Early outcomes in the elderly: a meta-analysis of 4921 patients undergoing coronary artery bypass grafting--comparison between off-pump and on-pump techniques

Multivessel Coronary Disease and Severe Atherosclerotic Aorta: Real-World Experience

Background and Objectives: Surgical revascularisation of patients with atherosclerosis of the ascending aorta remains a challenge. Different surgical strategies have been described in coronary surgical patients to offer alternative revascularisation strategies other than the conventional surgical revascularisation in patients unsuitable for it. The aim of this study is to compare the real-world outcomes between two groups of patients who underwent off-pump surgery (left internal mammary artery graft to the left anterior descending artery) or a hybrid with a percutaneous revascularisation procedure at a later stage. Materials and Methods: This is a single-centre retrospective observational study. Between the years 2010 and 2021, 91/6863 patients (1.33%) were diagnosed with severe atherosclerosis of the ascending aorta. All the patients were treated with off-pump revascularisation (91 patients), and the cardiologist would decide at a later stage whether the rest of the vessels would be treated with percutaneous revascularisation (25 patients). Results: There was no statistical difference in the various preoperative characteristics, except for coronary artery left main disease (30.30% vs. 64%; p = 0.0043). The two groups had no statistical differences in the perioperative characteristics and postoperative complications. The 1-, 5-, and 10-year mortality rates in the two groups were 6.1% vs. 0%, 59% vs. 80%, and 93.9% vs. 100%, respectively (off-pump vs. hybrid with percutaneous revascularisation procedure, p = 0.1958). Conclusions: Both strategies have high long-term comparable mortality. The off-pump surgery and the HCR procedure at a later stage may be solutions for these high-risk patients, but the target treatment should be complete HCR revascularisation during the index hospitalization.

Quality control in a training course of off-pump coronary artery bypass grafting surgery

Objectives

Off-pump coronary artery bypass grafting (OPCAB) surgery is controversial in part because of the surgeon's experience, which correlates with how the surgeon is trained. Because the training model of OPCAB is not uniform, the quality control in the training process seems to be more important and needs to be further discussed.

Methods

Nine surgeons accepted and completed an OPCAB training course at a single center to become independent surgeons. This training program is characterized by 6 progressive levels supervised by experienced trainers. In total, 2307 consecutive cases of OPCAB performed by the 9 trainee surgeons were analyzed for monitoring and evaluation in quality control. The funnel plots and cumulative summation (CUSUM) analysis method were used to evaluate the performance of each surgeon.

Results

The mortality and complications of each surgeon were all within the 95% confidence interval of funnel plots. The CUSUM learning curves of first 3 trainees was analyzed and showed that the trainees need to complete approximately 65 cases to cross the CUSUM learning curve to reach a steady state.

Conclusions

The trainees can directly receive the OPCAB training course under the guidance of experienced surgeons with a rigorous schedule. It is feasible to perform quality control by funnel plots and CUSUM method in OPCAB surgery to ensure the safety of the training course.

Long-Term Survival of Multiple Versus Single Arterial Coronary Bypass Grafting in Elderly Patients

Multiple arterial grafting (MAG) utilizes more than one arterial graft with any additional grafts being saphenous vein grafts (SVG). It remains an infrequently used coronary surgical revascularization technique, especially in elderly patients. Our study aims to evaluate the age-related association with the relative outcomes of multiple versus single arterial grafting (SAG). The Australian and New Zealand national registry was used to identify adult patients undergoing primary isolated CABG with at least two grafts. Exclusion criteria included reoperations, concomitant or previous cardiac surgery, and the absence of arterial grafting. Propensity score matching was used to match patient groups. The primary outcome was all-cause late mortality and the secondary outcomes were 30-day mortality and 30-day hospital readmission. We selected 69,624 eligible patients with a mean (standard deviation) age of 65.0 (10.2) years old. Matching between MAG and SAG generated 16,882 pairs of patients < 70 years old and 10,921 pairs of patients ≥ 70 years old. At a median [interquartile range] follow-up duration of 5.9 [3.2–9.6] years, MAG was associated with significantly reduced mortality compared to SAG (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.68–0.78; p < 0.001) in the younger subgroup as well as the elderly subgroup (HR, 0.84; 95% CI, 0.79–0.88; p < 0.001). In conclusion, MAG offers a survival benefit over SAG, in both younger and elderly patients.

Comparison of Post-operative Outcomes Between Direct Axillary Artery Cannulation and Side-Graft Axillary Artery Cannulation in Cardiac Surgery: A Systematic Review and Meta-Analysis

Background

There is a growing perception of using axillary artery cannulation to improve operative outcomes in cardiopulmonary bypass surgery. Two techniques, direct cannulation or side-graft cannulation, can be used for axillary artery cannulation, but which technique is better is controversial.

Methods

A meta-analysis of comparative studies reporting operative outcomes using direct cannulation vs. side-graft cannulation was performed. We searched the PubMed, EMbase, Web of Science, and Cochrane Library. Outcomes of interest were neurological dysfunction, cannulation-related complications and early mortality. The fixed effects model was used.

Results

A total of 1,543 patients were included in the final analysis. Direct cannulation was used in 846 patients, and side-graft cannulation was used in 697 patients. Meta-analysis showed a higher occurrence of neurological Complication in direct cannulation group [odds ratio, 1.45, 95% CI (1.00, 2.10), χ² = 4.40, P = 0.05] and a significantly higher incidence of cannulation-related complications in the direct cannulation group [odds ratio, 3.12, 95% CI (1.87, 5.18), χ² = 2.54, P < 0.0001]. The incidence of early mortality did not have a difference [odds ratio, 0.95, 95% CI (0.64, 1.41), χ² = 6.35, P = 0.79].

