND

Coronary artery bypass grafting (CABG) is a well-accepted therapeutic approach in patients with symptomatic multivessel coronary artery disease and severely depressed left ventricular function. However, the potential impact of off-pump CABG in this group of patients remains unknown. In addition, there are only scarce data regarding long-term survival and its predictors in this patient population.

METHODS

We retrospectively analyzed prospectively collected data of 2,725 consecutive patients (mean age, 65 +/- 11 years; 843 (31%) female) undergoing CABG between January 1998 and December 2005 (ejection fraction [EF] < or = 0.30; n = 495, 18%). Outcome measures included hospital mortality, major complications, and long-term survival. Multivariate analysis was performed to identify predictors of hospital mortality and late survival. Subgroup analysis for patients with EF less than or equal to 0.30 undergoing conventional CABG (n = 424, 86%) versus off-pump CABG (n = 71, 14%) was performed.

RESULTS

Hospital mortality was 1.8% (EF < or = 0.30, 3.6%; EF > 0.30, 1.4%; p = 0.002). Off-pump CABG did not have an impact on operative mortality (on-pump, 4%; off-pump, 3%; p = 0.509). Ejection fraction of 0.30 or less was not an independent risk factor of hospital mortality but predicted respiratory failure (odds ratio [OR] = 2.3) and sepsis (OR, 1.4). Long-term survival was significantly decreased in patients with EF of 0.30 or less: 1-year and 5-year survival 88% +/- 1.5% and 75% +/- 2.2% versus 96% +/- 0.4% and 81% +/- 1.2%, respectively (p = 0.001). Reoperation (OR, 6.9), peripheral vascular disease (OR, 3.2), chronic obstructive pulmonary disease (OR, 3.0), congestive heart failure (OR, 2.7), and female sex (OR, 2.1) were independent predictors of long-term survival.

CONCLUSIONS

Excellent results after CABG can be expected in patients with EF of 0.30 or less, with minimal increase in mortality and acceptable postoperative morbidity. Long-term survival remains limited, but recent results are substantially better than historical reports. Careful preoperative patient selection and perioperative management are essential in these patients undergoing CABG.

Predictors and outcome of gastrointestinal complications in patients undergoing cardiac surgery

OBJECTIVE

To determine the incidence and independent predictors of gastrointestinal complications (GICs) following cardiac surgery.

SUMMARY BACKGROUND DATA

Gastrointestinal ischemia and hemorrhage represent a rare but devastating complication following heart surgery. The profile of patients referred for cardiac surgery has changed during the last decade, questioning the validity of previously reported incidence and risk factors.

METHODS

We retrospectively analyzed prospectively collected data from 4819 patients undergoing cardiac surgery between 1998 and 2004. Patients with GICs were compared with the entire patient population. Study endpoints were mortality, postoperative morbidities, and long-term survival.

RESULTS

GICs occurred in 51 (1.1%) patients. Etiologies were intestinal ischemia (n = 30; 59%) and hemorrhage (n = 21; 41%). The incidence decreased during the study period (1998-2001: 1.3%, 2002-2004: 0.7%; P = 0.04). The incidence per type of procedure was as follows: coronary artery bypass grafting (CABG)/valve (2.4%), aortic surgery (1.7%), valve surgery (1.0%), and CABG (0.5%; P = 0.001). Multivariate analysis revealed age (odds ratio [OR] = 2.1), myocardial infarction (OR = 2.5), CHF (OR = 2.4), hemodynamic instability (OR = 2.8), cardiopulmonary bypass time >120 minutes (OR = 6.2), peripheral vascular disease (OR = 2.2), renal (OR = 3.2), and hepatic failure (OR = 10.8) as independent predictors of GICs. The overall hospital mortality among patients with GICs was 33%. Long-term survival was significantly decreased in patients with GICs compared with the control group.

