Off pump coronary artery bypass: a passing fad or ready for prime time? (original) (raw)
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Off‐Pump Coronary Artery Bypass Grafting: 30 Years of Debate
Journal of the American Heart Association
O ff-pump coronary artery bypass surgery (OPCAB) has been performed for >30 years. The promotion of OPCAB was based on its potential benefits over some of the limitations of traditional on-pump coronary artery bypass surgery (ONCAB) by avoiding the trauma of cardiopulmonary bypass (CPB) and by minimizing aortic manipulation. As such, reductions in early mortality and perioperative neurological events, renal failure, blood product transfusions, and hospital length of stay were expected according to the OPCAB proponents. In contrast, critics of OPCAB remain concerned about incomplete and/or poorer quality coronary revascularization with a potential increase in the need for repeat revascularization and late mortality. Despite 3 decades of debate, 115 randomized trials, and >60 meta-analyses comparing on-and off-pump coronary artery bypass grafting (CABG), controversy on both the role of and indications for OPCAB remains vigorous. In this review, we provide a comprehensive update of the evidence for the differences in the biological effects of offand on-pump surgery and the comparison of the clinical and angiographic results of the 2 techniques. Furthermore, we critically address the relevant technical aspects of OPCAB, the importance of surgeon experience, and the difference in the costs for the 2 procedures. Search Strategy The Arterial Grafting International Consortium (ATLANTIC) Alliance is an international writing group on coronary surgery. In January 2018, a comprehensive search to identify studies that evaluated the biological, clinical, angiographic, and economic aspects of OPCAB was performed in the following databases from inception to present: Ovid Medline, Ovid Embase, and the Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials [CENTRAL], Cochrane Methodology Register). Search keywords included myocardial revascularization in combination with coronary artery bypass, on pump, off pump, and OPCAB. Relevant abstracts were reviewed, and the related articles function was used for all included studies. References for all selected studies were cross-checked. The writing group selected the most relevant papers according to both methodological and clinical considerations. Observational series were considered only in the absence of data from randomized controlled trials (RCTs). The Technical Evolution of Beating-Heart Coronary Artery Bypass Surgery The very first direct coronary revascularization procedures in the early 1960s were performed on the beating heart
Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery, 2015
Objective At this consensus conference, we developed evidence-informed consensus statements and recommendations on the practice of off-pump coronary artery bypass graft (OPCAB) by systematically reviewing and performing meta-analysis of the randomized controlled trials (RCTs) comparing OPCAB and conventional coronary artery bypass (CCAB). Methods All RCTs of OPCAB versus CCAB through April 2013 were screened, and 102 relevant RCTs (19,101 patients) were included in a systematic review and meta-analysis (15 RCTs of 9551 high-risk patients; and 87 RCTs of 9550 low-risk patients) in accordance with the Cochrane Collaboration and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Consensus statements for the risks and benefits of OPCAB surgery in mortality, morbidity, and resource use were developed based on best available evidence. Results Compared to CCAB, it is reasonable to perform OPCAB to reduce risks of stroke [class IIa, level of evidence (L...
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
Current Status of Off-Pump Coronary Artery Bypass Surgery
Asian Cardiovascular and Thoracic Annals, 2008
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.
Safety and efficacy of off-pump coronary artery bypass grafting
The Annals of Thoracic Surgery, 2000
Background. We evaluated the application of the offpump coronary artery bypass (OPCAB) procedure relative to safety and efficiency as measured by operative mortality postoperative complications and longitudinal outcome.
Off-Pump Coronary Artery Bypass Disproportionately Benefits High-Risk Patients. Discussion
The Annals of Thoracic Surgery, 2009
Background. It is not known which patient subgroups may benefit most from off-pump coronary artery bypass grafting (OPCAB) rather than coronary artery bypass grafting on cardiopulmonary bypass (CPB). Methods. The Society of Thoracic Surgeons database was queried for all isolated, primary coronary artery bypass graft cases between January 1, 1997, and December 31, 2007, at a US academic center. The Society of Thoracic Surgeons Predicted Risk of Mortality (PROM) was calculated by a formula based on 30 preoperative risk factors. It was used in three ways to compare 30-day operative mortality between patients treated with OP-CAB versus CPB. First, patients were divided into quartiles based on their PROM, and mortality rates were compared between OPCAB and CPB patients within each PROM quartile. Second, a logistic regression model tested for an interaction between surgery type and PROM; a significant interaction would indicate that the relative mortality risk of OPCAB versus CPB varied with different PROM levels. Finally, locally smoothed kernel regression curves were used to visually estimate a threshold PROM point at which mortality rates diverge for the surgery types. Results. There were 14,766 consecutive patients, 7,083 OPCAB (48.0%) and 7,683 CPB (52.0%). There was no difference in operative mortality between OPCAB and CPB for patients in the lower two risk quartiles. In the higher risk quartiles there was a mortality benefit for OPCAB (odds ratio, 0.62 and 0.45 for OPCAB in the third and fourth risk quartiles). Logistic regression analysis confirmed a significant interaction between surgery type and PROM (p ؍ 0.005) meaning that OPCAB is especially beneficial to patients with higher PROM. This benefit is most significant for patients with PROM values above 2.5% to 3%, where mortality curves sharply diverge. Conclusions. Off-pump coronary artery bypass grafting is associated with lower operative mortality than coronary artery bypass grafting on CPB for higher risk patients. This mortality benefit increases with increasing PROM.