Conclusions

This study suggests that side-graft axillary artery cannulation is a better strategy as it reduces the incidence of neurological dysfunction and cannulation-related complications.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022325456.

Perioperative Cardiac Troponin T and Risk of Postoperative Atrial Fibrillation in Coronary Artery Bypass Graft Surgery

BACKGROUND

Postoperative atrial fibrillation (AF) is a common complication after cardiac surgery. We investigated whether perioperative cardiac troponin T (cTnT) is associated with the risk of AF after coronary artery bypass grafting (CABG).

METHODS

Two thousand four hundred twenty-one patients with isolated CABG were studied. High sensitivity cTnT (hs-cTnT) was assessed before and then at 80 hour and 24 hour after the operation. Logistic regression models were applied to investigate the association of perioperative hs-cTnT with postoperative AF. The ROC curve analysis was applied to determine the optimal cutoff values.

RESULTS

Postoperative AF was occurred in 356 (14.7%) patients. Age (adjusted odds ratio [ORs] 1.087-1.090), male gender (OR 1.390), left atrium size (ORs 1.055-1.111), on-pump coronary bypass (OR 1.561), and application of intra-aortic balloon pump (ORs 2.890-2.966) were independently associated with AF. Preoperative hs-cTnT was associated with AF in patients with off-pump coronary bypass (ORs 1.997-2.375). However, the area under the curve for preoperative hs-cTnT was 0.625 in this group. On-pump coronary bypass had major influence on postoperative hs-cTnT levels regardless of the occurrence of AF.

CONCLUSIONS

Preoperative hs-cTnT level is associated with the risk of AF after isolated CABG in patients undergoing off-pump coronary bypass, but the accuracy of this biomarker is yet inadequate. Postoperative levels of hs-cTnT have no predictive value considering large influence by the surgical technique and the cardiac surgery itself. Therefore, perioperative hs-cTnT is not a clinically useful biomarker for predicting AF following CABG.

A systematic review and meta-analysis of randomized controlled studies comparing off-pump versus on-pump coronary artery bypass grafting in the elderly

AIM

Comparison of short and mid-term outcomes between off-pump CABG (OPCAB) and on-pump CABG (ONCAB) in patients older than 65 throughout a meta-analysis of randomized clinical trials (RCTs).

EVIDENCE ACQUISITION

A literature search was conducted using 3 databases. RCTs reporting mortality outcomes of OPCAB versus ONCAB among the elderly were included. Data on myocardial infarction, stroke, re-revascularization, renal failure and composite endpoints after CABG were also collected. Random effects models were used to compute statistical combined measures and 95% confidence intervals (CI).

EVIDENCE SYNTHESIS

Five RCTs encompassing 6221 patients were included (3105 OPCAB and 3116 ONCAB). There were no significant differences on mid-term mortality (pooled HR: 1.02, 95%CI: 0.89-1.17, p=0.80) and composite endpoint incidence (pooled HR: 0.98, 95%CI: 0.88-1.09, p=0.72) between OPCAB and ONCAB. At 30-day, there were no differences in mortality, myocardial infarction, stroke and renal complications. The need for early re-revascularization was significantly higher in OPCAB (pooled OR: 3.22, 95%CI: 1.28-8.09, p=0.01), with a higher percentage of incomplete revascularization being reported for OPCAB in trials included in this pooled result (34% in OPCAB vs 29% in ONCAB, p<0.01).

CONCLUSIONS

Data from RCTs in elderly patients showed that OPCAB and ONCAB provide similar mid-term results. OPCAB was associated with a higher risk of early rerevascularization. As CABG on the elderly is still insufficiently explored, further RCTs, specifically designed targeting this population, are needed to establish a better CABG strategy for these patients.

Impact of Denervation by Heart Transplantation on Post-operative Atrial Fibrillation Susceptibility

Atrial fibrillation is common following cardiac and non-cardiac thoracic surgery and is associated with poorer outcomes, including: increased risk of stroke, hemodynamic instability, prolonged hospital stay, and increased mortality. Current understanding suggests that post-op atrial fibrillation results from the interplay of local and systemic operative inflammation, increased sympathetic activity, perhaps the release of free radical species in the perioperative period, and the patient's underlying cardiac substrate. Cardiac denervation following orthotopic heart transplant (OHT) using modern bicaval techniques presents a unique opportunity to study the relative contribution of the autonomic nervous system to post-op atrial fibrillation susceptibility. Observational studies show a reduced incidence of post-operative atrial fibrillation following orthotopic heart transplant compared to other cardiac and thoracic surgeries. Moreover, comparison of atrial fibrillation rates with double lung transplant recipients suggests that cardiac denervation has a contribution apart from surgical pulmonary vein isolation alone. This report reviews current concepts of the mechanisms of post-op atrial fibrillation with a focus on the role of the autonomic nervous system, the autonomic regulation of the native heart, and evidence regarding the impact of cardiac denervation following OHT.

Effect of Age on Clinical Outcomes Following On-/Off-Pump Coronary Artery Bypass: Meta-Analysis and Meta-Regression

Objective

There is currently much debate about which patients would benefit more after on- or off-pump coronary artery bypass grafting (CABG). The aim of this meta-analysis and meta-regression is to investigate the effect of age on short-term clinical outcomes after these approaches.

Methods

To identify potential studies, systematic searches were carried out in the Excerpta Medica dataBASE (EMBASE), PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL). The search strategy included the key concepts of “cardiopulmonary bypass” AND “coronary artery bypass grafting” AND “off pump” OR “on pump”. This was followed by a meta-analysis and meta-regression investigating the effect of age on the incidences of stroke, myocardial infarction (MI), and mortality.

