A prospective evaluation of hemodynamic instability during off-pump coronary artery bypass surgery (original) (raw)
Related papers
Risk Factors for Conversion to Cardiopulmonary Bypass During Off-Pump Coronary Artery Bypass Surgery
The Annals of Thoracic Surgery, 2012
Background. Off-pump coronary artery bypass graft (OPCAB) may be associated with improved hospital outcomes compared with on-pump coronary artery bypass graft. However, intraoperative conversion to onpump coronary artery bypass graft has been associated with adverse outcomes. The purpose of this study was to identify preoperative risk factors for intraoperative conversion in nonemergent patients undergoing isolated OPCAB.
Morbidity and mortality following acute conversion from off-pump to on-pump coronary surgery
European Journal of Cardio-Thoracic Surgery, 2006
Objective: Many studies have described reduced morbidity in hospital and equivalent midterm outcomes with off-pump coronary artery bypass (OPCAB) surgery compared to conventional CABG (CABG-CPB). However, OPCAB is sometimes converted acutely to CABG-CPB. We describe the risk of acute conversion and compare patients' outcomes for acutely converted OPCAB with unconverted OPCAB and CABG-CPB. Methods: Consecutive acute conversions, i.e. OPCAB patients in whom CPB was instituted urgently for hemodynamic or electrical instability, cardiac arrest or uncontrolled bleeding, were compared with propensity-matched unconverted OPCAB and CABG-CPB patients. Relative risks of death and complications in hospital, and subsequent survival were estimated. Results: The risk of acute conversion between 1996 and 2004 was 1.1% (27/2492): 5.1% in the first 2 years, 2.2% in the third year and 0.8% subsequently. Odds ratios for death in hospital compared to unconverted OPCAB and CABG-CPB were 4.4 (95% confidence interval (CI) 0.67-29.1) and 4.7 (95% CI 1.03-21.1), respectively, and ranged from 0 to 4.5 for serious complications. Converted patients had an increased hazard of death for 3 years after surgery compared to unconverted OPCAB (hazard ratio 3.21, 95% CI 1.20-8.59) and CABG-CPB patients (hazard ratio 3.23, 95% CI 1.41-7.39). Conclusions: Experienced OPCAB surgeons have a low risk of acute conversion. Acutely converted patients have a moderately increased risk of death and serious complications in hospital. These risks are difficult to quantify precisely because conversion is rare.
Conversion in off pump coronary artery bypass grafting: a retrospective analysis
Indian Journal of Thoracic and Cardiovascular Surgery, 2015
Background Intraoperative conversion of off-pump coronary artery bypass grafting (OPCAB) to on-pump coronary artery bypass grafting (ONCAB) has been associated with adverse outcomes. Inspite of several preoperative risk factors reported in the literature, conversion still remains an unpredictable event. This study aims to determine the incidence and predictors of conversion and attempts to evaluate strategies to prevent the same. Methods Between June 2011 to May 2012, out of 994 patients who were planned for elective OPCAB by 8 different surgical teams at our institution, 127 patients underwent intraoperative conversion to ONCAB. We conducted a retrospective analysis of these patients under two groups-ONCAB (n=127) and OPCAB (n=867). Patients undergoing elective ONCAB and emergency OPCAB were excluded from the study. Results The incidence of intraoperative conversion was 12.77 %. Those who underwent conversion had a significantly higher rate of postoperative complications including hospital mortality (9.44 versus 2.42 %). Left ventricular dysfunction, history of myocardial infarction, and left main disease emerged as independent predictors of conversion. Conclusion Association of certain preoperative risk factors can predict the occurrence of intraoperative conversion. Planned and smooth conduct of OPCAB plays a key role to avoid higher mortality and morbidity associated with conversion. If at all unavoidable, a timely conversion can prevent hazards of emergency conversion.
