Off-pump Coronary Artery Bypass Grafting Research Articles

Effect of elevated HbA1c on outcomes in on-pump versus off-pump coronary artery bypass grafting

BackgroundDiabetic patients are at an increased risk of cardiovascular morbidities. We aimed to examine if elevated pre-operative glycosylated hemoglobin (HbA1c) levels are associated with higher likelihood of experiencing adverse events in on-pump (ONCAB) versus off-pump (OPCAB) coronary artery bypass graft (CABG) procedures. We examined characteristics of patients undergoing CABG using our institutional STS Adult Cardiac Surgery Database (ACSD) from 2014 to 2020. Descriptive statistics and univariate analyses were used to compare postoperative outcomes between ONCAB and OPCAB based on preoperative HbA1c levels: (1) HbA1c ≤ 6.0%, (2) 6.0% < HbA1c ≤ 7.0%, (3) 7.0% < HbA1c ≤ 8.5%, (4) HbA1c > 8.5%. Multivariable models were built to assess risk factors associated with adverse events. Primary outcomes were operative mortality and stroke.ResultsFor ONCAB, statistically significant associations were found between increasing HbA1c and new post-operative dialysis (p=0.01), rates of readmission (p=0.003) and greater lengths of stay (p=0.002). For OPCAB, statistically significant associations were found between increasing HbA1c and rates of operative mortality (p=0.04), post-operative renal failure (p=0.0001), new post-operative dialysis (p=0.0001), sternal wound infection (p=0.01), and greater lengths of stay (p=0.03). No significant relationship was noted between HbA1c and stroke, reoperation due to bleeding, or post-operative transfusion.ConclusionsIncreasing HbA1c positively correlated with numerous adverse patient outcomes in both ONCAB and OPCAB, and differences were noted in which outcomes were most impacted between the two techniques. Pre-operative medical optimization from a diabetes standpoint is paramount to improve CABG outcomes in both on-pump or off-pump techniques.

Responsiveness to Infusion Load under Regional Anesthesia after Off-Pump Coronary Artery Bypass Graft Surgery

Objective. To evaluate the effect of erector spinae plane block (ESPB) and epidural anesthesia on responsiveness to infusion load after coronary bypass surgery on a beating heart.Materials and methods. A prospective randomized single-center study included 45 patients who were grouped into 3 equal arms based on anesthesia techniques: general anesthesia in combination with ESPB (GA+ESPB), general anesthesia and epidural anesthesia (GA+EA) and general anesthesia without regional techniques (GA). Patient’s response to volume loading was assessed using dynamic and orthostatic tests after transfer from the operating room and at the end of the first postoperative day. Passive leg raise (PLR) and standard bolus injection tests were done at the first stage; changes in hemodynamic parameters during verticalization were additionally evaluated at the second stage. Patients with 10% cardiac index (CI) increase after PLR test and 15% increase after bolus injection test were categorized as responders.Results. The concordance of obtained results in PLR and bolus injection tests for the GA+ESPB, GA+ EA and GA groups at the first stage was 0.53 (95% CI 0.12–0.94), 0.68 (95% CI 0.30–1.00) and 0.61 (CI 0.24–0.99), at the second stage — 0.70 (0.32–1.00), 0.84 (95% CI 0.55–1.00) and 0.82 (95% CI 0.47–1.00), respectively. There were no differences in distribution of responders between the groups. CI dynamics did not differ between the groups during verticalization, and there were no associations of CI changes during verticalization with the preceding PLR test results. The dynamics of troponin T and NT-proBNP did not differ between the groups.Conclusion. Methods of regional anesthesia (SPB or EA) do not significantly affect the responsiveness to infusion therapy in the postoperative period after coronary bypass surgery on a beating heart.

Early life threatening constrictive pericarditis following off-pump CABG

Abstract We present a unique case of aggressive symptomatic constrictive pericarditis within one month following off pump coronary artery bypass grafting surgery. The patient had a medical history of Hodgkin’s lymphoma treated with radiotherapy and chemotherapy 20 years ago. Investigations confirmed constrictive pericardium with patent grafts and good biventricular function. Pericardiectomy was successful with remarkable recovery of symptoms.

