Off-pump Coronary Artery Bypass Grafting Research Articles

Efficacy and safety of remimazolam tosylate for patients undergoing off-pump coronary artery bypass grafting: a study protocol for a non-inferiority randomised controlled trial in China

IntroductionMaintaining haemodynamic stability is crucial but challenging during the induction and maintenance of general anaesthesia (GA) in patients undergoing off-pump coronary artery bypass grafting (OPCABG). Remimazolam tosylate is a novel...

Preoperative red cell distribution width and its relation with in-hospital morbidities including atrial fibrillation after coronary artery bypass

Background and Aims: Atrial fibrillation (AF) and other adverse events are significant concerns following coronary artery bypass grafting (CABG). In recent years, Red Cell Distribution Width (RDW) has been identified as a potential biomarker for predicting these adverse outcomes. This study aims to assess early in-hospital adverse events in patients undergoing isolated off-pump CABG (OPCAB) and to analyze the relationship between these events and preoperative RDW levels. Methods: This study prospectively included 150 patients who underwent elective isolated OPCAB procedures. Patients were categorized into an “event group” (those experiencing adverse events) and a “no-event group” (those who did not). Additionally, they were stratified according to preoperative RDW levels into three groups: Group A (RDW ≤14%), Group B (RDW 14-16%), and Group C (RDW ≥16%). A receiver operating characteristic (ROC) curve, followed by both univariate and multivariate regression analyses were utilized to evaluate the predictive value of RDW for in-hospital morbidity. Results: The in-hospital mortality rate was 2.7%, and AF occurred in 20.7% of the patient population. The ROC analysis for early adverse events yielded an Area Under the Curve (AUC) of 0.681 with a p-value <0.001, indicating moderate predictive capability; the sensitivity was 73% and specificity was 64% for RDW ≥14.05%. Multivariate regression analysis demonstrated that RDW independently predicts in-hospital morbidity after OPCAB, with an odds ratio of 0.713 (95% CI 0.566-0.899, p=0.004). Conclusion: Elevated preoperative RDW levels serve as a simple and cost-effective independent predictor of early adverse events following isolated OPCAB.

Systemic immune inflammatory index (SII) and systemic inflammatory response index (SIRI) as predictors of postoperative delirium in patients undergoing off-pump coronary artery bypass grafting (OPCABG) with cerebral infarction

ObjectivePostoperative delirium (POD) is a common complication following off-pump coronary artery bypass grafting (OPCABG) and is associated with significant morbidity. This study aims to evaluate the correlation of systemic immune inflammatory index (SII) and systemic inflammatory response index (SIRI) with postoperative delirium (POD) in patients with cerebral infarction undergoing OPCABG.MethodsThe perioperative cohort study included 321 patients who underwent OPCABG. Patients were divided into two groups based on the occurrence of POD: the delirium group (n = 113) and the non-delirium group (n = 208). Baseline characteristics, including gender, left ventricular ejection fraction (LVEF), surgery duration, hypertension, age, and smoking history were analyzed. SII and SIRI values were calculated preoperatively, and their association with POD was assessed using univariate and multivariate logistic regression analyses. Receiver operating characteristic (ROC) curves were used to evaluate the predictive accuracy of SII and SIRI.ResultsStatistical differences between SII and SIRI in the two groups (P < 0.05) were observed. Multivariate analysis confirmed that SII and SIRI, age and preoperative smoking history were predictors of POD. ROC curve analysis demonstrated that SII and SIRI had considerable predictive power, with AUC values of 0.73 (0.67–0.79) for SII and 0.75 (0.69–0.81) for SIRI.ConclusionSII and SIRI were found to be associated with an increased risk of POD in patients undergoing OPCABG, but further research is needed to confirm these findings and determine their independence as risk factors.