Results

Thirty-seven studies including 15,324 participants were analysed. Overall, there was a significant odds reduction for patients receiving off-pump CABG suffering a stroke (odds ratio [OR] 0.770, 95% confidence intervals [CI] 0.594, 0.998, P=0.048); however, when patients were subdivided according to different age bands, this difference disappeared. There were also no significant differences in the odds of mortality (OR 0.876, 95% CI 0.703, 1.093, P=0.241) or MI (OR 0.937, 95% CI 0.795, 1.105, P=0.439). Meta-regression analysis revealed no significant relationship between age and stroke (P=0.652), age and mortality (P=548), and age and MI (P=0.464).

Conclusion

Patients undergoing CABG are becoming older and may suffer from multiple comorbidities increasing their risk profile. However, with respect to short-term clinical outcomes, the patient’s age does not help in determining whether off- or on-pump is superior.

Current Status of Off-Pump Coronary Artery Bypass

PURPOSE

Off-pump coronary arterial bypass grafting (OPCAB) has become a common practice for coronary artery bypass grafting (CABG) in Japan, with approximately 65% CABG procedures currently being performed using OPCAB. However, it is unclear whether OPCAB is superior in terms of associated mortality, incidence of complications, graft patency rate, and long-term outcomes compared with conventional CABG (CCABG).

METHODS

Literature consideration was performed, mainly based on observational studies involving large samples and randomized controlled trials (RCTs).

RESULTS

Many RCTs indicated that the acute-phase and long-term mortality rates were comparable between CCABG and OPCAB or that OPCAB was inferior to CCABG. In contrast, many observational studies indicated that OPCAB was superior to CCABG.

CONCLUSION

CABG is a delicate procedure, the outcomes of which vary in accordance with the patient's condition as well as the level of expertise of the associated institution and surgeon. In the future, we hope that reports will emerge with excellent results, including long-term results, from Japanese institutions experienced in performing OPCAB.

Preoperative Platelet-to-Lymphocyte Ratio Is Not Associated With Postoperative Atrial Fibrillation

BACKGROUND

Postoperative atrial fibrillation (POAF) is a common complication after coronary artery bypass grafting (CABG) and is associated with increased short-term and long-term mortality. While the precise etiology of POAF remains unclear, inflammation is a known contributing factor. Preliminary studies have suggested that an elevated preoperative platelet-to-lymphocyte ratio (PLR), an inexpensive and readily available novel inflammatory biomarker, may be associated with increased incidence of POAF after CABG. This study sought to further investigate this hypothesis.

METHODS

The study cohort included all patients undergoing isolated CABG, with no prior history of arrhythmia, who were operated on between August 1, 2010, and December 31, 2018, at a major Australian tertiary center (n = 1457). Patients were divided into low (<86) or high (≥86) PLR groups based on an optimal cutoff derived from receiver-operating characteristic curve analysis. The incidence of POAF was then compared. Categorical variables were analyzed using the chi-square test and continuous variables using logistic regression.

RESULTS

Of 1457 patients, 495 (34.0%) developed POAF. There was no statistically significant difference in the incidence of POAF between patients in the high-PLR and low-PLR groups (34.8% vs 31.0%; P = .22). Using multivariable logistic regression analysis, high PLR was not independently associated with POAF (odds ratio, 1.04; P = .78).

CONCLUSIONS

Elevated preoperative PLR is not independently associated with POAF in patients undergoing isolated CABG. The findings of this study differ from those of 2 previous smaller studies.

OPCAB experience in octogenarians: A comparison of perioperative events and long-term survival between patients aged 75 to 80 years and patients aged ≥80 years

INTRODUCTION

The advantages of off-pump coronary artery bypass grafting (OPCAB) in octogenarians are still undetermined.

METHODS

We retrospectively collected the data of 338 patients aged ≥75 with at least two coronary-artery diseases who underwent OPCAB. Then, the two groups were divided into follow-up survival and follow-up death subgroups. The baseline and perioperative data were compared for the younger and octogenarian groups, as well as for the subgroups. Moreover, long-term survival rates in the follow-up survival and follow-up death subgroups were compared; a Cox regression model was built to explore the independent risk factors that influence long-term survival.

RESULTS

NYNA ≥ III (39.4% vs 23.2%, P = .006), AMI (45.1% vs 24.3%, P = .001), and three diseased vessels with LM disease (38.0% vs 25.8%, P = .043) were more prevalent among octogenarians. Octogenarians required more intraoperative (11.3% vs 0.40%, P = .000) and postoperative (9.9% vs 2.2%, P = .003) IABP insertions and more ventilation time (P = .053), and they spent a longer time in the ICU (174.1 ± 34.9 vs 81.0 ± 6.4 hours, P = .010), had a longer total hospital stay (32.7 ± 3.1 vs 24.6 ± 0.8 days, P = .015), and had a longer postoperative hospital stay (20.5 ± 2.5 vs 14.5 ± 0.7 days, P = .021); however, fewer LIMA grafts were used among octogenarians (71.8% vs 90.3%, P = .000). The mortality and the postoperative complications between the two groups were similar. Long-term survival at 1, 5, and 10 years were satisfactory at 98.4 vs 91.5%, 89.7 vs 82.8%, and 61.1 vs 52.1% for the younger group and the octogenarians, respectively (P = .440). The Cox regression analysis results suggest that malignant ventricular arrhythmias (HR 4.058, CI, 1.760-9.358, P = .001; HR 7.256, CI, 2.112-24.932, P = .001) and reintubation (HR 3.593, CI, 1.646-7.845, P = .001; HR 4.252, CI, 1.797-10.060, P = .001) were independent risk factors that affect the long-term survival in both overall OPCAB patients and in the younger patient group.

