The future of off-pump coronary artery bypass grafting: a North American perspective

Comparison of Outcomes Between Total Arterial Off-Pump Versus On-Pump Coronary Artery Bypass Surgery: A Meta-Analysis and Meta-Regression

An essential aspect of achieving early optimal outcomes in coronary artery bypass grafting (CABG) is the careful selection of conduits. Total arterial grafting (TAG) has been debated, and recent studies suggest its benefits, especially when combined with off-pump coronary artery bypass grafting (OPCAB). We conducted a systematic review and meta-analysis of studies comparing outcomes of TAG in OPCAB versus on-pump CABG (ONCAB), using data from OVID MEDLINE, EMBASE, SCOPUS, and PUBMED. Seven studies with a total of 5417 patients were included. Short-term outcomes showed no significant differences in perioperative complications between TAG-OPCAB and TAG-ONCAB, but TAG-OPCAB was associated with reduced short-term mortality (OR 0.48, 95% CI [0.26, 0.89], p = 0.02), lower incidence of postoperative low cardiac output, atrial fibrillation, and MACCEs, as well as shorter intubation duration and hospital stay. Meta-regression did not reveal any associations between pre- or intraoperative variables and short-term mortality. In conclusion, TAG-OPCAB demonstrates favorable short-term outcomes and may be considered a safe and effective strategy in selected patients, while long-term outcomes remain inconclusive due to limited data.

Unsung Heroes of Coronary Interventions: Indian Cardiac Surgeons and the Challenges of South Asian Coronary Anatomy and Physiology

Background and significance: The coronary artery disease (CAD) epidemic has seen a logarithmic increase in morbidity and mortality over the past decade. Cardiovascular diseases account for about 19.1 million deaths annually—with 80% of reports coming from low and middle-income countries, which have been attributed to a lack of infrastructure, human resources, and financial coverage. In tandem with the developed world, India has also seen significant growth in interventional and surgical cardiovascular care. The dominance of coronary artery bypass grafting (CABG) procedures in India has attracted the attention of the world. With this review, the authors aim to highlight the role of cardiac surgeons in India as the “unsung heroes” of coronary interventions. Observations: A pernicious atherosclerotic pathology develops in thendian population as a result of genetic and socio-cultural predispositions, which is further complicated by anatomical and physiological differences. The pathology manifests as a diffuse disease in relatively small caliber coronary arteries, necessitating the consideration of CABG over interventional procedures. Indian cardiac surgeons have stood up to the challenge and have powered health tourism to India from around the world due to the excellent success rate and long-term outcomes at a 50–80% lesser cost than most developed countries. Beyond the costs, a major highlight is the high rate of arterial bypass and off-pump surgery. These balance the unbridled exuberance of the interventional cardiology medical–industrial complex, providing a critical balance that benefits patients and improves acute and long-term outcomes. Conclusions: Indian cardiac surgery is now known globally not only for its affordability but also for the skill set and the quality of surgeons. The surgeons’ vast experience and risk-taking capacity have made them an indispensable part of the interventional cardiology team and has allowed a multidisciplinary collaboration that inspires the world. This is evident from the rising trend of medical tourism to India.

Revascularization Modalities in Acute Coronary Syndrome: A Review of the Current State of Evidence

Acute coronary syndrome (ACS) stands as a leading global cause of mortality, underscoring the importance of effective prevention, early diagnosis, and timely intervention. While medications offer benefits to many patients, revascularization procedures such as coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and emerging hybrid approaches remain pivotal for ACS management. This review delves into the 2018 ESC/EACTS guidelines alongside an analysis of existing literature to shed light on the spectrum of revascularization methods. While both CABG and PCI demonstrate promising outcomes, the optimal choice between the two hinges on a comprehensive assessment of individual patient factors, anatomical complexity guided by advanced imaging, comorbidities, and age. The determination of whether to pursue culprit or total revascularization, as well as immediate or staged revascularization, is contingent upon various factors, including age, disease complexity, and clinical outcomes. This evidence-based decision-making process is orchestrated by a multidisciplinary heart team grounded in ongoing clinical evaluation. The primary objective of this review is to provide valuable insights into revascularization strategies and scrutinize the congruence of current guidelines with recent advancements in the field.

[Features of surgical treatment of advanced age patients with coronary artery disease]

OBJECTIVE

To optimize surgical treatment of patients aged over 70 years with coronary artery disease.

MATERIAL AND METHODS

There were 398 patients aged over 70 years with coronary artery disease for the period 2006-2017. All patients were divided into 3 groups: group 1 - on-pump coronary artery bypass grafting (CABG) with cardiac arrest; group 2 - on-pump beating heart CABG, group 3 - off-pump CABG.

