On- or Off-pump Coronary Artery Bypass Surgery. Is the Debate Settling Down?

The Anaortic Technique with Bilateral Internal Thoracic Artery Grafting - Filling the Gap in Coronary Artery Bypass Surgery

Coronary artery bypass grafting (CABG) has consolidated its role as the most effective procedure for treating patients with advanced atherosclerotic coronary artery disease, reducing the long-term risk of myocardial infarction and death compared to other therapies and relieving angina. Despite the recognized benefits afforded by surgical myocardial revascularization, a subset of higher-risk patients bears a more elevated risk of perioperative stroke. Stroke remains the drawback of conventional CABG and has been strongly linked to aortic manipulation (cannulation, cross-clamping, and side-biting clamping for the performance of proximal aortic anastomoses) and the use of cardiopulmonary bypass. Adoption of off-pump CABG (OPCAB) is demonstrated to lower the risk of perioperative stroke, as well as reducing the risk of short-term mortality, renal failure, atrial fibrillation, bleeding, and length of intensive care unit stay. However, increased risk persists owing to the need for the tangential ascending aorta clamping to construct the proximal anastomosis. The concept of anaortic (aorta no-touch) OPCAB (anOPCAB) stems from eliminating ascending aorta manipulation, virtually abolishing the risk of embolism caused by aortic wall debris into the brain circulation. The adoption of anOPCAB has been shown to further decrease the risk of postoperative stroke, especially in higher-risk patients, entailing a step forward and a refinement of outcomes provided by the primeval OPCAB technique. Therefore, anOPCAB has been the recommended technique in patients with cerebrovascular disease and/or calcification or atheromatous plaque in the ascending aorta and should be preferred in patients with high-risk factors for neurological damage and stroke.

On-Pump Beating Heart versus Off-Pump Coronary Artery Bypass Graft Surgery: Short-Term Follow-up Outcomes of a Single Center

Background and Aim: Novel surgical approaches are gaining attention in an attempt to overcome possible adverse events following coronary artery bypass graft (CABG) surgery. This single-center study aimed to evaluate and compare the early postoperative outcomes of on-pump beating-heart (OPBH-CABG) versus off-pump CABG surgery in similar risk groups with a total number of 1–2 grafts.

Methods: The records of a total of 229 patients who underwent non-emergency, primary, isolated, either OPBH-CABG (n = 32) or off-pump CABG (n = 197) surgery were retrospectively evaluated. Reported outcome measures included baseline data, the number of coronary artery grafts, prophylactic intra-aortic balloon pump, time of extubation from mechanical ventilation, duration of stay in the coronary ICU and hospital, as well as early postoperative complications, in-hospital and early postoperative mortality.

Results: The groups were identical with regards to age and BMI. The patients in the off-pump group received a higher number of grafts (1.84 ± 0.36 vs. 1.18 ± 0.39, p <0.0001). The OPBH-CABG group had a higher Euroscore II score (2.514 ± 1.68 vs. 1.706 ± 1.93, p = 0.021). The time to extubation after the surgery, postoperative length of ICU stay, and total length of hospital stay were similar between the groups (p = 0.2228; p = 0.098; p = 0.717, respectively). The incidence of arrythmia and atrial fibrillation was higher in the on-pump group (12.5% vs. 2.53%, p <0.05). One patient in the on-pump, and four patients in the off-pump groups deceased due to postoperative complications.

Conclusions: OPBH-CABG surgery is comparable to off-pump CABG in terms of early postoperative outcomes. In patients who underwent OPBH-CABG, the risk of arrythmia and atrial fibrillation should be of concern and solved with optimal strategies.