CONCLUSIONS

OPCAB can be safely performed, with acceptable operative mortality and complication rates and satisfactory survival outcomes. The Cox regression analysis results demonstrated that malignant ventricular arrhythmia and reintubation were independent risk factors that affect long-term survival in both overall OPCAB patients and in the younger group of patients.

Long Term Outcomes of The Off-Pump and On-Pump Coronary Artery Bypass Grafting In A High-Volume Center

Coronary artery bypass grafting (CABG) remains the most frequent surgery in the practice of an adult cardiac surgeon and the most frequently performed cardiac surgical procedure worldwide. Despite the ongoing debates regarding the superiority or inferiority of off-pump coronary artery bypass grafting, it still comprises 15-30% of all CABG cases varying in different national registries. We performed a propensity matched study of 302 consecutive CABG patients,143 off -pump cases performed by the four experienced off-pump surgeons and the on-pump CABG cases performed by those surgeons and four other experienced coronary surgeons. The five year follow up was performed and data collected comprised of mortality, rehospitalization due to cardiac origin, repeated revascularization, myocardial infarction and cerebrovascular accident. Overall, the off-pump group of patients had a higher risk profile than the patients in the on-pump group. After matching, fewer differences were found between the groups. Propensity score matching analysis showed no difference in long-term survival as well as MACCE and repeated revascularization. The higher risk profile of the patients subjected to OPCAB and the comparable survival to lower risk CPB patients in this series indicate that in experienced hands, OPCAB is a valuable option in this important subgroup of patients.

Strategy of Cardiovascular Surgery for Patients With Dementia as Evaluated by Mini-Mental State Examination

BACKGROUND

The strategy for cardiovascular surgery in dementia patients is controversial, so we aimed to investigate whether preoperative dementia and its severity might affect the outcomes of cardiovascular surgery by evaluating with the Mini-Mental State Examination (MMSE). Methods and Results: The study group comprised 490 patients undergoing cardiovascular surgery. Their preoperative cognitive status was evaluated using the MMSE, and analysis was performed to compare the patients with MMSE score <24 (dementia group, n=51) or MMSE score 24-30 (non-dementia group, n=439). Furthermore, the effect of the severity of dementia was analyzed with a cut-off MMSE score of 19/20. Risk factors for surgical outcomes were explored using multivariate logistic regression analysis. Hospital mortality was 11.8% in the dementia group and 2.1% in the non-dementia group (P=0.002). Regarding the postoperative morbidities, the incidence of cerebrovascular disorder (P=0.001), pneumonia (P=0.039), delirium (P=0.004), and infection (P=0.006) was more frequent in dementia group. Among the patients with MMSE <20, hospital mortality was as high as 25%, and the rate of delirium was 58%. Multivariate logistic regression analysis revealed that MMSE score <24 (P=0.003), lower serum albumin (P=0.023) and aortic surgery (P=0.036) were independent risk factors for hospital death.

CONCLUSIONS

Preoperative dementia affects the outcomes of cardiovascular surgery with regard to hospital death and delirium. The surgical indication for patients with MMSE <20 might be difficult, but surgery with an appropriate strategy should be considered for patients with MMSE <24.

A comparison of early clinical outcomes of off-pump and on-pump coronary artery bypass grafting surgery in elderly patients

BACKGROUND

The reply of question of "which coronary artery bypass grafting (CABG) technique is superior in elderly patients, off-pump or on-pump CABG surgery?" is controversial. We aimed to compare the early clinical outcomes in elderly patients undergoing off-pump and on-pump CABG.

METHODS

From January 2009 to January 2015, 344 elderly patients (aged 70 or older) underwent off-pump (n = 137) or on-pump (n = 207) CABG. Patients' medical records were retrospectively reviewed, and their baseline preoperative characteristics, operative data and postoperative outcomes were analyzed, thereby a comparison of early outcomes between off-pump and on-pump patients was performed.

RESULTS

Mean age of patients was 74.4 ± 3.8 years. Both groups were statistically similar in terms of baseline preoperative characteristics. Number of distal bypass was significantly lower in off-pump group than in on-pump group. Postoperative length of intensive care unit and hospital stay were similar between two groups. Amounts of transfused blood products were significantly lower in off-pump CABG group. There were no significant differences in terms of postoperative complications and mortality between two groups.

CONCLUSIONS

Our results did not reveal a significant benefit of either surgical technique with respect to early-term clinical outcomes in elderly CABG patients. Further investigations are needed to determine whether off-pump CABG is superior than on-pump CABG in elderly patients.

Use of cardiopulmonary pump support during coronary artery bypass grafting in the high-risk: a meta-analysis

BACKGROUND

Data from randomized trials evaluating the efficacy of on- versus off-pump coronary artery bypass grafting remain inconclusive, particularly in high-risk populations.

AIMS

The aim of this study is to compare the outcomes associated with on- versus off-pump coronary artery bypass grafting among high-risk patients.

METHODS

We performed a meta-analysis of randomized control trials comparing on- versus off-pump coronary artery bypass grafting, focusing on high-risk populations. Studies focusing on "high-risk" features: European System of Cardiac Operative Risk Evaluation (EuroSCORE) ≥ 5, age > 70 years, preexisting renal insufficiency, history of stroke(s), and the presence of left ventricular dysfunction were included. MEDLINE, Scopus, and Embase were searched for all publications between January 1, 2000 and August 1, 2016, using the following terms: on-pump, off-pump, coronary artery bypass, high-risk, left ventricular dysfunction, elderly, aged, and renal insufficiency. Endpoints included cardiovascular and all-cause mortality, non-fatal myocardial infarction, stroke, need for revascularization, renal failure, and length of hospital stay.