Perioperative Implementation of Low-Dose Pregabalin in an Enhanced Recovery After Cardiac Surgery Protocol: A Pre-Post Observational Study

Determine the effect of low-dose pregabalin in the perioperative enhanced recovery after cardiac surgery protocol. Pre-post observational study. Tertiary care hospital. Patients undergoing off-pump coronary artery bypass graft procedures. Pregabalin 75 mg BID for 48 hours postoperatively versus no pregabalin in a perioperative setting. Perioperative opioid use, pain scores, length of stay, time to extubation, and mortality were all measured. Descriptive data were presented as mean (SD), median (IQR), or N (%). Ordinal and continuous data used the t-test or Kruskal-Wallis test. Categorical data were compared between groups using the chi-square test or Fisher's exact test, as appropriate. Low-dose pregabalin administration (75 mg twice daily for 48 hours after surgery) was associated with a clinically significant reduction in opioid consumption on postoperative day 0 by 30.6%, with a median requirement of 318 (233, 397) morphine milligram equivalents (MME) in the pregabalin group compared with 458 (375, 526) MME in the control group (p < 0.001). There was no significant difference in pain scores between the groups with the exception at 0-to-12 hours, during which the pregabalin group had greater pain scores (median 3.32 [1.65, 4.36] v 2.0 [0, 3.25], p=0.013) (Table 3). Moreover, there was no significant difference in pain scores on postoperative day 1 (p=0.492), day 2 (p=0.442), day 3 (p=0.237), and day 4 (p=0.649). The difference in average Richmond Agitation Sedation Score scores was also not statistically significant between groups at 12 hours (p=0.954) and at 24 hours (p=0.301). The pregabalin group had no increased incidence of adverse events or any significant differences in intensive care unit length of stay, time to extubation, or mortality. In this evaluation of perioperative pregabalin administration for patients requiring cardiac surgery, pregabalin reduced postoperative opioid use, with significant reductions on postoperative day 0, and without any significant increase in adverse reactions. However, no differences in intensive care unit length of stay, time to extubation, or mortality were noted. The implementation of low-dose perioperative pregabalin within an Enhanced Recovery After Cardiac Surgery protocol may be effective at reducing postoperative opioid use in the immediate postoperative period, and may be safe with regard to adverse events. Ideal dosing strategies have not been determined; thus, further randomized control trials with an emphasis on limiting confounding factors need to be conducted.

Comparison of Early Postoperative Outcome Between Intermittent Intravenous Heparin versus Continuous Heparin Infusion after Initial Bolus Dose during Off-Pump Coronary Artery Bypass Surgery

Background: Heparin is an anticoagulant used invariably in all cardiac surgery. Heparin dosing and its reversal is determined by monitoring Activated Clotting Time (ACT). Surgery under cardiopulmonary bypass requires much more heparin than off-pump cardiac operations. Intermittent heparin dosing after initial bolus dose is widely practiced to maintain ACT level 200- 300 seconds in OPCAB. Fluctuation of ACT level from this range may causes adverse postoperative outcome. This study was aimed to compare early postoperative outcome between intermittent heparin dose and continuous heparin infusion after initial bolus dose during OPCAB. Methods: This comparative cross-sectional study was carried out in National Institute of Cardiovascular Diseases (NICVD) from January 2019 to December 2020. Total 110 patients were enrolled by purposive sampling and divided into 2 groups: group-A where 55 patients received intermittent heparin after initial bolus dose and group-B where 55 patients received continuous heparin infusion after initial bolus dose. Data were analyzed by statistical package for social science (SPSS) version 26.0 and p value &lt;0.05 was considered significant. Results: Baseline ACT level of group-A was 87.04±5.51 seconds and group-B was 87.31±5.74 seconds, which was not significant (p = 0.800). After bolus dose of Heparin, ACT level of group-A was 252.02 ± 25.131 seconds and group-B was 259.04 ± 12.645 seconds. Difference between the groups was not significant (p = 0.068). Mean maintenance ACT was 326.34±22.774 seconds in group-A and 258.67±12.285 seconds in group-B patient, which was significant (p&lt;0.001). Peroperatively 29% from group-A and 11% from group-B developed arrhythmia. Postoperative mean Troponin I level in group-A was 5.78± 1.15 and group-B was 5.32± 1.05 ng/dl, which is significant (p = 0.030). Postoperative blood loss was significantly higher in group-A than group-B (986.36± 398.31 vs 852.73±241.22, p=0.036). There was significantly better reduction of arrhythmia and ischemia in postoperative and on discharge ECG finding in group-B patients (p=0.002). On discharge echocardiography 31% from group-A and 13% from group-B had regional wall motion abnormality, which is significant (p=0.018). But there was no significant difference in LVEF% (52.65±5.99 vs 53.85±5.77, p = 0.287). There was only one mortality which was from group-A. The patient was suffering from critical left main disease and developed postoperative arrhythmia and low output syndrome. Conclusion: Early postoperative outcome of continuous heparin infusion is better than intermittent intravenous heparin after initial bolus dose during Off-pump coronary artery bypass surgery. So, during OPCAB use of continuous heparin infusion after bolus dose is eminent time worthy. Cardiovasc j 2023; 16(1): 17-23

