Off-pump Coronary Endarterectomy Research Articles

Short and long-term outcomes after off-pump coronary endarterectomy stratified by different target vessels

BackgroundThe efficacy of off-pump coronary endarterectomy (CE) has been proven in patients with diffuse coronary artery disease (DCAD). However, the clinical benefits of of-pump CE stratified by different target vessels remain controversial. This retrospective study assessed the effect of the territory and number of CE on short- and long-term outcomes of DCAD.MethodsFrom January 2012 to December 2014, 246 patients undergoing off-pump coronary artery bypass grafting (OPCABG) + CE were included. The patients were grouped by the territory and number of CE. The primary endpoints were postoperative acute myocardial infarction (PMI) and long-term major adverse cardiovascular and cerebrovascular events (MACCE).ResultsSixty-five patients (26.42%) were in the left anterior descending branch (LAD) group (CE on LAD), 134(54.47%) in the right coronary artery (RCA) group (CE on RCA), and 47(19.10%) in the multi-vessels group. PMI in the LAD group, RCA group, and multi-vessels group were 3.08%, 6.72%, and 14.89%, respectively (P = 0.08). Multi-vessels CE (OR = 9.042, 95%CI 2.198–37.193, P = 0.002), CE-plaque length ≥ 3 cm (OR = 6.247, 95%CI 2.162–18.052, P < 0.001), and type 2 diabetes mellitus (2DM) (OR = 4.072, 95%CI 1.598–10.374, P = 0.003) were independent risk factors of PMI. The long-term (mean 76 months) MACCE in the LAD group, RCA group, and multi-vessels group were 13.85%, 17.91%, and 10.64%, respectively (P = 0.552). Cox analysis indicated that PMI (HR = 7.113, 95%CI 3.129–16.171, P < 0.001) and Age ≥ 65 years (HR = 2.488, 95%CI 1.214–5.099, P = 0.013) increased the risk of long-term MACCE.ConclusionsMulti-vessel CE and CE-plaque length ≥ 3 cm significantly increased risk of PMI after OPCABG + CE, but the territory and number of CE did not affect long-term MACCE.

Mid-term outcomes of coronary endarterectomy combined with coronary artery bypass grafting.

The aim of this study was to evaluate the mid-term outcome of coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) and explore the potential risk factors for adverse events. A total of 208 consecutive patients underwent CE between 2008 and 2018 in our centre, of which 198 were included in this retrospective cohort study. The primary end point was major adverse cardiovascular and cerebrovascular events (MACCEs). Kaplan-Meier analysis was performed to evaluate event-free survival, whereas subgroup analysis and Cox regression were used to explore risk factors for the outcomes. The median follow-up time was 34.7 months. CE + CABG was performed mainly on the left anterior descending artery (42.3%) or right coronary artery (42.3%). Both operative mortality and incidence of perioperative myocardial infarction were 1.5%. The overall survival at 3 and 5 years was 98.0% and 95.9%, whereas the MACCE-free survival was 93.7% and 89.4%, respectively. No significant difference in the incidence of MACCE was observed between on-pump and off-pump CE (P = 0.256) or between left anterior descending artery and non-left anterior descending artery endarterectomy (P = 0.540). Advanced age (>65 years) was associated with a higher risk of MACCE both in univariate [hazard ratio (HR) 3.62, 95% confidence interval (CI) 1.37-9.62; P = 0.010] and multivariate analysis (HR 3.59, 95% CI 1.32-9.77; P = 0.013). When performed by experienced surgeons, CE + CABG could be an acceptable approach to achieve complete revascularization of diffusely diseased coronary arteries with satisfactory outcomes, although advanced age might increase the risk of MACCE.

Gender difference in long- and short-term outcomes of off-pump coronary endarterectomy.

Background:The role of gender in the selection of the most effective method for treatment of patients with diffused coronary artery diseases remains a matter of debate. This study thus evaluated the effect of gender on long- and short-term outcomes of off-pump coronary endarterectomy (CE).Methods:This was a single-center retrospective study of patients who had undergone coronary artery bypass graft (CABG). The patients were divided into two groups, the CABG and the CABG + CE group, and further stratified into male and female. Long-term survival for each group was estimated by Kaplan–Meier analysis with log-rank testing. In addition, Cox regression analyses of each gender were also carried out to identify the predictors of the primary and secondary endpoints.Results:Overall, 25.8% of the patients were female. Diseased vessels were not statistically different in the two groups – men and women. There was no significant difference in postoperative outcomes between males and females in the CABG and CABG + CE groups. There was no significant difference in hospital mortality in the two groups between males and females. Kaplan–Meier curves show that there was no significant difference in the 5-year cardiac mortality between males and females belonging to the CABG and CABG + CE groups.Conclusion:The results of this study show that there was no significant difference in the short- and long-term outcomes of off-pump CABG and CE in both genders although women tend to carry a greater risk.