RESULTS

Nine studies incorporating 11,374 patients with a mean age of 70 years were selected. There was no statistical difference in cardiovascular mortality, all-cause mortality, non-fatal myocardial infarction, and renal failure between the two groups. There was a decrease in further revascularization at 1 year with on-pump (OR 0.67 (0.50-0.89)). However, there was an increase in length of hospital stay by 2.24 days (p = 0.03) among the on-pump group with no difference in stroke (OR 1.34 (1.00-1.80)).

CONCLUSIONS

On-pump is associated with a decreased risk of additional revascularization by 1 year. However, this appears to be a cost of longer hospitalization.

Comparison of Mid-Term Graft Patency between On-Pump and Off-Pump Coronary Artery Bypass Grafting

BACKGROUND

Multiple studies have compared on-pump coronary artery bypass (ONCAB) grafting with off-pump coronary artery bypass (OPCAB) grafting, but the optimal surgical strategy has yet to be established. Furthermore, there is limited evidence regarding mid-term graft patency rates.

METHODS

Between April 2001 and March 2014, 365 consecutive patients underwent isolated coronary artery bypass grafting (CABG; male: 75%; mean age: 69 ± 10 years). After propensity-score-matched analysis, we assessed the results of 67 patients in each group (ONCAB: group A, OPCAB: group B). The mean follow-up period of graft patency and survival rate was 35 ± 37 months and 54 ± 47 months, respectively.

RESULTS

There were no significant differences in baseline characteristics between the two groups. There was a trend for an increased number of distal anastomoses in group B as compared to group A (group A vs. group B: 3.8 ± 1.1 vs. 4.1 ± 1.6, P = 0.17). The total graft patency rate was tend to be lower in group A, but not statistically significant (group A: 156 months, 45.2%; group B: 96 months, 72.6%; P = 0.21). There was no difference for survival and major-adverse-cardiac-and-cerebrovascular-events (MACCE) free rate (P = 0.42 and 0.76, respectively).

CONCLUSION

Propensity-score-matched analysis revealed no difference in mid-term survival rate, MACCE free rate, graft patency rates, and number of distal anastomoses between ONCAB and OPCAB groups.

Comparison of outcomes between off-pump versus on-pump coronary artery bypass surgery in elderly patients: a meta-analysis

The aim of this study was to analyze if off-pump coronary artery bypass surgery (CABG) is associated with better treatment outcomes in elderly patients (>70 years of age) than on-pump CABG, using meta-analysis. Medline, PubMed, Cochrane and Google Scholar databases were searched until September 13, 2016. Sensitivity and quality assessment were performed. Twenty-two studies, three randomized control trials (RCTs) and 20 non-RCTs were included with 24,127 patients. The risk of death associated with on-pump or off-pump CABG in the RCTs were similar (pooled OR=0.945, 95%CI=0.652 to 1.371, P=0.766). However, in the non-RCTs, mortality risk was lower in patients treated with off-pump CABG than on-pump CABG (pooled OR=0.631, 95%CI=0.587 to 0.944, P=0.003). No differences were observed between the two treatment groups in terms of the occurrence of 30-day post-operative stroke or myocardial infarction (P≥0.147). In the non-RCTs, off-pump CABG treatment was associated with a shorter length of hospital stay (pooled standardized difference in means=-0.401, 95%CI=-0.621 to -0.181, P≤0.001). The meta-analysis with pooled data from non-RCTs, but not RCTs, found that mortality was lower with off-pump compared with on-pump CABG, and suggested that there may be some benefit of off-pump CABG compared with on-pump CABG in the risk of mortality and length of hospital stay.

Current outcomes of off-pump coronary artery bypass grafting: evidence from real world practice

Coronary artery bypass grafting (CABG) can be performed conventionally using cardiopulmonary bypass (CPB) and aortic clamping or on a beating heart (BH) without the use of CPB, the so-called off-pump CABG. Some surgeons, who are proponents of off-pump CABG, preferentially use this technique for the majority of operations, whereas others use it only in certain situations which warrant avoidance of CPB. Ever since the conception of off-pump CABG, the never-ending debate about which technique of CABG is safe and efficacious continues to date. Several randomized controlled trials (RCTs) have been conducted that have either favored on-pump CABG or have failed to show a significant difference in outcomes between the two techniques. However, these RCTs have been fraught with claims that they do not represent the majority of patients undergoing CABG in real world practice. Therefore, assessment of the benefits and drawbacks of each technique through observational and registry studies would be more representative of patients encountered in daily practice. The present review examines various retrospective studies and meta-analyses of observational studies that compare the early and long-term outcomes of off- and on-pump CABG, which assesses their safety and efficacy. Additionally, their outcomes in older patients, females, and those with diabetes mellitus, renal dysfunction, presence of ascending aortic disease, and/or acute coronary syndrome (ACS) have also been discussed separately. The general consensus is that early results of off-pump CABG are comparable to or in some cases better than on-pump CABG. However, on-pump CABG provides a survival benefit in the long term according to a majority of publications in literature.