Early Outcome of Off-Pump Versus Conventional Coronary Artery Bypass Grafting Surgery in Patients with Multivessel Coronary Artery Disease in a Specialized center in Bangladesh

Early Outcome of Off-Pump Versus Conventional Coronary Artery Bypass Grafting Surgery in Patients with Multivessel Coronary Artery Disease in a Specialized center in Bangladesh

Renal implications of off-pump coronary artery bypass grafting: A retrospective cohort study analyzing postoperative creatinine levels

Background/Aim: Coronary artery disease is a significant health concern worldwide. While coronary artery bypass grafting is a gold standard of treatment, acute kidney injury (AKI) is a possible postoperative complication of concern. Off-pump coronary artery bypass grafting (OPCABG) aims to curtail perioperative complications; however, its impact on postoperative AKI is debated. This retrospective study aims to inform patient care by identifying potential effects of OPCABG on AKI utilizing postoperative creatinine alterations. Methods: This retrospective study was conducted at Koç University Hospital in Istanbul, Turkey. We reviewed the records of patients who underwent OPCABG between June 2018 and June 2019. Patients with incomplete records or individuals who had undergone renal replacement therapy prior to surgery were excluded. The primary metric was serum creatinine levels, which were assessed preoperatively and up to 7 days postoperatively. Preoperative creatinine levels were compared with postoperative levels using the Wilcoxon signed-rank test. Acute kidney injury was defined using Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Results: Seventy-two patients satisfied the inclusionary criteria. A significant increase in creatinine was observed on postoperative Day 1 (P&lt;0.001); creatinine levels fell below baseline by postoperative Day 4 and 5. We note that the incidence of AKI was low; there were no instances of Stage 2 or higher AKI during the observation period. Conclusion: Our data suggest that OPCABG may result in a transient increase in creatinine post-surgery. Creatinine levels normalize over time, implicating the renal safety of OPCABG. Despite these promising findings, additional comprehensive studies are essential to validate these observations and assess long-term renal outcomes after OPCABG.

Analysis of Cardiovascular Risk Factors in Patients with Coronary Heart Disease Qualified for Off-Pump Coronary Bypass

