The ability to achieve completeness of revascularization in OPCAB patients with multivessel disease without compromising graft patency has been directly assessed in recent studies by experienced OPCAB surgeons. Several studies comparing OPCAB and CABG with CPB have shown that complete revascularization with similar number of grafts can be effectively performed with OPCAB.1,2,3,4,5,6 In a prospective, randomized study of 200 unselected patients, Puskas et al. reported similar indices of completeness of revascularization (number of grafts performed/number of grafts intended) with no significant difference in the number of grafts performed in each group (3.39 + 1.04 OPCAB versus 3.40 + 1.08 CABG with CPB).5 Subsequently, early angiographic graft patency results were also similar between OPCAB (93.6%) and conventional CABG (95.8%) at 1-year follow-up.7
1. Systematic off-pump coronary artery revascularization in multivessel disease: experience of three hundred cases Cartier R, Brann S, Dagenais F, Martineau R, Couturier A. Department of Cardiac Surgery, Montreal Heart Institute, Quebec, Canada. OBJECTIVE: We sought to report our recent experience with off-pump coronary artery revascularization in multivessel disease. METHODS: Between October 1996 and December 1998, 300 off-pump beating heart operations were performed at the Montreal Heart Institute by a single surgeon, representing 94% of all procedures undertaken during this same time frame (97% for 1998). This cohort of patients was compared with 1870 patients operated on with cardiopulmonary bypass from 1995 to 1996. RESULTS: Mean age, sex distribution, and preoperative risk factors were comparable for the two groups. On average, 2.92 + 0.8 and 2.84 + 0.6 grafts per patient were completed in the beating heart and cardiopulmonary bypass groups, respectively. A majority of patients (70%) had either a triple or quadruple bypass. Coronary anastomoses were achieved with myocardial mechanical stabilization and heart "verticalization." Ischemic time was shorter in the beating heart group (29.8 + 0.9 vs 45 + 0.4 minutes, P<.05). Similarly, the need for transfusion was significantly less in the beating heart group (beating heart operations, 34%; cardiopulmonary bypass, 66%; P<.005). Reduced use of postoperative intra-aortic counterpulsation, as well as a lower rise in creatine kinase MB isoenzyme, was observed in the beating heart group. Operative mortality rates (beating heart operations, 1.3%; cardiopulmonary bypass, 2%) and perioperative myocardial infarction (beating heart operations, 3.6%; cardiopulmonary bypass, 4.2%) were comparable for the two groups. CONCLUSION: In a majority of patients, off-pump complete coronary artery revascularization is an acceptable alternative to conventional operations, yielding good results given progressive experience, rigorous technique, and adequate coronary artery stabilization. Journal of Thoracic and Cardiovascular Surgery. 2000 Feb;119(2):221-9.
2. Clinical outcomes and resource usage in 100 consecutive patients after off-pump coronary bypass procedures Lee JH, Abdelhady K, Capdeville M. Departments of Surgery and Anesthesiology, University Hospitals Heart Institute, University Hospitals of Cleveland, Cleveland, Ohio. BACKGROUND: Cardiopulmonary bypass initiates a cascade of inflammatory processes that may result in end-organ damage, leading to the increased prevalence of noncardiac complications. Therefore, off-pump coronary artery bypass graft (OPCAB) procedures have recently been introduced into clinical practice. METHODS: This study was a case-controlled study that compared the outcomes and cost of 100 consecutive OPCAB procedures with a control group of 100 contemporary matched conventional coronary artery bypass grafting procedures. All operations were performed by a single surgeon (J.H.L.) and complete revascularization that used off-pump techniques was achieved with the use of innovative exposure techniques to the lateral and posterior wall vessels. RESULTS: An average of 3.1 grafts per patient were performed in the OPCAB group (range, 1-5). The incidence of conversion to conventional coronary artery bypass grafting was 1%. The overall mortality rate was 2.0%. There were no instances of stroke, renal failure, or sternal infections in the OPCAB group. Thus, the OPCAB group had a shorter length of stay (6.1 + 2.5 versus 7.1 + 3.3 d; P=.003), with a corresponding reduction in variable direct cost per case of 29% (P<.001). CONCLUSION: Our experience suggests that OPCAB procedures are feasible for most patients who currently require complete revascularization. It is associated with very a low morbidity rate and may represent the ideal revascularization strategy for patients at high risk for undergoing cardiopulmonary bypass. Surgery. 2000 Oct;128(4):548-55.