Off-pump coronary endarterectomy with stent removal for in-stent restenosis in the left anterior descending artery.

In-stent restenosis (ISR) remains a major complication of percutaneous coronary intervention, even in the current era of drug-eluting stents (DESs). We reviewed the clinical and angiographic outcomes of coronary endarterectomy with stent removal using an off-pump technique in patients with ISR in the left anterior descending artery (LAD). Twelve patients with long-segment ISR in the LAD underwent off-pump coronary artery bypass grafting with coronary endarterectomy and stent removal at our institution from November 2005 to August 2012. Their mean age was 65.0 ± 6.3 years, and 11 were male. DESs were used in 10 patients and bare-metal stents were used in the remaining 2 patients. The interval from the latest intervention ranged from 4 to 102 months (median, 12 months). None of the procedures were converted to on-pump surgery, and there were no operative deaths. The left internal thoracic artery (LITA) was used to reconstruct the endarterectomized LAD in all patients, and the mean length of the arteriotomy in the LAD was 5.3 ± 1.0 cm. The LITA and LAD were patent in all patients on both early postoperative and follow-up angiography. At the median 24-month follow-up (range, 12-78 months), there were no late deaths and all patients were at a Canadian Cardiovascular Society class of 0 or I. Coronary endarterectomy with stent removal can be safely performed using an off-pump technique and provides favourable clinical and angiographic outcomes in patients with long-segment ISR in the LAD.

EComment. Does off-pump coronary endarterectomy improve long-term outcomes?

The publication by Takahashi et al. highlights an area with limited data [1]. They successfully performed off-pump coronary endarterectomy to the left anterior descending (LAD) artery in 12 patients. We congratulate the authors for their effort and successful results. In this report, there are a few topics we would like to discuss. The study population belonged to a consecutive series of 232 off-pump cases performed by a single surgeon. We believe that the surgeon's preference and experience played major role on the outcomes of coronary artery bypass grafting (CABG), particularly on graft patency. The ROOBY trial, which represents the largest randomized controlled study on off-pump versus on-pump CABG to date, documented that graft patency was significantly and consistently lower in the off-pump group. The results were consistent with 3 major coronary regions, including the LAD. The graft patency rates in the LAD region were 89.0% in the off-pump group and 93.2% in the on-pump group (P = 0.01) on 1-year angiograms. Moreover, the effective revascularization rate was lower in the off-pump group (50.1% vs 63.9%; P = 0.001) [2]. In on-pump coronary endarterectomy cases propensity-matched to CABG alone, Lapar et al. documented comparable operative mortality, major complication and long-term survival rates [3]. Similarly, Schwann et al. reported survival benefits in on-pump CABG patients with endarterectomy similar to that described in isolated CABG patients with the use of multiple arterial grafts [4]. There are no studies documenting this relation between off-pump endarterectomy and isolated CABG. Due to the abovementioned facts, we do not think that patients will really benefit from off-pump endarterectomy. Conflict of interest: none declared

Early and mid-term results of off-pump endarterectomy of the left anterior descending artery

Many patients referred for coronary artery bypass surgery (CABG) today have diffusely diseased coronary vessels, and some of them may require coronary endarterectomy to provide adequate revascularization. Most reports of coronary endarterectomy describe an on-pump procedure. As off-pump coronary artery bypass graft has become safer and more routine, there is renewed interest in off-pump coronary endarterectomy. We report on our series of patients who underwent off-pump coronary endarterectomy of the left anterior descending (LAD) artery using an open endarterectomy technique. All patients undergoing open heart surgery at The Mount Sinai Medical Center are entered into a state-mandated, audited database. A retrospective review of this database revealed 12 patients between January 2008 and June 2012 who underwent off-pump endarterectomy of the LAD as part of their coronary revascularization. Additional data were collected from a review of the patients' charts. There were a total of 12 patients, with a mean age of 72 ± 4 years. Nine (75%) were male and 3 (25%) were female. Comorbidities included hypertension in 11 (92%) patients, dyslipidaemia in 10 (83%), diabetes in 8 (67%), renal failure in 6 (50%) and stroke in 1 (8%). The mean number of diseased coronary territories was 3 ± 0.4 (range 2-3), and the mean number of coronary bypass grafts performed was 4 ± 0.8 (range 2-5). Eight patients required transfusion with packed red blood cells (67%). One (8%) patient was converted from off-pump to on-pump. The mean intensive care unit stay was 3 ± 2.8 (range 1-8 days), and the mean hospital length of stay was 15 ± 13 (range 4-54 days). Postoperative follow-up (mean 24 ± 19 months, range 1-53) is complete, and no ischaemic events have occurred in the early and mid-term follow-up period. We conclude that off-pump endarterectomy of the LAD is a viable option for patients with diffuse LAD disease.

