Minimal extracorporeal circulation reduces the incidence of postoperative major adverse events after elective coronary artery bypass grafting in high-risk patients. A single-institutional prospective randomized study. (original) (raw)
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ASAIO Journal, 2010
Recognition of the adverse effects of conventional extracorporeal circulation (CECC) led to the development of alternative technologies and techniques to minimize their impact while maintaining circulation during coronary artery bypass grafting (CABG). Off-pump coronary artery bypass (OPCAB) grafting has become established as one such alternative and more recently minimalized extracorporeal circulation (MECC) circuits have been developed with the aim of providing circulatory support while minimizing the interface between blood and the foreign surfaces of the circuit that initiates the associated adverse effects of CECC. Recently, some authors have suggested that MECC may be an alternative to OPCAB in patients undergoing CABG; the aim of this article is to systematically analyze and compare the impact of CABG with MECC with that of OPCAB, studying the adverse outcomes related to CECC. We performed a systematic search to identify all studies directly comparing OPCAB and MECC. Endpoints were subcategorized into four key areas of interest: length of stay (LOS), hemorrhage, cerebrovascular injury, and 30-day mortality. Random effect modeling techniques were applied to identify differences in outcomes between the two groups. Six studies fulfilled the inclusion criteria, incorporating 2,072 patients of whom 930 underwent OPCAB and 1,142 underwent revascularization supported by MECC. We found no statistically significant difference in hospital or intensive care unit (ICU) LOS, blood loss, mean number of patients transfused, neurocognitive disturbance, or 30-day mortality between the two groups but a trend toward an increased number of cerebrovascular events in the MECC group was observed. The number of studies comparing these alternative techniques for coronary revascularization is small, and there is a lack of highquality data. Currently, there seems little difference between MECC and OPCAB but larger randomized controlled trials focusing on high-risk patients are required. ASAIO Journal 2010; 56:446 -456.
International Journal of Cardiology, 2013
Background: This study aims to develop a methodological framework for the comparative economic evaluation between Minimal Extracorporeal Circulation (MECC) versus conventional Extracorporeal Circulation (CECC) in patients undergoing coronary artery bypass grafting (CABG) in different healthcare systems. Moreover, we evaluate the cost-effectiveness ratio of alternative comparators in the healthcare setting of Greece, Germany, the Netherlands and Switzerland. Methods: The effectiveness data utilized were derived from a recent meta-analysis which incorporated 24 randomized clinical trials. Total therapy cost per patient reflects all resources expensed in delivery of therapy and the management of any adverse events, including drugs, diagnostics tests, materials, devices, blood units, the utilization of operating theaters, intensive care units, and wards. Perioperative mortality was used as the primary health outcome to estimate life years gained in treatment arms. Bias-corrected uncertainty intervals were calculated using the percentile method of non-parametric Monte-Carlo simulation. Results: The MECC circuit was more expensive than CECC, with a difference ranging from €180 to €600 depending on the country. However, in terms of total therapy cost per patient the comparison favored MECC in all countries. Specifically it was associated with a reduction of €635 in Greece, €297 in Germany, €1590 in the Netherlands and €375 in Switzerland. In terms of effectiveness, the total life-years gained were slightly higher in favor of MECC. Conclusions: Surgery with MECC may be dominant (lower cost and higher effectiveness) compared to CECC in coronary revascularization procedures and therefore it represents an attractive new option relative to conventional extracorporeal circulation for CABG.
Coronary artery bypass graft with minimal extracorporeal circulation
The heart surgery forum, 2003
BACKGROUND To evaluate the advantages and benefits of a minimized extracorporeal circulation system in the performance of coronary artery bypass grafts. METHODS From September 2000 to February 2003, 279 consecutive patients underwent isolated coronary artery bypass grafting with minimal extracorporeal circulation. A group of 243 patients at good risk as defined by a Euro- SCORE of 3 underwent complete bypass and blood cardioplegia, and a high-risk group of 45 patients (EuroSCORE, 6) underwent operations with partial assistance and a beating heart. In a prospective substudy analysis of thrombocyte and platelet counts, transfusion requirements, PaO2/FIO2, leukocyte count, C-reactive protein level, postoperative bleeding, intensive care unit stay, and ventilation, 40 patients from the good-risk group were matched and compared with 40 patients who underwent operations with a conventional extracorporeal system. RESULTS Revascularization was complete with a mean of 2.8 distal anastomoses ...
During the last decade, minimized extracorporeal circulation (MECC) systems have shown beneficial effects to the patients over the conventional cardiopulmonary bypass (CECC) circuits. This is a prospective randomized study of 99 patients who underwent coronary artery bypass grafting (CABG) surgery, evaluating the postoperative haematological effects of these systems. Less haemodilution (p=0.001) and markedly less haemolysis (p<0.001), as well as better preservation of the coagulation system integrity (p=0.01), favouring the MECC group, was found. As a clinical result, less bank blood requirements were noted and a quicker recovery, as far as mechanical ventilation support and ICU stay are concerned, was evident with the use of MECC systems. As a conclusion, minimized extracorporeal circulation systems may attenuate the adverse effects of conventional circuits on the haematological profile of patients undergoing CABG surgery.