The aim. To analyze the prevalence of cardiovascular risk factors for circulatory diseases in patients with coronary heart disease (CHD) after coronary bypass surgery (off-pump coronary artery bypass grafting).&#x0D; Material and methods. The study included 991 subjects (786 men, 205 women), mean age 64.3 ± 1.4 years. All the study participants underwent off-pump coronary bypass surgery.&#x0D; Results. Based on modern ideas about risk factors for circulatory diseases and CHD, it is impossible to ignore the influence of cardiovascular factors, both modifiable and non-modifiable. The analysis of medical and social risk factors for CHD, which include age, body weight, eating habits and smoking, showed that these medical and social factors are common among patients with CHD. It was found that the prevalence of excess body weight among men with CHD was significantly higher in patients with multivessel lesions than in those with 1-vessel lesions (p=0.05, χ2=3.69). Among women with CHD, excess body weight was significantly higher in the clinical group with multivessel lesions compared to 2-vessel lesions (p=0.002, χ2=9.06). It was also found that the prevalence of excess body weight was significantly higher in clinical groups with 1-vessel lesions among men compared to women (p=0.04, χ2=3.95). It was established that the frequency of obesity was significantly more common in women of different clinical groups compared to men: with 1-vascular lesions (p=0.04, χ2=3.95); with 2-vessel lesions (p=0.0001, χ2=24); with multivessel lesions (p=0.0001, χ2=186.57). It was established that men smoke significantly more often than women (p=0.0001, χ2=31.22). The obtained results complement the scientific data of the world epidemiological studies regarding the determination of the role of medical and social factors in the development of CHD. The article analyzes excess body weight, obesity and smoking as the leading etiological factors for CHD. It was established that the risk of developing CHD is reliably associated with excess body weight, obesity and smoking, among different clinical groups of male and female patients, both with single-vessel lesions and with multivessel lesions in CHD.&#x0D; Conclusions. Analysis of cardiovascular risk factors for the development of CHD, which include age, body weight, eating habits, and smoking, showed that their further study is relevant, as these are common among patients with CHD. It was established that frequency of excess body weight in patients with CHD, both in men and women, was significantly higher among individuals with multivessel lesions. The prevalence of obesity among patients with CHD presented for off-pump coronary artery bypass grafting was significantly higher among women in groups with different numbers of affected coronary vessels. As for smoking, it was established that this behaviorally associated habit is significantly more common among men with CHD. The reliable patterns of prevalence of excess body weight, obesity and smoking in patients with CHD established as a result of the study of cardiovascular factors prove that these factors have high etiological contribution to the development, course and number of affected vessels in CHD.

Propensity score-matched comparison of total arterial off- and on-pump coronary artery bypass with complete revascularization

Little is known regarding the long-term (> 10 years) outcomes and risk factors of total arterial coronary artery bypass grafting (CABG). This study evaluated the long-term outcomes and risk factors for all-cause mortality and major adverse cardiac and cerebrovascular events (MACCEs) following total arterial on-pump CABG (ONCAB) or off-pump CABG (OPCAB) with complete revascularization. This retrospective cohort analysis enrolled patients with stable angina who underwent total arterial CABG with complete revascularization in our institute between July 2000 and June 2019. The endpoints were all-cause mortality and MACCE incidence, including a comparison between OPCAB and ONCAB. Long-term (10-year) outcomes were analyzed using propensity score-matched pairs, and risk factors were evaluated using univariate and multivariate analyses. Overall, 401 patients who underwent primary total arterial CABG were classified into the OPCAB (n = 269) and ONCAB (n = 132) groups. Using propensity score matching (PSM), 88 patients who underwent OPCAB were matched with 88 patients who underwent ONCAB. The mean follow-up period was 7.9 ± 6.3 years. No significant difference in all-cause mortality (hazard ratio, 1.04; 95% confidence interval, 0.53–2.04; p = 0.9138) and MACCE incidence (hazard ratio, 1.06; 95% confidence interval, 0.68–1.65; p = 0.7901) was observed between the two groups. Renal failure requiring dialysis was a significant risk factor for mortality (p < 0.0001) and MACCEs (p = 0.0003). Long-term outcomes of total arterial OPCAB and ONCAB with complete revascularization showed similar findings using PSM. Renal failure requiring dialysis was a significant risk factor for mortality and morbidity.Journal standard instruction requires an unstructured abstract; hence the headings provided in abstract were deleted. Kindly check and confirm.Thank you for your kindness.Clinical registration number 5598, Tokyo Women’s Medical University Hospital.

A modified technique for reducing the duration of ischemic time of the heart and myocardial reperfusion in multivalve correction combined with coronary grafting

The aim – to develop and put into practice a method of reducing the ischemic time of the heart during long-term cardiac surgery interventions.Materials and methods. A modified technique of coronary artery bypass grafting has been developed for combined operations that require a long time to clamp the aorta. The results of simultaneous correction of valve defects and coronary artery bypass grafting in 15 patients were analyzed. At the first stage, off-pump coronary artery bypass grafting was performed, followed by correction of valvular lesions.Results. The used technique requires more time to perform and is technically more difficult, but it allows to significantly reduce the ischemic time of the myocardium, which in turn will prevent heart failure and postoperative complications.Conclusions. The application of the technique proposed in the experiment has significant advantages in terms of the duration of artificial blood circulation and the ischemic time of the heart, which favorably affects its performance.