Rapid Recovery After Full Sternotomy Off-Pump Coronary Artery Bypass Grafting in Complex Cases: A Report of 3 Cases

Rapid Recovery After Full Sternotomy Off-Pump Coronary Artery Bypass Grafting in Complex Cases: A Report of 3 Cases

Investigating the influence of possible liver fibrosis on mortality in patients with coronary artery disease - a post-hoc ISCHEMIA trial analysis

Abstract Background There is a plethora of studies demonstrating that comorbidities (e.g., diabetes and renal dysfunction) directly influence outcomes in patients undergoing PCI or CABG for coronary artery disease (CAD). Yet, liver dysfunction is not really included in current risk assessment beyond the presence of liver cirrhosis. Retrospective single center evidence now suggests that the presence of liver fibrosis may be an indicator of elevated risk. Using the FIB-4 score, where increasing values correlate with increaseing degrees of histological liver fibrosis, liver fibrosis could already be detected with all required laboratory values (AST, ALT, platelets) within normal range. In addition, the study suggests a beneficial effect of off-pump CABG when FIB-4 is elevated. This finding contradicts current randomized evidence, negating any difference between off and on-pump CABG. Since randomized trials always suffer from strong selection of low risk patients, it is conceivable that trial patients may primarily have low FIB-4 scores. Purpose To address the distribution of FIB-4 scores in a selected trial population with CAD (from the ISCHEMIA trial) and relate the degree of liver fibrosis reflected by the score to mortality. Methods The FIB-4 score was calculated for all patients. According to the standard classification, a value of greater than 1.2 reflects a 90% chance of the presence of histological liver fibrosis. The imapct of FIB-4 on late all-cause mortality was assessed as a continuous and categorical variable using maximally selected rank statistics determined FIB-4 cutoff. Cox regression model was peformed including the adjustment for the main CAD risk factors. Results Among 3735 included patients, 58.8% had a FIB-4 value above 1.2. Patients with higher FIB-4 score (cutoff= 1.64) were slighly older, presented higher prevalence of male sex, prior PCI and CABG, and prior history of atrial fibrillation and cerebrovascular disease. FIB-4 score was directly associated with higher risk of mortality when addressed as a continouos variable and as a categorical variable (Fig. 1). This relationship was evident in the overall population and in all subsets (PCI, CABG and no revascularization; Fig. 2). Conclusions The use of Fib-4 to determine the degree of liver fibrosis may be powerful to predict mortality in CAD populations which may not show any evident clinical signs of liver dysfunction. The Fib-4 distribution in this trial population, considered as selected and low risk, warrants investigating randomized trial populations having compared on- and off-pump CABG.Figure 1.Mortality: overall population.Figure 2.Mortality: by therapy subsets.

Impact of High-Intensity Statin on Atrial Fibrillation After Off-Pump Coronary Artery Bypass.

There is uncertainty regarding the impact of high-intensity statins on postoperative outcomes in patients undergoing surgical myocardial revascularization. This study was conducted to evaluate the impact of high-intensity statin treatment on the occurrence rate of new-onset postoperative atrial fibrillation (POAF) after off-pump coronary artery bypass grafting (OPCAB). Six hundred thirteen patients (66.8±9.8 years, male:female = 476:137) who underwent isolated OPCAB were retrospectively enrolled. Hypertension (n = 409, 66.7%), diabetes mellitus (n = 343, 59.6%) and chronic kidney disease (n = 138, 22.5%) were common comorbidities. Statins and beta-blockers were administered to all patients until the day of surgery and resumed within 6 hours after surgery. Risk factors associated with POAF were analyzed, including the use of high-intensity statins (atorvastatin 40 mg-80 mg or rosuvastatin 20 mg), as well as baseline characteristics and preoperative risk factors. High-intensity statins were used in 158 patients (25.8%). POAF occurred in 184 patients (30.0%). The use of high-intensity statins was not correlated with preoperative levels of low-density lipoprotein (P = 0.135) or high sensitivity C-reactive protein (P = 0.365). Multivariate logistic regression analysis revealed that the use of high-intensity statins was significantly associated with a reduced occurrence of POAF (P = 0.022, odds ratio [95% confidence interval] = 0.592 [0.378-0.926]). Age, acute coronary syndrome, insulin-dependent diabetes mellitus and chronic kidney disease were also significantly associated with POAF. Preoperative administration of high-intensity statins was associated with a 41% reduction in the occurrence rate of POAF in patients who underwent OPCAB.