RESULTS

On-pump beating heart CABG in patients over 70 years old is followed by reduced incidence of perioperative complications including acute heart failure, acute respiratory failure, neurological complications, reduced length of ICU- and hospital-stay compared with on-pump CABG and cardiac arrest. However, off-pump CABG is optimal in advanced age patients because this approach reduces duration of surgery, intraoperative blood loss, incidence of acute heart failure, neurological complications and cardiac rhythm disturbances. Postoperative annual and 5-year survival rates were 98.1 and 84.2%, respectively.

CONCLUSION

Off-pump CABG is preferable in advanced age patients. Surgical treatment of these patients is characterized by high clinical efficacy in long-term period after surgery.

Short-Term and Mid-Term Clinical Outcomes Following Hybrid Coronary Revascularization Versus Off-Pump Coronary Artery Bypass: A Meta-Analysis

BACKGROUND

Off-pump coronary artery bypass grafting (OPCAB) is one of the standard treatments for coronary artery disease (CAD) while hybrid coronary revascularization (HCR) represents an evolving revascularization strategy. However, the difference in outcomes between them remains unclear.

OBJECTIVE

We performed a meta-analysis to compare the short-term and mid-term outcomes of HCR versus OPCAB for the treatment of multivessel or left main CAD.

METHODS

We searched the PubMed, EMBASE, Web of Science and Cochrane databases to identify related studies and a routine meta-analysis was conducted.

RESULTS

Nine studies with 6121 patients were included in the analysis. There was no significant difference in short-term major adverse cardiac and cerebrovascular event (MACCE) rate (RR: 0.55, 95% CI: 0.30-1.03, p = 0.06) or mortality (RR: 0.51, 95% CI: 0.17-1.48, p = 0.22). HCR required less ventilator time (SMD: -0.36, 95% CI: -0.55- -0.16, p < 0.001), ICU stay (SMD: -0.35, 95% CI: -0.58 - -0.13, p < 0.01), hospital stay (SMD: -0.29, 95% CI: -0.50- -0.07, p < 0.05) and blood transfusion rate (RR: 0.57, 95% CI: 0.49-0.67, p < 0.001), but needed more operation time (SMD: 1.29, 95% CI: 0.54-2.05, p < 0.001) and hospitalization costs (SMD: 1.06, 95% CI: 0.45-1.66, p < 0.001). The HCR group had lower mid-term MACCE rate (RR: 0.49, 95% CI: 0.26-0.92, p < 0.05) but higher rate in mid-term target vessel revascularization (TVR, RR: 2.20, 95% CI: 1.32-3.67, p < 0.01).

CONCLUSIONS

HCR had similar short-term mortality and morbidity comparing to OPCAB. HCR decreased the ventilator time, ICU stay, hospital stay, blood transfusion rate and increased operation time and hospitalization costs. HCR has a lower mid-term MACCE rate while OPCAB shows better in mid-term TVR.

CArbon dioxide surgical field flooding and aortic NO-touch off-pump coronary artery bypass grafting to reduce Neurological injuries after surgical coronary revascularisation (CANON): protocol for a randomised, controlled, investigator and patient blinded single-centre superiority trial with three parallel arms

INTRODUCTION

Neurological injuries remain a major concern following coronary artery bypass grafting (CABG) that offsets survival benefit of CABG over percutaneous coronary interventions. Among numerous efforts to combat this issue is the development of off-pump CABG (OPCABG) that obviates the need for extracorporeal circulation and is associated with improved neurological outcomes. The objective of this study is to examine whether the neuroprotective effect of OPCABG can be further pronounced by the use of two state-of-the-art operating techniques.

METHODS AND ANALYSIS

In this randomised, controlled, investigator and patient blinded single-centre superiority trial with three parallel arms, a total of 360 patients will be recruited. They will be allocated in a 1:1:1 ratio to two treatment arms and one control arm. Treatment arms undergoing either aortic no-touch OPCABG or OPCABG with partial clamp applying carbon dioxide surgical field flooding will be compared against control arm undergoing OPCABG with partial clamp. The primary endpoint will be the appearance of new lesions on control brain MRI 3 days after surgery. Secondary endpoints will include the prevalence of new focal neurological deficits in the first 7 days after surgery, the occurrence of postoperative cognitive dysfunction at either 1 week or 3 months after surgery and the incidence of delirium in the first 7 days after surgery. Data will be analysed on intention-to-treat principles and a per protocol basis.

ETHICS AND DISSEMINATION

Ethical approval has been granted for this study. Results will be disseminated through peer-reviewed media.

TRIAL REGISTRATION NUMBER

NCT03074604; Pre-results.

DATE AND VERSION IDENTIFIER

10-Mar-2017 Original.