3. Multivessel off-pump coronary artery bypass surgery in the elderly Demers P, Cartier R. Department of Surgery, Montreal Heart Institute, Research Center, Montreal, Quebec, Canada. OBJECTIVE: Coronary artery bypass grafting in the elderly patient is associated with increased perioperative morbidity and mortality. The avoidance of cardiopulmonary bypass (CPB) in this population is potentially beneficial. We examined our initial experience with off-pump multivessel coronary artery revascularization in patients aged 70 years and older. METHODS: In a consecutive series of 300 off-pump coronary artery bypass (OPCAB) operations performed by a single surgeon between 1996 and 1999, 98 patients were aged 70 years and older. These patients were compared with a consecutive cohort of 497 patients aged 70 years and older operated on with CPB in the same institution from 1995 to 1996, period where OPCAB surgery was not performed in our institution. RESULTS: Patients in the beating heart group were older (75 + 4 vs. 74 + 3 years; P=0.001). Gender distribution and other preoperative risk factors were comparable for the two groups. On average, 3.0 + 0.8 and 2.8 + 0.7 grafts per patient were completed in the OPCAB and the CPB groups, respectively (P=0.007). Perioperative mortality rates (OPCAB group, 3.1%; CPB group, 3.6%), perioperative myocardial infarction (OPCAB, 2.0%; CPB, 5.1%) and neurologic events (OPCAB, 1.0%; CPB, 3.2%) were comparable for the two groups. The incidence of postoperative atrial fibrillation was lower in the OPCAB group (42 vs. 54%; P=0.05). The need for allogenic blood transfusions was significantly less in the OPCAB group (53 vs. 82%; P=0.001). CONCLUSIONS: In patients aged 70 years and older, multivessel OPCAB surgery is associated with lower rates of postoperative atrial fibrillation and reduced transfusion requirements. Multivessel OPCAB in the elderly patient is an acceptable alternative to procedures performed with CPB. European Journal of Cardio-Thoracic Surgery. 2001 Nov;20(5):908-12.
4. Off-pump multivessel coronary artery surgery in high-risk patients Meharwal ZS, Mishra YK, Kohli V, Bapna R, Singh S, Trehan N. Department of Cardiovascular Surgery, Escorts Heart Institute and Research Centre, New Delhi, India. BACKGROUND: Coronary artery bypass surgery on cardiopulmonary bypass is associated with significant morbidity and mortality, which may be more marked in high-risk patients. We evaluated our results of off-pump coronary artery bypass (OPCAB) in high-risk patients with multivessel coronary artery disease and compared them with results in similar patients who underwent operation on cardiopulmonary bypass. METHODS: A total of 1,075 patients who underwent OPCAB between October 1996 and June 2001 and who had one or more of the following risk factors were included in the study: poor left ventricular function (EF < 30%), advanced age (> 70 years), left main stenosis, acute myocardial infarction, and redo coronary artery surgery. These patients were compared with 2,312 similar patients who underwent coronary artery bypass grafting on cardiopulmonary bypass during the same period. Preoperative risk factors, intraoperative variables, and postoperative results were analyzed and compared between two groups. RESULTS: The average number of grafts was 3.0 + 0.4 and 3.2 + 0.3 in the off-pump (OPCAB) and on-pump (CCAB) groups, respectively. Hospital mortality was 3.2% and 4.5% in OPCAB and CCAB groups respectively (p = 0.109). Perioperative myocardial infarction, requirement of inotropic agents, stroke, and renal dysfunction were comparable in two groups. Intubation time (19 + 5 vs 24 + 6 hours, p < 0.001), mean blood loss (362 + 53 vs 580 + 66 mL, p < 0.001), atrial fibrillation (14.3 vs 19.7%, p < 0.001), and prolonged ventilation (4.6 vs 7.6%, p = 0.002) were less in OPCAB group. Intensive care unit stay (20 + 8 hours) and hospital stay (6 + 3 days) were significantly less in the OPCAB group (p < 0.001). CONCLUSIONS: Off-pump coronary artery surgery can be safely performed in high-risk patients with multivessel coronary artery disease. Operative mortality is comparable to that associated with on-pump surgery, and avoidance of cardiopulmonary bypass is associated with reduced postoperative morbidity in these patients. Annals of Thoracic Surgery. 2002 Oct;74(4):S1353-7.
5. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting Puskas JD, Williams WH, Duke PG, Staples JR, Glas KE, Marshall JJ, Leimbach M, Huber P, Garas S, Sammons BH, McCall SA, Petersen RJ, Bailey DE, Chu H, Mahoney EM, Weintraub WS, Guyton RA. Division of Cardiothoracic Surgery, Emory University School of Medicine, and the Emory Center for Outcomes Research, Crawford Long Hospital, Atlanta, GA. OBJECTIVE: Retrospective comparisons of selected patients undergoing off-pump versus conventional on-pump coronary artery bypass grafting have yielded inconsistent results and raised concerns about completeness of revascularization in off-pump coronary artery bypass grafting. METHODS: Two hundred unselected patients referred for elective primary coronary artery bypass grafting were randomly assigned to undergo off-pump coronary artery bypass grafting with an Octopus tissue stabilizer (Medtronic, Inc, Minneapolis, Minn) or conventional coronary artery bypass grafting with cardiopulmonary bypass by a single surgeon. Revascularization intent determined before random assignment was compared with the revascularization performed. All management followed strict, unbiased, criteria-driven protocols. Patients and nonoperative care providers were blinded to surgical group. RESULTS: Baseline characteristics were similar. The number of grafts performed per patient (mean + SD 3.39 + 1.04 for off-pump coronary artery bypass grafting, 3.40 + 1.08 for conventional coronary artery bypass grafting) and the index of completeness of revascularization (number of grafts performed/number of grafts intended, 1.00 + 0.18 for off-pump coronary artery bypass grafting, 1.01 + 0.09 for conventional coronary artery bypass grafting) were similar. Likewise, the index of completeness of revascularization was similar between groups for the lateral wall. Combined hospital and 30-day mortalities and stroke rates were similar. Postoperative myocardial serum enzyme measures were significantly lower after off-pump coronary artery bypass grafting, suggesting less myocardial injury. Adjusted postoperative thromboelastogram indices, fibrinogen, international normalized ratio, and platelet levels all showed significantly less coagulopathy after off-pump coronary artery bypass grafting. Patients undergoing off-pump coronary artery bypass grafting received fewer units of blood, were more likely to avoid transfusion altogether, and had a higher hematocrit at discharge. Cardiopulmonary bypass was an independent predictor of transfusion (odds ratio 2.42, P =.0073) by multivariate analysis. More patients undergoing off-pump coronary artery bypass grafting were extubated in the operating room and within 4 hours. Postoperative length of stay (in days) was shorter for off-pump coronary artery bypass grafting (5.1 + 6.5 for off-pump coronary artery bypass grafting, 6.1 + 8.2 for conventional coronary artery bypass grafting, P =.005 by Wilcoxon test). One patient (in the conventional coronary artery bypass grafting group) required angioplasty for graft closure within 30 days. CONCLUSIONS: When compared with conventional coronary artery bypass grafting with cardiopulmonary bypass, off-pump coronary artery bypass grafting achieved similar completeness of revascularization, similar in-hospital and 30-day outcomes, shorter length of stay, reduced transfusion requirement, and less myocardial injury. Journal of Thoracic and Cardiovascular Surgery. 2003 Apr;125(4):797-808.