Impact of Perioperative Pulmonary Artery Catheter Use on Clinical Outcomes Following Cardiac Surgery: A Nationwide Cohort Study

BackgroundEvidence on the effectiveness of pulmonary artery catheters (PACs) in cardiac surgery is scarce. Research QuestionDoes perioperative PAC use decrease on 1-year all-cause mortality in patients undergoing cardiac surgery? Study Design and MethodsThis nationwide, population-based cohort study included all adult patients who underwent cardiac surgery in Korea between January 2011 and December 2020 using a Korean health insurance claim database. We compared the primary outcome, the risk of 1-year all-cause mortality, between patients with and without perioperative use of PACs (PAC and no-PAC groups, respectively) using logistic regression analysis after stabilized inverse probability of treatment weighting. A subgroup analysis was performed to determine whether the association varied according to the type of cardiac surgery and institutional case volume. ResultsA total of 61,405 patients were analyzed. The PAC group had a significantly lower risk of 1-year all-cause mortality than that in the no-PAC group (adjusted odds ratio [OR], 0.81; 95% confidence interval [CI], 0.76–0.86). In the subgroup analysis, both the type of cardiac surgery and institutional case volume were identified as significant modifiers (all P for interaction<0.001). Specifically, the PAC group had a significantly lower risk of 1-year all-cause mortality following isolated off-pump coronary artery bypass grafting (adjusted OR, 0.54; 95% CI, 0.48–0.61) compared to the no-PAC group. PAC use was associated with a significant reduction in the risk of 1-year all-cause mortality in the lowest-case volume centers (<100 cases/year; OR, 0.70; 95% CI, 0.65–0.76). InterpretationPerioperative use of PACs was associated with a significant reduction in the risk of postoperative 1-year all-cause mortality. This association was predominantly driven by patients who underwent off-pump coronary artery bypass grafting and those who underwent cardiac surgery in less experienced centers.

Dynamic shunt flow alterations through patent foramen ovale during off-pump coronary artery bypass grafting induced by airway pressure changes: a case report.

Interatrial right-to-left shunt flow through a patent foramen ovale (PFO) can be caused by changes in heart position for anastomosis during off-pump coronary artery bypass (OPCAB). We herein present a case in which the direction of PFO shunt flow changed with heart position during OPCAB and the ventilation settings after sternal closure. A 66-year-old man with interstitial pneumonia underwent OPCAB. Preoperative transesophageal echocardiography revealed right-to-left shunt flow through a PFO induced by the Valsalva maneuver. During OPCAB, heart displacement resulted in right-to-left shunting and acute hypoxemia, which quickly improved with increase of inspired oxygen fraction. After chest closure, bidirectional shunt flow developed under increased airway pressure. Vigilant intraoperative monitoring with TEE and postoperative airway pressure management are important to address shunt flow and hypoxemia due to PFO.

Serum Free Fatty Acid Concentration Predicts ARDS after Off-Pump CABG: A Prospective Observational Study.

Free fatty acids (FFAs) are established risk factors for various cardiovascular and metabolic disorders. Elevated FFAs can trigger inflammatory response, which may be associated with the occurrence of acute respiratory distress syndrome (ARDS) in cardiac surgery. In this prospective study, we aimed to investigate the association between circulating FFA and the incidence of ARDS, as well as the length of ICU stay, in patients undergoing off-pump coronary artery bypass grafting (CABG). We conducted a single-center, prospective, observational study among patients undergoing off-pump CABG. The primary endpoint was the occurrence of ARDS within 6days after off-pump CABG. Serum FFA were measured at baseline and 24h post-procedure, and the difference (Δ-FFA) was calculated. A total of 180 patients were included in the primary analysis. The median FFA was 2.3mmol/L (quartile 1 [Q1]-Q3, 1.4-3.2) at baseline and 1.5mmol/L (Q1-Q3, 0.9-2.3) 24h after CABG, with a Δ-FFA of 0.6mmol/L (Q1-Q3, -0.1 to 1.6). Patients with elevated Δ-FFA levels had a significantly higher ARDS occurrence (55.6% vs. 22.2%; P < 0.001). Elevated Δ-FFA after off-pump CABG correlated with a significantly lower PaO2/FiO2 ratio, prolonged mechanical ventilation, and extended length of ICU stay. The area under the curve (AUC) of Δ-FFA for predicting ARDS (AUC, 0.758; 95% confidence interval, 0.686-0.831) significantly exceeded the AUC of postoperative FFA (AUC, 0.708; 95% CI 0.628-0.788; P < 0.001). Elevated Δ-FFA levels correlated with ARDS following off-pump CABG. Monitoring FFA may assist in identifying high-risk patients for ARDS, facilitating timely interventions to improve clinical outcomes.