Comparative efficacy on outcomes of C-CABG, OPCAB, and ONBEAT in coronary heart disease: a systematic review and network meta-analysis of randomized controlled trials.

Coronary artery bypass grafting (CABG) remains the gold standard for the treatment of multivessel and left main coronary heart disease. However, the current evidence about the optimal surgical revascularization strategy is inconsistent and is not sufficient to allow for definite conclusions. Thus, this topic needs to be extensively discussed. The aim of this present study was to compare the clinical outcomes of off-pump CABG (OPCAB), conventional on-pump CABG (C-CABG), and on-pump beating heart (ONBEAT) CABG via an updated systematic review and network meta-analysis of randomized controlled trials. PubMed, Web of Science, and the Cochrane Central Registry were searched for relevant randomized controlled trials that were published in English before 1 December 2021. Published trials that included patients who received OPCAB, C-CABG, and ONBEAT CABG were selected. Two authors independently screened the search results, assessed the full texts to identify eligible studies and the risk of bias of the included studies, and extracted data. All processes followed the Preferred Reporting Items for Systematic Review and Meta-analysis of Individual Participant Data. The primary outcome was postoperative mortality in patients who underwent C-CABG, OPCAB, or ONBEAT CABG. The secondary outcomes were postoperative myocardial infarction, stroke, and renal impairment in the three groups. The time point for analysis of outcomes was all time periods during the postoperative follow-up. A total of 39385 patients (83496.2 person-years) in 65 studies who fulfilled the prespecified criteria were included. In the network meta-analysis, OPCAB was associated with an increase of 12% in the risk of all-cause mortality when compared with C-CABG [odds ratio (OR): 1.12; 95% CI: 1.04-1.21], a reduction of 49% in the risk of myocardial infarction when compared with ONBEAT (OR: 0.51; 95% CI: 0.26-0.99), a reduction of 16% in the risk of stroke when compared with C-CABG (OR: 0.84; 95% CI: 0.72-0.99) and a similar risk of renal impairment when compared with C-CABG and ONBEAT. OPCAB was associated with higher all-cause mortality but lower postoperative stroke compared with C-CABG. OPCAB was associated with a lower postoperative myocardial infarction than that of ONBEAT. Early mortality was comparable among OPCAB, ONBEAT, and C-CABG.

Coronary artery bypass grafting in left ventricular dysfunction: when and how.

The surgical management of patients undergoing coronary artery bypass grafting (CABG) with low ejection fraction presents unique challenges that require meticulous attention to details and good surgical technique and judgement. This review details the latest evidence and best practices in the care of such patients. CABG in patients with low ejection fraction carries a significant risk of perioperative mortality and morbidity related to the development of postcardiotomy shock. Preoperative optimization with pharmacological or mechanical support is required, especially in patients with cardiogenic shock. Rapid and complete revascularization is what CABG surgeons aim to achieve. Multiple arterial revascularization should be reserved to selected patients. Off-pump CABG, on-pump breathing heart CABG, and new cardioplegic solutions remain of uncertain benefit compared with traditional CABG. Tremendous advancements in CABG allowed surgeons to offer revascularization to patients with severe left ventricular dysfunction and multivessel disease with acceptable risk. Despite that, there is a lack of comprehensive and robust studies particularly on long-term outcomes. Individualized patient assessment and a heart team approach should be used to determine the optimal surgical strategy for each patient.

Phase Angle as a Reliable Biomarker of Frailty to Predict Postoperative Outcomes in Patients Undergoing Off-Pump Coronary Artery Grafting: A Prospective Observational Study