Circulating Biomarkers Predictive of Postoperative Atrial Fibrillation

Postoperative atrial fibrillation (PoAF), a common complication of cardiac surgery, contributes significantly to morbidity, mortality, and increasing healthcare costs. Despite advances in surgical and medical management, the overall incidence of PoAF has not changed significantly, partly because of the limited understanding of mechanisms underlying acute surgery-related factors, such as myocardial injury, inflammation, sympathetic activation, and oxidative stress, which play an important role in the initiation of PoAF, whereas a preexisting atrial substrate appears to be more important in the maintenance of this dysrhythmia. Thus, in a majority of patients, PoAF becomes a manifestation of an underlying arrhythmogenic substrate that is unmasked after acute surgical stress. As such, the ability to identify which patients have this proarrhythmic substrate and are, therefore, at high risk for developing AF postoperatively, is important for the improved selection for prophylactic interventions, closer monitoring for complications, and establishing the probability of AF in the long term. This review highlights the role of the underlying substrate in promoting PoAF, proposed mechanisms, and the potential role of serum biomarkers to identify patients at risk for PoAF.

Laparoscopic-assisted versus open distal gastrectomy with D2 lymph node resection for advanced gastric cancer: effect of learning curve on short-term outcomes. a meta-analysis

Laparoscopic-assisted distal gastrectomy (LADG) with D2 resection is gradually being performed for treating advanced gastric cancer. This meta-analysis aims to compare the clinical outcomes between LADG and open distal gastrectomy (ODG) when considering the impact of the learning curve. The PubMed, Embase, and ISI databases and the Cochrane Library were electronically searched. Randomized controlled trails and retrospective comparative studies published between 1994 and 2013 were collected. We divided the included studies into two subgroups according to whether the authors had experience of at least or fewer than 40 cases of LADG with D2 resection and then compared the operative time, intraoperative bleeding, the amount of resected lymph nodes, short-term recovery parameters, and complications between LADG and ODG groups. Ten comparative studies including 1100 patients were selected. Meta-analysis showed that when LADG was compared with ODG, surgeons with experience of at least 40 cases could achieve more resected lymph nodes (P=.002), reduced time to flatus (P<.0001), shortened time to liquid diet (P<.00001), and lower complication rates (P=.02). However, the above advantages of LADG faded in the subgroup of surgeons with experience of fewer than 40 cases. Our meta-analysis suggested that the learning curve has significant effects on most of the important surgical and short-term recovery outcome parameters. Accomplishment of 40 cases of LADG with D2 lymphadenectomy is required to achieve optimum proficiency.

Robotics and surgery: A sustainable relationship?

Robotic surgery is increasingly being employed to overcome the disadvantages associated with use of conventional techniques such as laparoscopy. However, despite significant promise, there are some clear disadvantages and robust evidence base supporting the use of robotic assistance remains lacking. In this paper, the advantages and drivers for robotics will be discussed, its drawbacks and its future role in surgery.

Circulating cardiac biomarkers and postoperative atrial fibrillation in the OPERA trial

BACKGROUND

Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and predicts increased morbidity and mortality. Identification of patients at high risk of POAF with the help of circulating biomarkers may enable early preventive treatment but data are limited, especially in contemporary surgical patients.

METHODS

Plasma concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) were measured at enrollment, on the morning of cardiac surgery, at end surgery, and 2 days postsurgery in 562 patients undergoing cardiac surgery, randomized to perioperative supplementation with oral fish oil or placebo in the Omega-3 Fatty Acids for Prevention of Post-Operative Atrial Fibrillation trial (OPERA). The primary endpoint was incident POAF lasting ≥ 30 s, centrally adjudicated and confirmed electrocardiographically.

RESULTS

Higher levels of NT-proBNP and hs-cTnT before surgery were associated with older age, renal or cardiac dysfunction and EuroSCORE. NT-proBNP peaked on postoperative day 2 (2172 [1238-3758] ng/L, median [Q1-Q3]), while hs-cTnT peaked at the end of surgery (373 [188-660] ng/L). Fish oil supplementation did not alter the time course of the cardiac biomarkers (P > 0.05). Concentrations of NT-proBNP or hs-cTnT, on the morning of surgery, or changes in their level between morning of surgery and postsurgery, were not significantly associated with POAF after adjustment for clinical and surgical characteristics.

CONCLUSION

Among patients undergoing cardiac surgery, NT-proBNP and hs-cTnT are related to clinical and surgical characteristics, have different perioperative time courses but are not independently associated with risk of POAF.

Predicting New-Onset Postoperative Atrial Fibrillation in Cardiac Surgery Patients

OBJECTIVE

To derive a simple clinical prediction rule identifying patients at high risk of developing new-onset postoperative atrial fibrillation (POAF) after cardiac surgery.

DESIGN

Retrospective analysis on prospectively collected observational data.

SETTING

A university-affiliated cardiac hospital.

PARTICIPANTS

Adult patients undergoing coronary artery bypass grafting and/or valve surgery.

INTERVENTIONS

Observation for the occurrence of new-onset postoperative atrial fibrillation.

MEASUREMENTS AND MAIN RESULTS

Details on 28 preoperative variables from 999 patients were collected and significant predictors (p<0.2) were inserted into multivariable logistic regression and reconfirmed with recursive partitioning. A total of 305 (30.5%) patients developed new-onset POAF. Eleven variables were associated significantly with atrial fibrillation. A multivariable logistic regression model included left atrial dilatation, mitral valve disease, and age. Coefficients from the model were converted into a simple 7-point predictive score. The risk of POAF per score is: 15.0%, if 0; 20%, if 1; 27%, if 2; 35%, if 3; 44%, if 4; 53%, if 5; 62%, if 6; and 70%, if 7. A score of 4 has a sensitivity of 44% and a specificity of 82% for POAF. A score of 6 has a sensitivity of 11% and a specificity of 97%. Bootstrapping with 5,000 samples confirmed the final model provided consistent predictions.

CONCLUSIONS

This study proposed a simple predictive score incorporating three risk variables to identify cardiac surgical patients at high risk of developing new-onset POAF. Preventive treatment should target patients ≥ 65 years with left atrial dilatation and mitral valve disease.