Myocardial revascularization of patients with diffuse coronary artery disease

Off-pump coronary artery bypass grafting (off-pump CABG) after off-pump coronary endarterectomy (CE) for myocardial revascularization is a way to rescue the patients with diffuse coronary artery disease (CAD). This study retrospectively analyzed its clinical outcomes and experiences, and explored the safety and effectiveness. From October 2003 to December 2008, 177 diffuse CAD patients with 229 vascular lesions received off-pump CABG plus CE. Incision was made at the hardest part of coronary artery and ≥ 2 cm from the distal intervention site. Then bypass graft was performed by internal mammary artery or saphenous vein. The intra-operative blood tests showed that 215 (93.9%) bridges were satisfied with (27 ± 12) ml/min blood flow while 14 bridges were dissatisfied. The blood flow was (7 ± 4) ml/min. Six (3.4%) cases suffered peri-operative myocardial infarction. Among them, 3 patients had no significant cardiac hemodynamic changes. Three suffered a low cardiac output and improved by intra-aortic balloon counter pulsation support. And they were then discharged after treatment. After 3 - 40 months, 98 patients underwent coronary angiography to measure the graft latency. And the blood flow was excellent. Off-pump CABG plus CE for diffuse coronary artery disease is both feasible and safe. And it is an effective treatment with a high degree of vascularization.

Off-Pump Coronary Endarterectomy in High-Risk Patients

The outcome of off-pump endarterectomy in patients with diffuse coronary artery disease and increased risk factors for cardiopulmonary bypass was reviewed. Thirty-eight procedures were carried out in 32 patients (21 men and 11 women) aged 59 to 78 years (mean, 69 years). Mean left ventricular ejection fraction was 38.6% (range, 24% - 55%). The number of grafts per patient was 2.6. The left internal mammary artery was used in 29 patients (91%). Endarterectomy was performed on the right coronary artery and its branches (18), the left anterior descending artery (15), diagonal branch (2), and the circumflex system (3). Overall operative mortality was 3.1%. Perioperative myocardial infarction occurred in 6.2%. Follow-up was complete in 30 patients (94%). The mean follow-up period was 14 +/- 3.3 months. Late survival was 93%. Freedom from cardiac events that required hospital re-admission was 89%. Freedom from angioplasty of the endarterectomized vessel was 96%. These findings indicate that off-pump endarterectomy can be performed with good results in patients with diffuse coronary artery disease.

Coronary endarterectomy in the current era

The increasing incidence of diffuse coronary artery disease in the current era challenges cardiac surgeons in accomplishing their goal of complete revascularisation. Although coronary endarterectomy is used with encouraging results in most institutions, there remains some controversy in its indications, technique, and results. The purpose of this review is to highlight the important evolutions of technique in the recent past. Despite the increased risk factors and comorbidities in patients presenting with diffuse coronary artery disease requiring coronary endarterectomy, the results of coronary endarterectomy are improving inline with the improvements in the results of conventional coronary artery bypass grafting surgery. The improving results of coronary endarterectomy in the left anterior descending artery are further clarified. The intra- and postoperative use of prostacyclin has been shown to be effective in reducing mortality and perioperative myocardial infarction. The technique of open coronary endarterectomy with on-lay patch bypass grafting has been shown to be safe and effective in reducing mortality and improving patency as compared with the closed (traction) method of coronary endarterectomy. The use of coronary endarterectomy was also found to be effective in the treatment of in-stent restenosis in the setting of diffuse coronary artery disease. The results of off-pump coronary endarterectomy are encouraging and comparable with the conventional coronary endarterectomy using cardiopulmonary bypass. With the increasing incidence of diffuse coronary artery disease and improving results of coronary endarterectomy, it is vital for cardiac surgeons to have coronary endarterectomy in their armamentarium to achieve complete coronary revascularisation.

Coronary endarterectomy with off-pump coronary artery bypass surgery

Background The aim of this study is to review our experience in coronary artery endarterectomy performed without cardiopulmonary bypass. Methods Between May 1998 and June 2000 off-pump coronary endarterectomy was performed on 11 patients who had unstable angina pectoris. The mean ejection fraction (EF) was 26.3 ± 4.4, and all of the patients were New York Heart Association (NYHA) III or IV. Off-pump open left anterior descending (LAD) endarterectomy was performed on 7 patients, and closed endarterectomy of the right coronary artery (RCA) was done on the remaining 4. Results There were no deaths. None of the procedures was converted to on-pump operation; all the endarterectomies and bypasses were performed on the beating heart. All patients were completely revascularized, the left internal mammary artery was bypassed to the LAD in all operations, and all other grafts were of saphenous vein. At the end of the first year all bypasses to the endarterectomized arteries were patent. The overall patency rate was 95.6%. The mean postoperative EF was 34.7 ± 9.1, which was significantly higher than the preoperative one ( p < 0.05). At the end of the first year 9 patients were NYHA I or II and all were angina free in Canadian Cardiovascular Society class 0 or I. Conclusions Endarterectomy without cardiopulmonary bypass can be performed in patients with severe left ventricular dysfunction who are expected to benefit from the complete revascularization.