TCT-289 Different Efficacy of 12-Month Dual Antiplatelet Therapy Following Off-Pump vs On-Pump Coronary Artery Bypass Grafting

TCT-289 Different Efficacy of 12-Month Dual Antiplatelet Therapy Following Off-Pump vs On-Pump Coronary Artery Bypass Grafting

How to Use a Right Internal Thoracic Artery Graft in On- and Off-Pump Coronary Artery Bypass Grafting

In coronary artery bypass grafting, internal thoracic artery grafts and other arterial grafts have shown superior results compared with saphenous vein grafts. The right internal thoracic artery (RITA) has been reported as one of these various arterial graft options. However, there are some limitations and concerns associated with using the RITA. This review presents the current topics and scientific evidence on the use of RITA grafts in coronary artery bypass grafting. The reviewed papers mainly focus on the operative results of using the RITA, graft configurations and target vessels, and the comparison between on- or off-pump coronary artery bypass procedure. The results of these studies suggest the followings. The method of using the RITA (either in situ or as a free graft) should be selected based on the need to reach crucial targets and the number of required target vessels. A free RITA graft anastomosed to the aorta with modified proximal anastomosis allows for the revascularization of multiple vessels with acceptable flow characteristics. For revascularization of the right coronary artery system with low-grade proximal stenosis, the RITA should not be used. The decision to use cardiopulmonary bypass depends on the patient's condition, target vessels, as well as the experience of institution. Skeletonized harvesting is more effective in preventing sternal wound infections in coronary artery bypass grafting using bilateral internal thoracic arteries compared with using a single internal thoracic artery.

Cost Analysis of Robot-Assisted Versus On-Pump and Off-Pump Coronary Artery Bypass Grafting: A Single-Center Surgical and 30-Day Outcomes Comparison.

Throughout Europe, the interest in implementing robot-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) has been growing. However, concerns about additional costs have emerged concurrently. In this analysis, we aim to provide a comparison of the cumulative perioperative costs of RA-MIDCAB, on-pump coronary artery bypass grafting (CABG), and off-pump CABG (OPCAB). We conducted a propensity score-matched analysis comparing patients undergoing RA-MIDCAB with those undergoing CABG or OPCAB at our institution from January 2016 to December 2021. After matching, we analyzed the combined intraoperative surgical costs and 30-day postoperative costs. We first compared RA-MIDCAB costs to CABG and then to OPCAB separately. Violin plots illustrated the cost distribution among individual patients. Total cost uncertainty was estimated using 1,000 bootstrapping iterations. Seventy-nine RA-MIDCAB patients were matched to 158 CABG patients, and 80 RA-MIDCAB patients were matched to 149 OPCAB patients. Considering both surgical and clinical outcomes, RA-MIDCAB yielded an average cost of €17,121 per patient (€16,781 to €33,294), CABG was €16,571 per patient (€16,664 to €41,860), and OPCAB was €15,463 per patient (€10,895 to €57,867). After bootstrap iterations, RA-MIDCAB was found to be €472 (2.8%) and €1,599 (10.3%) more expensive per patient than CABG and OPCAB, respectively. In The Netherlands, the adoption of RA-MIDCAB did not show a significant economic impact on hospital resources. The additional robotic costs for the surgery were almost entirely offset by the cost savings during the postoperative hospital stay. However, these comparisons may differ when considering hybrid coronary revascularization with its additional percutaneous coronary intervention costs.