Perfusion
Introduction: Despite low mortality, cardiac surgery patients may experience serious life-threatening post-operative complications, often due to extracorporeal circulation and reperfusion. Miniaturised cardiopulmonary bypass (minimally invasive extracorporeal circulation) has been developed aiming to reduce the risk of post-operative complications arising with conventional extracorporeal circulation. Methods: The COMICS trial is a multi-centre, international, two-group parallel randomised controlled trial testing whether type II, III or IV minimally invasive extracorporeal circulation is effective and cost-effective compared to conventional extracorporeal circulation in patients undergoing elective or urgent coronary artery bypass grafting, aortic valve replacement or coronary artery bypass grafting + aortic valve replacement. Randomisation (1:1 ratio) is concealed and stratified by centre and surgical procedure. The primary outcome is a composite of 12 serious complications, object...
European Journal of Cardio-Thoracic Surgery, 2015
OBJECTIVES: Coronary artery bypass grafting (CABG) remains the standard of care in patients with extensive coronary artery disease. Yet the use of cardiopulmonary bypass (CPB) is believed to be a major determinant of perioperative morbidity. Novel techniques are sought to tackle the shortcomings of CPB, among them off-pump coronary artery bypass (OPCAB) and miniaturized extracorporeal circulation (MECC) systems have been extensively tested in randomized controlled trials (RCTs). To assess perioperative safety and efficacy of MECC and OPCAB when compared with conventional extracorporeal circulation (CECC). METHODS: Published literature and major congress proceedings were screened for RCTs evaluating the safety and efficacy of MECC, OPCAB and CECC. Selected end-points such as 30-day all-cause mortality, myocardial infarction (MI), cerebral stroke, postoperative atrial fibrillation (POAF) and renal dysfunction were assessed in a Bayesian-framework network meta-analysis. RESULTS: A total of 134 studies with 22 778 patients were included. When compared with CECC, both OPCAB and MECC significantly reduced 30-day all-cause mortality [odds ratios (95% credible intervals): 0.75 (0.51-0.99) and 0.46 (0.22-0.91)], respectively. No differences in respect to MI were demonstrated with either strategy. OPCAB, when compared with CECC, reduced the odds of cerebral stroke [0.57 (0.34-0.80)]; 60% reduction was observed with MECC when compared with CECC [0.40 (0.19-0.78)]. Both OPCAB and MECC reduced the odds of POAF [0.66 (0.48-0.90) and 0.62 (0.35-0.98), respectively] when compared with CECC. OPCAB conferred over 30% reduction of renal dysfunction when compared with CECC [0.69 (0.46-0.92)]. MECC reduced these odds by more than 50% [0.47 (0.24-0.89)]. Ranking of treatments emerging from the probability analysis (highest to lowest SUCRA values) was MECC followed by OPCAB and CECC. CONCLUSIONS: MECC and OPCAB both improve perioperative outcomes following coronary bypass surgery when compared with conventional CABG performed with extracorporeal circulation. MECC may represent an attractive compromise between OPCAB and CECC.
Interactive Cardiovascular and Thoracic Surgery, 2010
Isolated aortic valve replacement (AVR) or coronary artery bypass grafting (CABG) using minimized extracorporeal circulation (MECC) has been shown to have less deleterious effects than standard cardiopulmonary bypass (CPB). In this prospective cohort study, we evaluated and compared clinical results of combined AVR with CABG using MECC. We prospectively collected preoperative, intraoperative, postoperative and follow-up data of 65 patients who underwent combined AVR with CABG using MECC and compared these with 135 patients undergoing combined AVR with CABG using standard CPB. No significant differences were seen in patients demographic characteristics or intraoperative data. Patients in the MECC group experienced a smaller preoperative haemoglobin drop (4.5"0.8 gydl vs. 5.0"0.5 gydl, Ps0.002) resulting in higher haemoglobin at discharge (11.3"1.3 gydl vs. 10.8"1.1 gydl, Ps0.03). They had decreased blood products requirements (Ps0.004) compared to patients in the standard CPB group. No differences were noted in pulmonary complications, neurological events or mortality. We present for the first time data showing that combined AVR with CABG using MECC is feasible and provides better clinical results compared to standard CPB with regard to blood products requirements, without compromising operative morbidity or mortality.
Aim: Intraoperative allogeneic blood product transfusion (ABPT) in cardiac surgery is associated with worse overall outcome, including mortality. The objective of this study was to evaluate the ABPTs in minimalized extracorporeal cardiopulmonary (MECC TM) compared with standard open system on-pump coronary revascularization. Methods: Data of 156 patients undergoing myocardial revascularization between September 2008 and September 2010 were reviewed. 83 patients were operated by the MECC technique and 73 were treated by standard extracorporeal circulation (sECC). ABPT and overall early postoperative complications were analyzed. Results: Operative mortality and morbidity were similar in both groups. ABPT in the MECC group was significantly lower than in the sECC group both intraoperatively (7.2 vs. 60.3% of patients p<0.001) and during the first five postoperative days (19.3 vs. 57.5%; p<0.001). " Skin to skin "-(214 ± 45 vs. 232 ± 45 min; p=0.012), cardiopulmonary byp...