6. Total arterial myocardial revascularization with composite grafts improves results of coronary surgery in elderly: a prospective randomized comparison with conventional coronary artery bypass surgery Muneretto C, Bisleri G, Negri A, Manfredi J, Metra M, Nodari S, Culot L, Dei Cas L. Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy. BACKGROUND: Total arterial myocardial revascularization with composite grafts proved to enhance the long-term benefits of coronary surgery. We assessed the hypothesis that full arterial revascularization (FAR) may improve clinical outcome even in elderly and at short term. METHODS AND RESULTS: A prospective randomized study was designed to compare FAR with conventional coronary artery bypass grafting (CABG) surgery [left interval thoracic artery (LITA) on left anterior descending (LAD) plus additional saphenous vein grafts] with the following end points: early and late death, graft occlusion, reintervention, angina recurrence, and acute myocardial infarction (AMI). We enrolled 200 consecutive patients > 70 years of age; population was equally divided at random in Group 1 (G1, FAR) and Group 2 (G2, Conventional). The groups resulted comparable with respect to all preoperative continuous and discrete variables and risk factors (Euroscore: G1=8.4 versus G2=8.1). No differences between G1 versus G2 were observed in terms of postoperative complications (perioperative AMI:2% versus 3%), mean intensive care unit (ICU) (hours: 39 + 11 versus 40 + 9) and hospital stay (days: 6 + 2 versus 7 + 3) nor were there any differences in hospital mortality(G1=5% versus G2=4%). At the mean follow-up of 14 + 5 months the incidence of angina recurrence was 3% in G1 versus 12% in G2. Angiographic controls of grafts showed a superior graft patency rate of all the arterial grafts when compared with saphenous vein grafts. Conventional CABG surgery was identified as incremental risk factor for angina recurrence and as predictor for graft occlusion. CONCLUSIONS: Total arterial myocardial revascularization improved clinical outcome of patients undergoing coronary surgery in the elderly, whereas saphenous vein grafts negatively affected patient prognosis in terms of graft patency and freedom from late cardiac events. Circulation. 2003 Sep 9;108 Suppl 1:II29-33.
7. Off-pump vs conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial Puskas JD, Williams WH, Mahoney EM, Huber PR, Block PC, Duke PG, Staples JR, Glas KE, Marshall JJ, Leimbach ME, McCall SA, Petersen RJ, Bailey DE, Weintraub WS, Guyton RA. Division of Cardiothoracic Surgery,Emory University School of Medicine and Emory Center for Outcomes Research, Atlanta, GA, USA. CONTEXT: Previous trials of off-pump coronary artery bypass (OPCAB) have enrolled selected patients and have not rigorously evaluated long-term graft patency. A preliminary report showed OPCAB achieved improved inhospital outcomes, similar completeness of revascularization, and shorter lengths of stay compared with conventional coronary artery bypass grafting (CABG). OBJECTIVE: To assess graft patency, clinical and quality-of-life outcomes, and cost among patients while in the hospital and at 1-year follow-up. DESIGN, SETTING, AND PATIENTS: Randomized controlled trial of patients unselected for coronary anatomy, ventricular function, or comorbidities between March 10, 2000, and August 20, 2001, at a US academic center. A total of 200 patients were enrolled; 3 patients were withdrawn after randomization for mitral valve repair or replacement. Follow-up was complete for 197 patients at 30 days; 185 at 1 year. INTERVENTIONS: One surgical session consisting of elective OPCAB or CABG with cardiopulmonary bypass.The surgeon had extensive experience performing off-pump surgery; patients were subsequently managed by blinded protocols. MAIN OUTCOME MEASURES: Coronary angiography documented graft patency prior to hospital discharge and at 1 year; health-related quality of life; and cost of the index and subsequent hospitalization(s). RESULTS: Graft patency was similar for OPCAB and conventional CABG with cardiopulmonary bypass at 30 days (absolute difference, 1.3%; 95% confidence interval [CI], -0.66% to 3.31%; P =.19) and at 1 year (absolute difference, -2.2%; 95% CI, -6.1% to 1.7%; P =.27). Rates of death, stroke, myocardial infarction, angina, and reintervention were similar at 30 days and 1 year. There were no significant differences in health-related quality of life. Mean total hospitalization cost per patient at hospital discharge was 2272 dollars (95% CI, 755 dollars-3732 dollars) less for OPCAB (P =.002) and 1955 dollars (95% CI, -766 dollars to 4727 dollars) less at 1 year (P =.08). CONCLUSIONS: In this randomized single-surgeon trial among unselected patients with angiographic follow-up, OPCAB achieved similar graft patency in the hospital and at 1 year. Cardiac outcomes and health-related quality of life at 30 days and 1 year were similar and patients incurred a lower cost. OPCAB may provide complete revascularization that is durable and cost-effective. Journal of the American Medical Association (JAMA). 2004 Apr 21;291(15):1841-9. |
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