CABG Case Volume and Patient Outcomes at the Veterans Healthcare Administration: On-Pump versus Off-Pump

Objective: To evaluate use trends and perioperative outcomes of on- and off-pump coronary artery bypass graft (CABG) in US Veterans. Methods: We retrospectively reviewed 44,960 Veteran Health Administration (VHA) patients who underwent isolated CABG between 2008–2021. Multivariable logistic regression was used to analyze associations between surgical technique and outcomes. Adjusted hazard ratios (aHR) are reported. p &lt; 0.05 using two sided tests was considered significant. Results: 6169/44,960 (13.7%) patients underwent isolated off-pump CABG and 38,791/44,960 (86.3%) patients underwent on-pump CABG. Between 2008 and 2021, the proportion of off-pump procedures decreased: 18.8% between 2008–2012, 11.6% between 2013–2017, and 8.6% between 2018–2021 (χ2 = 712.78, df = 2, p &lt; 0.001). Groups were found to be well balanced with respect to age, history of chronic obstructive pulmonary disease (COPD), history of diabetes, history of prior cardiac surgery, as well as left ventricular ejection fraction and history of smoking, and thus an analysis was conducted using the entire cohort. After covariate adjustment, group status was found to not be a predictor of death (aHR = 0.92, 95% confidence interval (95% CI) = 0.66–1.28, p = 0.62), stroke (aHR = 1.33, 95% CI = 0.83–2.12, p = 0.23), myocardial infarction (MI) (aHR = 0.86, 95% CI = 0.51–1.46, p = 0.58). However, given the large imbalance between group size, the groups were then propensity matched on age, history of chronic obstructive pulmonary disease (COPD), diabetes hypertension, smoking, prior cardiac surgery, and left ventricular ejection fraction, resulting in a smaller cohort of 12,130 patients: 5961 (49.1%) on pump and 6169 (50.9%) off pump. After covariate adjustment, the on-pump group in the matched cohort had increased risk of the following within 30 days: death (aHR = 2.60, 95% CI = 1.50–4.51, p &lt; 0.001), stroke (aHR = 1.61, 95% CI = 1.09–2.38, p = 0.016), acute renal failure (aHR = 2.31, 95% CI = 1.46–3.66, p &lt; 0.001), atrial fibrillation (aHR = 1.39, 95% CI = 1.23–1.57, p &lt; 0.001), intraoperative death (aHR = 1.67, 95% CI = 1.07–2.59, p = 0.023), and prolonged intubation (aHR = 1.53, 95% CI = 1.27–1.85, p &lt; 0.001). They also experienced increased length of stay (Beta = 0.05, p &lt; 0.001). Group did not predict risk of reintubation, perioperative myocardial infarction, or postoperative cardiac arrest requiring cardiopulmonary resuscitation (CPR). Conclusions: In a propensity matched cohort of veterans undergoing isolated CABG, off-pump technique was associated with decreased risk of multiple perioperative outcomes measures. However, the proportion of off-pump procedures within the VHA decreased between 2008–2021. This may be secondary to more selective use as overall volume has decreased, though additional study is needed to evaluate these trends.

Horner’s syndrome caused by the first rib fracture sustained during coronary artery bypass grafting: a case report and literature review

BackgroundHorner’s syndrome is a rare complication of cardiovascular surgery. A bone fragment and hematoma due to rib fracture after cardiac surgery may cause injury to the brachial nerve plexus and sympathetic nerve trunk, leading to neurologic disorders and Horner’s syndrome. However, few reports have revealed the etiology of Horner’s syndrome after cardiovascular surgery based on imaging. Herein we present a case in which a plain CT scan confirmed the etiology of Horner’s syndrome after coronary artery bypass grafting (CABG), reviewing 139 CABG cases retrospectively in our hospital and 6 case reports of Horner’s syndrome associated with cardiovascular surgery.Case presentationA 69-year-old woman with a history of percutaneous coronary intervention and total abdominal hysterectomy with bilateral salpingo-oophorectomy had chest pain on exertion. Coronary angiography showed severe triple vessel disease. She underwent off-pump coronary artery bypass grafting (CABG). A median sternotomy was performed, and the split sternums were widened using a sternal retractor. The bilateral internal thoracic arteries were harvested. A triple CABG was performed. She had left shoulder pain after surgery. She complained of anhidrosis involving the left face and hyperhidrosis involving the right face from postoperative day (POD) 6. Left ptosis and blurry vision appeared after discharge from the hospital, for which she saw a neurologist in our hospital on POD 48. Miosis could not be clearly confirmed. She was diagnosed with Horner’s syndrome. A plain CT scan revealed displaced fractures of the bilateral first ribs and left second rib. The bone fragment of the left first rib head was displaced 3 mm anteriorly compared to the left first rib head before surgery, which suggested that the fragment affected the stellate ganglion in the sympathetic trunk. The patient had regular follow-up evaluations. The anhidrosis persisted, but the ptosis improved, and the miosis was not confirmed at the 6-month follow-up evaluation.ConclusionsWe should recognize that Horner’s syndrome is one of the complications of cardiovascular surgery, especially CABG. Fracture of the first rib head with a displaced bone fracture was shown to be a contributor to ipsilateral Horner’s syndrome. When symptoms of Horner’s syndrome and other neurologic symptoms are noted after open heart surgery, a plain CT examination should be obtained.