To elucidate the association between phase angle (PA) and a composite adverse outcome in patients requiring off-pump coronary artery bypass grafting (OPCAB). A prospective observational study. High-volume single center. A total of 229 adult patients who underwent OPCAB from May 2019 to October 2020. Each patient underwent bioelectrical impedance analysis, including PA assessment before surgery (PApre), immediately postoperatively (PApost), and 1 day postoperatively (PAPOD1), using an Inbody S10. Frailty index and nutritional assessments also were obtained before surgery. Patient outcomes were assessed using a composite adverse outcome comprising death, myocardial infarction, revascularization, new-onset atrial fibrillation, acute kidney injury, stroke, postoperative pulmonary complications, wound complications, sepsis, reoperation, and/or delirium occurring during hospitalization and over the following year. Patients for whom composite adverse outcomes were reported had lower PApre than those without complications (5.4 ± 0.9 v 6.0 ± 0.9, p < 0.001). The PA was significantly associated with in-hospital and 1-year composite postoperative outcomes. The odds ratios (OR, [95% confidence interval]) for PApre by time were in-hospital complications (0.435 [0.314, 0.604], p < 0.001; 1-year complications: 0.459 [0.330, 0.638], p < 0.001) and PAPOD1 (OR, in-hospital complications: 0.400 [0.277, 0.576], 1-year complications: 0.429 [0.298, 0.619], p < 0.001). The PApre was significantly associated with days alive and out of hospital until 1 year. The cut-off value of PApre for optimal prediction of in-hospital complications was 6.0 (area under the curve: 0.691 [0.623-0.758], p < 0.001). Low PA as an indicator of frailty is associated with adverse postoperative outcomes after OPCAB. Low PA may be employed as a noninvasive and practical tool for the prediction of prognosis in patients with coronary artery disease.

Recent Advances in Coronary Artery Bypass Grafting Techniques and Outcomes: A Narrative Review.

Coronary artery bypass grafting (CABG) has witnessed remarkable progress in recent years, driven by innovative techniques and refined approaches that have transformed patient outcomes and treatment paradigms. This review article comprehensively explores the latest advances in CABG techniques and their consequential impacts on patient outcomes. The advent of minimally invasive CABG techniques has revolutionized traditional surgical approaches. Robotic-assisted surgery and small thoracotomy methods offer reduced invasiveness, yielding shorter recovery times and improved patient satisfaction. Integrating CABG with percutaneous coronary intervention (PCI), hybrid procedures have emerged as a versatile strategy, providing tailored treatment solutions for complex coronary anatomies. The paradigm shift to off-pump CABG, which preserves the beating heart during surgery, has shown promise in reducing perioperative complications and neurocognitive deficits. Advances in graft selection, particularly the utilization of arterial grafts such as the internal thoracic artery and radial artery, have significantly enhanced graft patency rates and long-term survival. Adjunctive technologies, such as intraoperative imaging and graft flow assessment, have bolstered the precision of CABG procedures. Pharmacological agents have demonstrated their potential to improve graft outcomes. Surgical decision-making is now optimized based on patient characteristics and disease severity owing to the development of patient selection and risk stratification tools. Long-term results have also significantly improved. Patients undergoing CABG have higher survival rates, less angina, and better quality of life. Developing more resilient grafts through tissue engineering, using bioresorbable materials in graft fabrication, and using gene therapy to improve graft patency and overall cardiac recovery are all exciting future research directions. This review's summary of current developments in CABG procedures highlights their profoundly positive effects on patient outcomes. These developments can change the face of cardiovascular care by giving clinicians more tools to treat coronary artery disease (CAD) and enhance patients' quality of life.

The Urethral Perfusion Index During Off-Pump Coronary Artery Bypass Surgery: An Observational Study

ObjectiveThe IKORUS system (Vygon, Écouen, France) allows continuous monitoring of the urethral perfusion index (uPI) using a photoplethysmographic sensor mounted near the base of the urinary catheter balloon. We aimed to test the hypothesis that the uPI decreases during off-pump coronary artery bypass (OPCAB) surgery and to investigate the relationship between the uPI and macrocirculatory variables. DesignProspective observational study SettingUniversity Medical Center Hamburg-Eppendorf, Hamburg, Germany Participants20 patients having OPCAB surgery InterventionsNone Measurements and Main ResultsThe primary endpoint was changes in the uPI during OPCAB surgery. We additionally investigated associations between the uPI and cardiac output, mean arterial pressure, and heart rate as well as point-of-care variables.We included 20 patients with 24,137 uPI measurements. Overall, there was a high inter-individual variability in the uPI. Compared to the preparation phase (during which the median (interquartile range) uPI was 7.7 (5.6 to 12.0)), uPI decreased by 14% (95% CI: 13% - 15%) during the bypass grafting phase, by 35% (95% CI: 34% - 36%) during the cardiac positioning phase, and by 7% (95% CI: 6% - 9%) during hemostasis. There was no clinically important association between uPI and either cardiac output, mean arterial pressure, or heart rate. ConclusionsThe uPI decreases during OPCAB surgery, specifically during the cardiac dislocation phase. There was no clinically important association between uPI and either cardiac output, mean arterial pressure, or heart rate. It thus remains to be determined whether intraoperative uPI decreases are clinically important, reflect alterations in intra-abdominal tissue perfusion that are not reflected by systemic macrohemodynamics, and can help clinicians guide therapeutic interventions.