European Journal of Cardio-thoracic Surgery, 2003
Objective: Although there has been some evidence supporting the theoretical and practical advantages of off-pump coronary artery bypass (OPCAB) over the conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB), it has not yet been determined which group of patients would benefit most from it. It has been advocated recently that high-risk patients could benefit most from avoidance of CPB. The aim of this retrospective study is to assess the efficacy of the OPCAB technique in multi-vessel myocardial revascularization in a large series of high-risk patients. Methods: The records of 1398 consecutive high-risk patients who underwent primary isolated CABG at Harefield Hospital between August 1996 and December 2001 were reviewed retrospectively. Patients were considered as high-risk and included in the study if they had a preoperative EuroSCORE of $5. Two hundred and eighty-six patients were operated on using the OPCAB technique while 1112 patients were operated on using the conventional CABG technique with CPB. The OPCAB patients were significantly older than the CPB patients (68.1^8.3 vs. 63.7^9.9 years, respectively, P , 0:001). The OPCAB group included significantly more patients with poor left ventricular (LV) function (ejection fraction (EF) #30%) (P , 0:001) and more patients with renal problems (P , 0:001). Results: There was no significant difference in the number of grafts between the groups. The CPB patients received 2.8^1.2 grafts per patient while OPCAB patients received 2.8^0.5 grafts per patient (P ¼ 1). Twenty-one (7.3%) OPCAB patients had one or more major complications, while 158 (14.2%) CPB patients (P ¼ 0:008) developed major complications. Thirty-eight (3.4%) CPB patients developed peri-operative myocardial infarction (MI) while only two (0.7%) OPCAB patients developed peri-operative MI (P ¼ 0:024). The intensive therapy unit (ITU) stay for OPCAB patients was 29.3^15.4 h while for CPB patients it was 63.6^167.1 h (P , 0:001). There were ten (3.5%) deaths in the OPCAB patients compared to 78 (7%) deaths in the CPB patients (P ¼ 0:041) within 30 days postoperatively. Conclusions: This retrospective study shows that using the OPCAB technique for multi-vessel myocardial revascularization in high-risk patients significantly reduces the incidence of peri-operative MI and other major complications, ITU stay and mortality. Even though the OPCAB group included a significantly higher proportion of older patients with poor LV function (EF #30%) and renal problems, the beneficial effect of OPCAB was evident. q
Interactive cardiovascular and thoracic surgery, 2012
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: In patients undergoing off-pump coronary artery bypass (OPCAB) surgery, does the off-pump to on-pump conversion rate have an impact on post-operative results? Altogether more than 420 papers were found using the reported search, of which 14 randomized controlled trials (RCTs) represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated and ordered according to the sample size. In the 14 RCTs reviewed, the off-pump to on-pump conversion rate incidence ranged from 0 to 13.3%. The most frequent causes of conversion were haemodynamic instability and intramyocardial-coronary target. A low conversion rate (<2%) was reported by five studies. Three of them did not show any difference in terms of mortality between the OPCAB ...
Annals of Cardiac Anaesthesia, 2017
Background: There has been a constant emphasis on developing management strategies to improve the outcome of high-risk cardiac patients undergoing surgical revascularization. The performance of coronary artery bypass surgery on an off-pump coronary artery bypass (OPCAB) avoids the risks associated with extra-corporeal circulation. The preliminary results of goal-directed therapy (GDT) for hemodynamic management of high-risk cardiac surgical patients are encouraging. The present study was conducted to study the outcome benefits with the combined use of GDT with OPCAB as compared to the conventional hemodynamic management. Material and Method: Patients with the European System for Cardiac Operative Risk Evaluation ≥3 scheduled for OPCAB were randomly divided into two groups; the control and GDT groups. The GDT group included the monitoring and optimization of advanced parameters, including cardiac index (CI), systemic vascular resistance index, oxygen delivery index, stroke volume variation; continuous central venous oxygen saturation (ScVO 2), global end-diastolic volume, and extravascular lung water (EVLW), using FloTrac ™ , PreSep ™ , and EV-1000 ® monitoring panels, in addition to the conventional hemodynamic management in the control group. The hemodynamic parameters were continuously monitored for 48 h in Intensive Care Unit (ICU) and corrected according to GDT protocol. A total of 163 patients consented for the study. Result: Seventy-five patients were assigned to the GDT group and 88 patients were in the control group. In view of 9 exclusions from the GDT group and 12 exclusions from control group, 66 patients in the GDT group and 76 patients in control group completed the study. Conclusion: The length of stay in hospital (LOS-H) (7.42 ± 1.48 vs. 5.61 ± 1.11 days, P < 0.001) and ICU stay (4.2 ± 0.82 vs. 2.53 ± 0.56 days, P < 0.001) were significantly lower in the GDT group as compared to control group. The duration of inotropes (3.24 ± 0.73 vs. 2.89 ± 0.68 h, P = 0.005) was also significantly lower in the GDT group. The two groups did not differ in duration of ventilated hours, mortality, and other complications. The parameters such as ScVO 2 , CI, and EVLW had a strong negative and positive correlation with the LOS-H with r values of − 0.331, −0.319, and 0.798, respectively. The study elucidates the role of a goal-directed hemodynamic optimization for improved outcome in high-risk cardiac patients undergoing OPCAB.