Off-pump vs. on-pump coronary artery bypass grafting in patients with chronic kidney disease: an updated systematic review and meta-analysis.

In patients with chronic kidney disease (CKD), cardiovascular disease is found to be the primary cause of mortality, and after coronary artery bypass grafting (CABG), their prognosis deteriorates. We conducted a meta-analysis comparing off-pump CABG versus on-pump CABG in CKD patients. We searched electronic databases, including PubMed, Cochrane, and Google Scholar, using relevant keywords. We included studies comparing off-pump CABG with on-pump CABG in patients with chronic kidney disease, which was defined as an estimated glomerular filtration rate (eGFR) < 60ml/min per 1.73m2. Effect estimates were synthesized using a random-effects model and expressed as risk ratios (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, with corresponding 95% confidence intervals (CIs). Our primary outcome was short-term mortality. A total of 25 studies, of which 23 were observational and 2 were RCTs, were included in this meta-analysis, comprising 234,585 patients (66,591 in the off-pump group and 167,994 in the on-pump group). Our meta-analysis showed that there was a significantly higher mortality rate in the on-pump CABG group as compared to the off-pump CABG group (RR: 0.73, 95% CI [0.61, 0.88]; P = 0.0006, I2 = 60%). Compared with OPCAB, short-term mortality was significantly higher in ONCAB.

Off versus on pump myocardial revascularization in patients with severe asymptomatic carotid stenosis.

Coronary artery disease is a global cause of morbidity and mortality, often managed by coronary artery bypass grafting (CABG). This study addresses a critical decision-making dilemma in CABG procedures for patients with severe asymptomatic carotid stenosis, comparing off-pump and on-pump techniques. We conducted a retrospective single-center analysis, employing propensity scored matched-pair methodology to compare perioperative outcomes in patients with asymptomatic severe carotid stenosis undergoing off-pump or on-pump CABG. The primary endpoint was the occurrence of perioperative stroke. Secondary endpoints included postoperative delirium, intrahospital mortality, intensive care unit stay, length of hospitalization and long-term survival. The study involved 243 patients with asymptomatic severe carotid stenosis operated between July 2009 and October 2018, subsequently propensity score matched into two groups of 78 patients each (off-pump and on-pump). The incidence of perioperative stroke was significantly higher in the On-Pump group compared to the off-pump group (10.3% vs. 1.3%, P=0.03). However, secondary endpoints, such as intrahospital mortality and length of hospitalization, showed no significant differences between the two groups. Long-term survival rates were also comparable. Our findings indicate that off-pump CABG significantly reduces the risk of perioperative stroke in patients with severe asymptomatic carotid stenosis compared to on-pump CABG, without compromising long-term outcomes. These results support the preference for off-pump CABG in this high-risk patient population, highlighting the need for tailored surgical approaches based on individual patient risk profiles.