Surgical Porcine Model of Chronic Myocardial Ischemia Treated by Exosome-laden Collagen Patch and Off-pump Coronary Artery Bypass Graft.

Chronic myocardial ischemia resulting from progressive coronary artery stenosis leads to hibernating myocardium (HIB), defined as myocardium that adapts to reduced oxygen availability by reducing metabolic activity, thereby preventing irreversible cardiomyocyte injury and infarction. This is distinct from myocardial infarction, as HIB has the potential for recovery with revascularization. Patients with significant coronary artery disease (CAD) experience chronic ischemia, which puts them at risk for heart failure and sudden death. The standard surgical intervention for severe CAD is coronary artery bypass graft surgery (CABG), but it has been shown to be an imperfect therapy, yet no adjunctive therapies exist to recover myocytes adapted to chronic ischemia. To address this gap, a surgical model of HIB using porcine that is amenable to CABG and mimics the clinical scenario was used. The model involves two surgeries. The first operation involves implanting a 1.5 mm rigid constrictor on the left anterior descending (LAD) artery. As the animal grows, the constrictor gradually causes significant stenosis resulting in reduced regional systolic function. Once the stenosis reaches 80%, the myocardial flow and function are impaired, creating HIB. An off-pump CABG is then performed with the left internal mammary artery (LIMA) to revascularize the ischemic region. The animal recovers for one month to allow for optimal myocardial improvement prior to sacrifice. This allows for physiologic and tissue studies of different treatment groups. This animal model demonstrates that cardiac function remains impaired despite CABG, suggesting the need for novel adjunctive interventions. In this study, a collagen patch embedded with mesenchymal stem cell (MSC)-derived exosomes was developed, which can be surgically applied to the epicardial surface distal to LIMA anastomosis. The material conforms to the epicardium, is absorbable, and provides the scaffold for the sustained release of signaling factors. This regenerative therapy can stimulate myocardial recovery that does not respond to revascularization alone. This model translates to the clinical arena by providing means of physiological and mechanistic explorations regarding recovery in HIB.

At the Right Place, at the Right Time. Reply to Vetrugno et al. Comparison between FlowTrac and Pulmonary Arterial Catheter in Off-Pump Cardiac Surgery Patients: "Why Did We Miss Our Appointment?". Comment on "Oh et al. Comparison between Fourth-Generation FloTrac/Vigileo System and Continuous Thermodilution Technique for Cardiac Output Estimation after Time Adjustment during Off-Pump Coronary Artery Bypass Graft Surgery: A

We thank Vetrugno et al. for their interest and comments [...].

Comparison of Early Outcome of Off-pump and Conventional Coronary Artery Bypass Graft Surgery in Patients with Left Main Coronary Artery Disease with Left Ventricular Dysfunction