[Epidemiology of cerebral perioperative vascular accidents]

OBJECTIVES

Stroke is a well-described postoperative complication, after carotid and cardiac surgery. On the contrary, few studies are available concerning postoperative stroke in general non-cardiac non-carotid surgery. The high morbid-mortality of stroke justifies an extended analysis of recent literature.

ARTICLE TYPE

Systematic review.

DATA SOURCES

Firstly, Medline and Ovid databases using combination of stroke, cardiac surgery, carotid surgery, general non-cardiac non-carotid surgery as keywords; secondly, national and European epidemiologic databases; thirdly, expert and French health agency recommendations; lastly, reference book chapters.

RESULTS

In cardiac surgery, with an incidence varying from 1.2 to 10% according to procedure complexity, stroke occurs peroperatively in 50% of cases and during the first 48 postoperative hours for the others. The incidence of stroke after carotid surgery is 1 to 20% according to the technique used as well as operator skills. Postoperative stroke is a rare (0.15% as mean, extremes around 0.02 to 1%) complication in general surgery, it occurs generally after the 24-48th postoperative hours, exceptional peroperatively, and 40% of them occurring in the first postoperative week. It concerned mainly aged patient in high-risk surgeries (hip fracture, vascular surgery). Postoperative stroke was associated to an increase in perioperative mortality in comparison to non-postoperative stroke operated patients.

CONCLUSION

Postoperative stroke is a quality marker of the surgical teams' skill and has specific onset time and induces an increase of postoperative mortality.

Off-pump coronary surgery: current justifications

Although the literature has failed to project an overall superiority of off-pump vs. on-pump surgery, nevertheless, small randomized control trials and large meta-analysis studies have concluded that the incidence of a stroke is less than 1 % when anaortic off-pump techniques are advocated in patients with diseased ascending aorta. Furthermore, off-pump techniques or their combination with hybrid procedures may lead to a reduction of adverse outcome in the aged high-risk population with concomitant poor left ventricular function and co-morbidities. However, despite this, controversy still exists among the cardiac surgery community in terms of the benefit of this technique and its safety; hence, off-pump is becoming out of fashion. In this review paper, by looking at a "marginal group of patients" (elderly, high risks, atherosclerotic aortas) we attempt to re-establish and justify this technique and re-invent its usage.

Outcomes and predictors of mortality and stroke after on-pump and off-pump coronary artery bypass surgery in octogenarians

OBJECTIVE

Octogenarians, as the fastest growing stratum of the population and with the highest prevalence of coronary artery disease, are being increasingly referred for coronary artery bypass grafting (CABG). The general perception is that the presence of comorbidities and the propensity for neurological injury expose them to a higher risk for mortality and morbidity after conventional on-pump CABG, and therefore, off-pump CABG should be preferentially offered to octogenarians to improve outcomes. This study evaluates the in-hospital outcomes and predictors of mortality and stroke in octogenarians undergoing on- and off-pump CABG at our institution.

METHODS

From January 2000 to December 2010, a total of 290 octogenarians underwent off-pump (n = 217) and on-pump (n = 73) CABG. Their data were prospectively entered into the cardiac surgery database (Patients Analysis & Tracking System; Dendrite Clinical Systems, Ltd, Oxford, England, United Kingdom) and analyzed retrospectively. Outcome measures included in-hospital mortality, major complications, and length of stay. Multivariate analysis was performed to identify predictors of combined outcome of in-hospital mortality and stroke.

RESULTS

The mean ± SD age of the patients was 82 ± 2.0 years. Preoperative demographics were similar for the on-pump and off-pump groups. The patients who underwent off-pump CABG had a lower number of distal anastomoses performed compared with the patients who underwent on-pump CABG [mean difference, 0.2; 95% confidence interval (CI), 0.02-0.4; P = 0.03]. However, the ratio of grafts (received/needed) was the same in both groups. In-hospital mortality for the entire cohort was 7.2%, with no significant difference between the groups for death (6.0% vs 11.0%; P = 0.08), stroke (2.8% vs 2.8%; P = 1.0), other major complications, and length of hospital stay. Independent predictors of combined outcome identified from the multiple logistic model included heart failure [odds ratio (OR), 4.4; 95% CI, 1.5-13.0; P = 0.008], diabetes (OR, 2.6; 95% CI, 1.0-6.0; P = 0.046), nitrate infusion (OR, 2.9; 95% CI, 1.1-8.0; P = 0.04), postoperative renal failure requiring hemofiltration (OR, 8.6; 95% CI, 3.5-21.1; P < 0.001), and postoperative ventricular arrhythmias (OR, 7.3; 95% CI, 1.9-27.8; P = 0.009).

CONCLUSIONS

Both on-pump and off-pump CABG are reasonable revascularization strategies in octogenarians. Careful patient selection and individualized treatment decisions can minimize postoperative mortality and morbidity in octogenarians undergoing on- and off-pump CABG.

The evolution of cardiovascular surgery in elderly patient: a review of current options and outcomes

Due to the increase in average life expectancy and the higher incidence of cardiovascular disease with advancing age, more elderly patients present for cardiac surgery nowadays. Advances in pre- and postoperative care have led to the possibility that an increasing number of elderly patients can be operated on safely and with a satisfactory outcome. Currently, coronary artery bypass surgery, aortic and mitral valve surgery, and major surgery of the aorta are performed in elderly patients. The data available show that most cardiac surgical procedures can be performed in elderly patients with a satisfactory outcome. Nevertheless, the risk for these patients is only acceptable in the absence of comorbidities. In particular, renal dysfunction, cerebrovascular disease, and poor clinical state are associated with a worse outcome in elderly patients. Careful patient selection, flawless surgery, meticulous hemostasis, perfect anesthesia, and adequate myocardial protection are basic requirements for the success of cardiac surgery in elderly patients. The care of elderly cardiac surgical patients can be improved only through the strict collaboration of geriatricians, anesthesiologists, cardiologists, and cardiac surgeons, in order to obtain a tailored treatment for each individual patient.