CONCLUSIONS

Gastrointestinal complications following cardiac surgery remain rare with an incidence <1% in a contemporary series. The key to a lower incidence of GICs lies in systematic application of preventive measures and new advances in intraoperative management. Identification of independent risk factors would facilitate the determination of patients who would benefit from additional perioperative monitoring. Future resources should therefore be redirected to mitigate GICs in high-risk patients.

Preoperative noncontrast chest computed tomography identifies potential aortic emboli

BACKGROUND

Intraoperative epiaortic scanning identifies aortic atheroma. Avoiding atheroma manipulation reduces cerebral vascular accidents (CVA). Unfortunately, epiaortic scanning can only be performed after the time of sternotomy. We sought to determine whether (1) preoperative noncontrast chest computed tomography (CT) identifies areas of aorta at risk for embolization in high-risk patients, and (2) operative strategies designed at the reduction of aortic manipulation of these areas can reduce permanent strokes.

METHODS

The rate of permanent strokes was examined at a single institution between two time periods using the chi2 method. From January 2002 through June 2003 (pre-CT) 230 patients underwent elective cardiac procedures. All patients received routine intraoperative transesophageal echocardiography but only selective epiaortic scanning. From July 2003 through December 2005 (post-CT), 273 patients underwent cardiac operations and 114 patients at high risk for a stroke (history of CVA or transient ischemic attack, peripheral vascular disease, end-stage renal disease, age >70 years old or calcifications on cardiac catheterization) also received a preoperative noncontrast chest CT.

RESULTS

In the pre-CT period, 7 patients received epiaortic scans that resulted in a change in operative strategy in only 1 patient. In the post-CT period, the 114 CT scans identified 20 patients with significant calcifications in the ascending aorta. Operative strategy was altered in 19 patients, including 12 axillary artery cannulations, four off-pump, no-touch aorta coronary bypasses, and three ascending aortic replacements. The CVA rate was 3.04% in the pre-CT period and 0.73% in the post-CT period (p = 0.05).

CONCLUSIONS

Aggressive screening and avoidance of ascending aortic atheroma reduces stroke. Preoperative CT scans in patients at high risk may help identify aortic areas at risk before entering the operating room, lead to more thorough screening in the operating room, and result in a more aggressive strategy to avoid calcified areas.

Revascularization with off-pump coronary artery surgery: what appears new is actually the old rediscovered

The enormous progress in interventional cardiology during the last 10 years has resulted in a major change in the spectrum of patients referred for coronary artery bypass grafting. Several large retrospective analyses, meta-analyses, and the randomized trials that addressed different aspects of ONCAB and OPCAB to date have compared the two surgical strategies. It is suggested that patients may achieve an excellent outcome with either type of procedure, and individuals' outcomes more likely depend on factors other than whether they underwent ONCAB or OPCAB. Nevertheless, there appear to be trends in most studies. These trends include less blood loss and need for transfusion, less myocardial enzyme release up to 24 h, less early neurocognitive dysfunction, and less renal insufficiency after OPCAB and propensity to lower costs, thereafter proving OPCAB to be safe and clinically effective. Here, we review the physiological advantages and clinical outcomes of OPCAB for myocardial revascularization and examine whether either strategy is superior and in which patients.

An Alternative Technique of Proximal Anastomosis in Patients with an Atherosclerotic Ascending Aorta

Coronary artery bypass grafting operations in patients with an atherosclerotic ascending aorta are still associated with an increased risk of cerebral embolism and mortality despite previously described techniques. Here we present an alternative technique for the construction of a proximal anastomosis avoiding aortic clamping and deep hypothermic circulatory arrest.

Propensity Case-Matched Analysis of Off-Pump Versus On-Pump Coronary Artery Bypass Grafting in Patients With Atheromatous Aorta

BACKGROUND

Patients with severe atheromatous disease of the aorta who underwent coronary artery bypass grafting have an increased risk of stroke and death. We hypothesize that in these high-risk patients off-pump coronary artery bypass grafting is associated with lower rates of stroke and mortality.