Left Main (LM) coronary artery disease and left ventricular dysfunction both are important predictors of in-hospital mortality. To avoid the harmful effects of cardio pulmonary bypass (CPB), many cardiac surgeons are using Offpump Coronary Artery Bypass (OPCAB) as an effective alternative to conventional CABG (CCAB) even in these sub-groups of patients. This study performed in the National Institute of Cardiovascular Diseases (NICVD) evaluated the early outcomes of OPCAB in terms of mortality and major post-operative morbidities and compared them with that of CCAB in patients with left main coronary artery diseases with left ventricular (LV) dysfunction. Total 120 patients with left main coronary artery disease with reduced left ventricular ejection fraction (&lt;_40%) were allocated into two groups: a) 60 patients who underwent OPCAB and b) another 60 patients who underwent conventional CABG between January 2012 and December 2017. All risk factors and co-morbidities were homogenously distributed between the two groups. Majority of the patients had triple vessel disease. Nearly three-quarters (73.3%) of patients in OPCAB group and 80% in CCAB group received 3 grafts (p=0.470). The mean total operative time (p&lt; 0.001), intubation times (p&lt;0.001), blood losses (p &lt; 0.001); requirements for blood and blood products (p &lt; 0.0010), intensive care unit stays (p&lt;0.001) and hospital stays (p&lt; 0.001) were all significantly lower in the OPCAB group. OPCAB is a safe and effective operative revascularization procedure for patients with left main coronary artery disease with left ventricular dysfunction and is associated with reduced morbidity.&#x0D; Bangabandhu Sheikh Mujib Med. Coll. J. 2022;1(1):04-08

Association of Hospital Volume and Outcomes Following Off-Pump Coronary Artery Bypass Grafting.

Off-pump coronary artery bypass grafting (OPCAB) has been used to mitigate the negative systemic effects of cardiopulmonary bypass. Recent consortium and single-institution studies suggest an association between operator experience and long-term survival. We thus aimed to ascertain the relationship between institutional OPCAB volume and outcomes using a contemporary nationwide all-payer database. Adult admissions for elective isolated OPCAB were identified from the 2016-2019 Nationwide Readmissions Database. The primary outcome was major adverse events (MAE), defined as a composite of mortality, reoperation, prolonged mechanical ventilation, acute kidney injury requiring dialysis, or perioperative stroke during the index hospitalisation. Secondary outcomes included temporal trends, postoperative length of stay (pLOS), hospitalisation costs, non-home discharge, and 30-day readmission rate. High-volume hospitals (HVH) were defined to have annual caseloads >35 based on cubic spline analysis. Of an estimated 41,154 patients, 59.9% were treated at HVH. The proportion of coronary artery bypass grafting operations that were OPCAB significantly decreased from 21.1% in 2016 to 18.3% in 2019. After adjustment, HVH status was associated with lower adjusted odds of MAE (adjusted odds ratio [AOR] 0.78, 95% confidence interval [CI] 0.70-0.88), compared to others. HVH were also associated with shorter pLOS (β -0.10, 95% -0.13, -0.07), reduced costs (β -US$4,900, - US$6,300, - US$3,600), non-home discharge (AOR 0.54, 95% CI 0.45-0.64), and 30-day readmission (AOR 0.86, 95% CI 0.77-0.96). Our results suggest that OPCAB requires a distinct set of surgical expertise and institutional aptitude. As a result, centralisation of care to centres of excellence should be considered.

Effect of different coronary artery revascularization procedures on cognition: A systematic review

Coronary revascularization interventions have been associated with post-intervention cognitive decline. Hence, this systematic review aims to compare the long-term effects of different coronary revascularization interventions on cognition. The Cochrane Library and MEDLINE databases were searched for articles published between January 2009 and January 2023. Articles on clinical trials and cohort studies that compared at least two different interventions with a minimum three months follow up were included to evaluate the consequences of different intervention techniques on cognition. Each selected study was evaluated using a revised tool to assess the risk of bias in randomized trials (RoB 2), and Risk of Bias In Non-Randomized Studies - of Interventions(ROBINS-1) was used for evaluating non-randomized studies. Five eligible studies, with four different comparisons, were included. Out of these studies, three RCTs and two cohort studies were included A participants gone through different procedures; on-pump and off-pump coronary artery bypass grafting (CABG), Percutaneous coronary intervention (PCI conventional cardiopulmonary bypass (CCPB), the miniaturized cardiopulmonary bypass (MCPB) and endoscopic coronary artery bypass grafting (Endo-CABG). These comparisons showed that different interventions have different effects on cognition; however, there is no solid evidence of correlations between them. Thus, the results of this review suggest that there should be greater focus on comparing interventions and that a reasonable follow-up duration should be set to avoid the influence of confounders. There is also a need to determine the effect of long-term cognitive decline while reducing interference by other variables.