Association of pre and intraoperative variables with postoperative complications in coronary artery bypass graft surgery

OBJECTIVE

To associate the pre- and intraoperative variables with postoperative complications of patients undergoing coronary artery bypass graft surgery.

METHODS

The pre- and intraoperative risk factors of individuals of both genders with diagnosis of coronary insufficiency undergoing coronary artery bypass graft have been studied.

RESULTS

Fifty-eight individuals with median age 62 ± 10 year-old were included in the study, 67% of whom were male. Fourteen (24.1%) patients were smokers, 39 (67.2%) had previous myocardial infarction history, 11 (19%) had undergone coronary angioplasty, 74% had hypertension, 27% had diabetes mellitus, 64% had dyslipidemia and 15.5% had chronic obstructive pulmonary disease. Eighteen (31%) patients presented postoperative complications, most frequent being: infection in surgical incision, difficulties in deambulation, dyspnea, urinary infection and generalized weakness. Male patients had fewer complications than females (P=0.005). Patients with chronic obstructive pulmonary disease remained hospitalized for longer time periods (P=0.019). Postoperative complications occurred in 50% of the patients with creatinine increased, while only 27.1% of the patients with normal value of creatinine had complications (P=0.049). In addition, complications occurred in 50% of the patients with diabetes mellitus, while only 23.8% of patients without diabetes mellitus had complications (P=0.032). The intraoperative factors showed no statistically significant differences.

CONCLUSION

The preoperative factors are associated with postoperative complications in patients undergoing coronary artery bypass graft surgery.

Myocardial revascularization for the elderly: current options, role of off-pump coronary artery bypass grafting and outcomes

The increase in life expectancy has confronted cardiac surgery with a rapidly growing population of elderly patients requiring surgical myocardial revascularization. Recent advances in surgical and anesthetic techniques and improvements in postoperative care have made coronary artery bypass grafting an established therapeutic option for the treatment of coronary artery disease in this group of patients. However, conventional coronary artery bypass grafting on cardiopulmonary bypass is associated with significant risk and related morbidity and mortality in the elderly. In recent years off-pump coronary artery bypass grafting has emerged as a safe and less invasive strategy for surgical myocardial revascularization. Off-pump coronary artery bypass grafting by avoiding the deleterious effects of cardiopulmonary bypass can offer potential benefits to elderly patients requiring surgical myocardial revascularization. This review article provides an overview of the age-related cardiovascular changes, epidemiology of coronary artery disease in the elderly and focuses on outcomes of surgical myocardial revascularization with special emphasis on the impact of off-pump coro-nary artery bypass surgery in the elderly.

Meta-analysis of randomized controlled trials on the efficacy of thoracic epidural anesthesia in preventing atrial fibrillation after coronary artery bypass grafting

Background

Postoperative atrial fibrillation (POAF) is one of the most common complications in patients undergoing coronary artery bypass grafting (CABG). The goal of this meta-analysis was to evaluate the efficacy of thoracic epidural anesthesia (TEA) in preventing POAF in adult patients undergoing CABG.

Methods

MEDLINE and EMBASE were searched to identify randomized controlled trails in adult patients undergoing CABG who were randomly assigned to receive general anesthesia plus thoracic epidural anesthesia (GA + TEA) or general anesthesia only (GA). Two authors independently extracted data using a standardized Excel file. The primary outcome measure was the incidence of POAF. We used DerSimonian-Laird random-effects models to compute summary risk ratios with 95% confidence intervals.

Results

Five studies involving 540 patients met our inclusion criteria. No significant difference in the incidence of POAF was observed between the two groups (risk ratio, 0.61; 95% confidence interval, 0.33 to 1.12; P = 0.11), with significant heterogeneity among the studies (I² = 73%, P = 0.005). Sensitivity analyses by primary endpoint, methodological quality and surgical technique yielded similar results.

Conclusions

The limited evidence suggests that TEA shows no beneficial efficacy in preventing POAF in adult patients undergoing CABG. However, the results of this meta-analysis should be interpreted with caution due to significant heterogeneity of the studies included. Thus, the potential infuence of TEA on the incidence of atrial fibrillation following CABG warrants further investigation.

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 surgery may reduce stroke, respiratory failure, and mortality in octogenarians

BACKGROUND

Octogenarians are a challenging group of patients referred for cardiac surgery. The aim of this study is to assess early outcomes of coronary artery bypass grafting (CABG) performed in the elderly population.

METHODS

We performed a meta-analysis of all published observational studies comparing early results of conventional CABG surgery and off-pump CABG surgery in patients aged 80 years or older. The outcomes of interest were mortality, stroke, respiratory failure, renal failure, incidence of support with intraaortic balloon pump, and incidence of postoperative atrial fibrillation. The random effects model was used.

RESULTS

Fourteen studies were analyzed. The total number of included subjects was 4,991, of whom 3,113 underwent conventional CABG surgery (62.4%), and 1,878 (37.6%) underwent off-pump CABG surgery. The rates of mortality, stroke, and respiratory failure were significantly higher in the conventional CABG surgery group.

CONCLUSIONS

These results confirm that off-pump CABG surgery remains a valuable option of surgical myocardial revascularization, and may optimize the outcome in senior patients.