Conversion and Safety in Off-Pump Coronary Artery Bypass: A System Failure That Needs Re-Emphasis
The Annals of Thoracic Surgery, 2011
Institution of cardiopulmonary bypass after commencement of "off-pump" coronary artery bypass surgery is known as conversion. This may be an emergency or elective process. The phenomenon of conversion, although widely reported, remains under-emphasized. Emergency conversion may lead to poorer patient outcomes and therefore warrants serious consideration. The rate of conversion may influence the results of randomized controlled trials, and be considered a surrogate performance indicator of surgical competence in offpump coronary artery bypass. Several causes and predictors of conversion are reported in published literature. This article aims to examine the phenomenon of conversion in off-pump coronary artery bypass and proposes a framework for its prevention.
The Annals of Thoracic Surgery, 2008
Background. We have evaluated the immediate and intermediate outcome after off-pump (OPCAB) and conventional on-pump coronary artery bypass surgery (CCAB) in patients with unstable angina pectoris requiring nitrates infusion until arrival in the operating room. Methods. A consecutive series of 153 and 161 patients with unrelenting angina pectoris underwent CCAB and OPCAB, respectively. Conversion from OPCAB to beating heart surgery with perfusion occurred in 4 patients. Results. The OPCAB patients had a significantly higher operative risk than CCAB patients (logistic European System for Cardiac Operative Risk Evaluation [EuroSCORE]: 13.8 ؎ 12.8% vs 10.5 ؎ 10.0%, p ؍ 0.005). In the overall series, a lower 30-day postoperative mortality was observed among OPCAB patients (1.9% vs 3.9%, p ؍ 0.33), the difference increased along the logistic EuroSCORE tertiles (upper tertile: 3.2% vs 9.5%, p ؍ 0.14), but failed to reach statistical significance. Similar results have been observed among one-to-one propensity score matched pairs. The results of three surgeons who treated most of their patients (96.9%) with OPCAB were compared with those of three surgeons who used, in most of cases (97.1%), the CCAB technique. When adjusted for logistic EuroSCORE, patients operated on by CCAB surgeons had a significantly higher 30-day postoperative mortality (7.1% vs 2.1%, p ؍ 0.04; odds ratio [OR] 10.143; 95% confidence interval [CI] 1.084 to 94.945) as well as a higher risk of combined adverse events (47.1% vs. 35.1%, p ؍ 0.009; OR 2.586; 95% CI 1.274 to 5.250). Conclusions. This study provided further evidence on the safety and efficacy of OPCAB in the treatment of high-risk patients. A dedicated approach to OPCAB seems to provide particularly good results. Such findings further support a more confident approach with OPCAB in these patients.
European Journal of Cardio-Thoracic Surgery, 2005
Objective: Recent developments in cardiac stabilization devices, have made OPCAB feasible. However, there is conflicting evidence to date regarding the rate and adverse events associated with conversion from OPCAB to CABG with CPB. The objective of the present study was to review all conversions in the setting of a randomized controlled trial comparing CABG with or without CPB. Methods: Three hundred patients requiring CABG surgery at a single institution were prospectively randomized to have the procedure performed with CPB (nZ150) or OPCAB (nZ150). Patients that could not be performed OPCAB were defined as conversion group (cross over). Results:Twenty patients were converted from OPCAB to CABG with CPB because of hemodynamic instability (14/20), small target vessel (5/20), or inadequate visualization (1/20). Seventeen were converted during attempts at coronary anastomosis: LAD/diagonal (7/20), circumflex (8/20), or right coronary (2/20). The overall in hospital mortality rate for the trial was 1% but was significantly higher in converted patients (10 vs. 0%; PZ0.01). Converted patients required significantly more inotropes (PZ0.001) and blood transfusions (PZ0.05). An elevated BMI was the only pre-operative variable that appeared to be associated with conversion. Conclusions: In the setting of a randomized controlled trial the overall conversion rate associated with OPCAB reached 13% and was associated with an increased risk of mortality. q