Intermittent Cross-Clamp Fibrillation Versus Cardioplegic Arrest During Coronary Surgery in 6,680 Patients: A Contemporary Review of an Historical Technique

Abstract

Myocardial management during on-pump coronary artery bypass grafting (CABG) surgery includes aortic cross-clamping followed by fibrillation (XCF) and aortic cross-clamping followed by diastolic cardioplegia (cardioplegia). The authors wished to compare in-hospital and survival outcomes between these procedures. A retrospective observational study utilizing propensity matching. Tertiary Referral Centre for Heart Surgery. A total of 8,875 consecutive patients undergoing CABG surgery between August 1999 and February 2018. After 1:1 matching, the authors had 3,340 patients in the cardioplegia group and 3,340 in the XCF group. Baseline characteristics were not significant between the matched cardioplegia and XCF groups. The XCF group had shorter pump times (61.8 minutes +/-26.8 v 74.7 minutes +/-29.5, p < 0.0001) and shorter cross-clamp times (27.80 minutes +/-10.5 v 44.44 minutes +/-18.0, p < 0.0001) compared with the cardioplegia group despite a similar median number of distal anastomoses (3 v 3, p = 0.08). After surgery, atrial arrhythmias (32% v 36%, p = 0.01) and inotropic requirement (25% v 28%, p = 0.006) were less in the XCF group compared with the cardioplegia group, respectively. Other postoperative outcomes (such as mortality and cerebrovascular events) were not statistically different. There was a mean survival advantage in using cardioplegia compared with XCF (15.4 years versus 14.7 years, log-rank, p = 0.014; 10-year survival 64% v 61% and 18-year survival 38% v 34%). This is the largest analysis of XCF. XCF does not adversely affect in-hospital outcomes. Long-term results demonstrate cardioplegic arrest may convey a survival advantage that would preclude routine XCF in the modern era.