Association of Preoperative Neutrophil to Lymphocyte Ratio with Early Postoperative Acute Kidney Injury Following Isolated Off-Pump Coronary Artery Bypass Grafting

Objective: Acute kidney injury (AKI) is a frequent complication after off-pump coronary artery bypass grafting (OPCAB) that complicates recovery, increases treatment cost and mortality. Neutrophil to lymphocyte ratio (NLR) is a systemic inflammatory marker easily derived from complete blood count that has many prognostic potentials. The purpose of this study was to evaluate if there is an association of preoperative NLR with early postoperative AKI following isolated OPCAB. Methods: This cross-sectional study was carried out in the Department of Cardiac Surgery, National Institute of Cardiovascular Diseases (NICVD) on a total of 60 patients aged 31-70 years with no preoperative renal dysfunction undergoing isolated OPCAB between August 2021 and July 2022. Group A included 30 patients with preoperative NLR &lt; 2.65 and Group B included 30 patients with preoperative NLR ≥ ≥≥2.65. Patients were monitored for development of early postoperative AKI according to serum creatinine criteria of Kidney Disease Improving Global Outcomes (KDIGO) 2012 guideline. Results: Two patients from group A and twenty patients from group B developed early postoperative AKI (p &lt; 0.001). Events of AKI were significantly higher in group B patients at all postoperative time points. Multivariate binary logistic regression analysis revealed preoperative NLR ≥ ≥≥2.65 as an independent predictor of early post OPCAB AKI (p = 0.004, OR = 13.746). In receiver operating curve (ROC) analysis area under curve (AUC) was 0.933 (95% CI 0.874-0.992, p &lt; 0.001). It showed 90.91% sensitivity and 73.7% specificity at the pre-set cut off value of NLR at 2.65 where optimal predictability of post-OPCAB AKI occurred with 66.67% positive predictive value, 93.33% negative predictive value and 80% accuracy. Conclusion: Preoperative NLR is significantly associated with early postoperative AKI following isolated OPCAB and therefore it should be incorporated in routine clinical practice for early prediction of AKI and implementing timely preventive strategies. (Bangladesh Heart Journal 2024; 39(2): 151-160

Does Chronic Obstructive Pulmonary Disease Impact Outcome after Coronary Artery Bypass Grafting? A Population-Based Retrospective Study in Germany.

Background: The interaction between chronic obstructive pulmonary disease (COPD) and coronary artery bypass grafting (CABG) is discussed controversial. Methods: In this population-based retrospective analysis including non-emergency CABG in Germany between 2015 and 2021, the aim was to compare in-hospital mortality, hospital length of stay (HLOS), and perioperative ventilation time (VT) in patients affected by COPD and not affected by COPD. In addition, we compared outcomes after off-pump coronary artery bypass (OPCAB) and on-pump coronary artery bypass (ONCAB) surgery and outcomes after CABG with a minimally invasive technique with and without cardiopulmonary bypass (CPB) in COPD patients. Results: Of the 274,792 analyzed cases undergoing non-emergency CABG, 7.7% suffered from COPD. COPD patients showed a higher in-hospital mortality (6.0% vs. 4.2%; p < 0.001), a longer HLOS (13 days (10-19) vs. 12 days (9-16); p < 0.001), and a longer VT (33 h (11-124) vs. 28 h (9-94); p < 0.001). In subgroup analyses, COPD patients undergoing OPCAB surgery showed a lower in-hospital mortality (3.5% vs. 6.4%; p < 0.001), a shorter HLOS (12 days (9-16) vs. 13 days (10-19); p < 0.001) and a shorter VT (20 h (10-69) vs. 36 h (11-135); p < 0.001) compared to ONCAB surgery. Regression analyses confirmed that using cardiopulmonary bypass in COPD patients is associated with a higher risk of in-hospital mortality (OR, 1.86; 95% CI: 1.51-2.29, p < 0.001), a longer HLOS (1.44 days; 95% CI: 0.91-1.97, p < 0.001), and a longer VT (33.67 h; 95% CI: 18.67-48.66, p < 0.001). In further subgroup analyses, COPD patients undergoing CABG with a minimally invasive technique without CPB showed a lower in-hospital mortality (3.5% vs. 16.5%; p < 0.001) and a shorter VT (20 h (10-69) vs. 65 h (29-210); p < 0.001) compared to CABG with a minimally invasive technique and CPB. Regression analyses confirmed that using CPB in COPD patients undergoing CABG with a minimally invasive technique is associated with a higher risk of in-hospital mortality (OR, 4.80; 95% CI: 2.42-9.51, p < 0.001). Conclusions: COPD negatively impacts outcomes after non-emergency CABG. According to our results, OPCAB surgery and CABG with a minimally invasive technique without CPB seem to be beneficial for COPD patients. Further studies should be performed to confirm this.