METHODS

From January 1995 through June 2004, a total of 24,107 patients underwent coronary artery bypass grafting. Routine intraoperative transesophageal echocardiography was performed in 18,501, of which 6,991 (29.0%) were found to have severe atheromatous disease in the ascending aorta or aortic arch. Propensity matched-pairs analysis was used to match patients undergoing off-pump coronary artery bypass grafting (n = 3,000) with 3,000 patients undergoing conventional coronary artery bypass grafting by age, sex, ejection fraction, diabetes, preoperative intraaortic balloon pump, congestive heart failure, chronic obstructive pulmonary disease, acute myocardial infarction, peripheral vascular disease, history of stroke or cerebrovascular disease, renal disease, carotid artery disease, atrial fibrillation, emergency surgery, or previous cardiac surgery.

RESULTS

Univariate analysis revealed decreased hospital mortality (1.4% versus 3.3%; p < 0.001) and stroke prevalence (0.50% versus 0.97%; p = 0.05) in off-pump coronary artery bypass grafting compared with conventional coronary artery bypass grafting. Multivariate analysis revealed that increased mortality was associated with conventional coronary artery bypass grafting (odds ratio, 2.6; p = 0.001), age (odds ratio, 2.1; p = 0.003), acute myocardial infarction (odds ratio, 1.8; p = 0.03), history of stroke or cerebrovascular disease (odds ratio, 1.6; p = 0.04), congestive heart failure (odds ratio, 2.1; p = 0.04), and diabetes mellitus (odds ratio, 1.9; p = 0.03). Multivariate analysis showed that off-pump coronary artery bypass grafting technique was the only independent predictor of decreased stroke rate (odds ratio, 1.4; p = 0.05).

CONCLUSIONS

Off-pump coronary artery bypass grafting surgery in patients with atheromatous disease of the aorta is associated with lower risk of stroke and death. Routine intraoperative evaluation of the aorta is helpful in identifying the disease and directs the appropriate surgical technique.

[Should we avoid cardiopulmonary bypass with diabetic patients?]

In the peri-operative and post-operative course of coronary bypass operations, the diabetic patient is susceptible to complications that cause morbidity and mortality. Morbidity might best be conceptualized as the cumulative effect of the diabetic patient chronically at risk and a variety of surgically related insults, including surgical stress, anaesthesia, hypo- and hypertension, anaemia, dysrhythmias, de- or hyperhydration and cardiopulmonary bypass (CPB) that exceed the compensatory capacities of the patient. Because all these factors for adverse outcome coexist, it becomes difficult to determine which ones are most important. However, it is reasonable that, in the presence of generalized atherosclerosis affecting the aorta ascendens, carotids and the cerebral arteries, the interaction of CPB-associated embolization, hypoperfusion and inflammation may cause neurologic morbidity. Many physiologic alterations (such as non-pulsatile perfusion and hemodilution) occur during CPB and may worsen renal dysfunction in patients with diabetic nephropathy. Pulmonary dysfunctions, associated with diabetic microangiopathy, could be unmasked by atelectasis, capillary leak and other pathophysiological conditions developing after the use of extracorporeal circulation. Actually, there is evidence that with the avoidance of CBP and the use of adequate OPCAB (Off Pump Coronary Artery Bypass) techniques, by experienced teams, the incidences of neurological, renal and pulmonary complications decrease, in high-risk patients, e. g. diabetics, as well as in unselected cohorts. Because it is not possible to identify confidently those patients who are at risk for CPB-associated complications, we use a strategy where all CABG (Coronary Artery Bypass Grafting) are performed in OPCAB technique. The total OPCAB approach will in addition ascertain the development of organizational OPCAB routines and expertise. The process of re-engineering the unit towards total OPCAB needs systematic training and re-training of cardiac surgeons by surgeons, experienced in both, OPCAB surgery and knowledge transfer, according to the principles of continuing medical education (CME). Thus, the chances of the OPCAB technique improving the outcome of diabetic patients can be fully realized.