Left atrial appendage emptying velocity and left ventricular function as predictors of inotropic support in patients undergoing elective off-pump coronary artery bypass grafting

Abstract Background: Patients undergoing elective off-pump coronary artery bypass grafting (CABG) are at risk of hemodynamic instability, ischemia, arrhythmia, and dysfunction. These events need to be managed by pharmacological supports or relieving of mechanical obstruction (octopus) of the heart to maintain the hemodynamic stability. There is a paucity of data on the effect of left ventricular (LV) dysfunction on left atrial appendage (LAA) emptying velocity. We evaluated the relationship between LV function and LAA emptying velocity and requirement of inotropic support perioperatively. Materials and Methods: In this prospective open-label all-comer study, fifty patients undergoing elective off-pump CABG under general anesthesia, we measured LAA emptying velocity by pulsed wave Doppler and evaluated if it could predict the need for inotropes perioperatively. It is a case series of 50 patients without a comparator arm. We measured pulsed wave Doppler across the mitral valve leaflet and early mitral inflow velocity (Evel) and late mitral inflow velocity, tissue Doppler at the lateral annulus of the mitral valve (e’) and also calculated the ratio of Evel and e’. Need for inotrope in the intraoperative and postoperative period was captured perioperatively. Vasoactive-inotropic score (VIS) was calculated for all the patients. Results: The VIS was significant (P &lt; 0.0001, with odds ratio of 131.6 and confidence interval of 95% (0.9–1). However, there was no significant correlation between ejection fraction (EF) and VIS (P = 0.87). In patients with the need of inotropes, LAA emptying velocity was significantly increased in the postgrafting period as compared to the pregrafting period (75.64 cm/s vs. 57.9 cm/s, P &lt; 0.001). Conclusion: The assessment of LAA emptying velocity value was a useful predictor of the need of inotropic support during off-pump surgery, especially during Obtuse marginal and Ramus grafting. This study paves the need of larger case–control studies to validate the findings.

Impact of regional anesthesia on left and right ventricular performance after off-pump coronary artery bypass grafting: randomized controlled study

Introduction. New anesthesia techniques require evidence of the safety of their implementation, however there is still the opinion about negative impact of regional anesthesia on heart performance and central hemodynamics. The objective of our study was to evaluate effect of regional anesthesia on systolic and diastolic myocardial function in off-pump coronary artery bypass grafting (OPCAB).Materials and methods. A prospective randomized controlled trial included 45 patients who underwent elective OPCAB, equally divided into 3 groups – general anesthesia in combination with epidural anesthesia (GA+EA), general anesthesia with erector spinae plane block (GA+ESPB) and general anesthesia without regional anesthesia (GA). The systolic function of the left (LV) and right ventricle (RV), as well as the diastolic function of the LV were evaluated during five stages perioperatively, using echocardiography and thermodilution via Swan-Ganz catheter.Results. There were no intergroup differences in parameters of LV or RV systolic function and LV diastolic function during study stages. Perioperatively, there was a decrease in LV end-diastolic volume in the groups of OA+ESPB (p = 0.001) and OA (p = 0.003).At the end of the first postoperative day (POD), pulmonary artery wedge pressure decreased in the groups of OA+EA (p = 0.003) and OA+ESPB (p = 0.008); meanwhile, ejection time (p = 0.003) and velocity-time integral (p = 0.005) from RV reduced only in the OA+ESPB group. In the OA+EA group at the end of POD1, the reservoir strain of left atrium (p = 0.022) and isovolumic relaxation time (p = 0.006) decreased.Conclusion. In OPCAB, epidural anesthesia and ESPB do not result in deterioration of LV systolic and diastolic function and do not have a negative impact on the RV.