Off-pump Group Research Articles

P312 Early changes of left ventricular myocardial work performance in patients undergoing coronary artery bypass surgery: off-pump vs. on-pump

Abstract Background Coronary-artery bypass grafting (CABG) without the use of cardio-pulmonary bypass (CPB) was introduced to avoid the potential damaging effects of fpreign surfaces. Nevertheless, the value of off-pump CABG (OPCAB) remains controversial. Regional myocardial work has been shown to reflect regional metabolic demand and provide a more comprehensive assessment of myocardial function. Recently a novel non-invasive method for assessing regional MW by LV pressure–strain loop analysis has been described. Purpose To detect changes of MW after CABG comparing off- and on-pump techniques. Methods We prospectively evaluated 93 patients undergoing CABG (50 on- vs. 43 off-pump). Patients underwent transthoracic echocardiography exams prior to and one week after surgery as well as concurrently systolic arterial blood pressure measurements at rest. Besides conventional echocardiography parameters, wemeasured global longitudinal strain (GLS), global work index (GWI) and global work efficiency (GWE). Results All patients survived surgery. Patients in the OPCAB group had significantly higher EuroSCORE II (3.3% vs. 1.1%, p < 0.001). Preoperatively, OPCABgroup had significantly lower EF (50.1 vs. 55.7%, p = 0.004), lower GWI (1411 vs. 1650mmHg%, p = 0.039) and lower GWE (86.7 vs. 91.6%, p = 0.017). GLS did not differ significantly between off- and on-pump groupspreoperatively. However, postoperatively GLS, MWI, MWE and EF decreased significantly within the on-pump group (p < 0.001, p < 0.001, p < 0.001 and p = 0.002, respectively). In the OPCAB group only GWI and GLSdecreased significantly (p = 0.028 and p = 0.017, respectively). Due to the fact, that mean differences between all pre- and postoperative values were higher in the on-pump group, no significant differences in systolic LV-function (sLVF) could be detected between on- and off-pump patients postoperatively. During the early postoperative phase, no correlation between GWI and GWE and clinical outcomes could be detected, onlylower preoperative-GWI values showed a weak correlation with the incidence of postoperative cardiogenic shock (r= -0.27, p = 0.029). Conclusion Despite having worse preoperative sLVF in the off-pump group determined by EF, GLS, GWI and GWE, the decrease in sLVF parameters was significantly higher in the on-pump group, leading to an equal distribution of LV-function parameters between off- and on-pump patients postoperatively. Our results suggest that off-pump CABG provides a better preservation of LV-function.

Mortality and Readmissions After On-Pump Versus Off-Pump Redo Coronary Artery Bypass Surgery

IntroductionLarge institutional and administrative datasets that have compared on pump versus off pump first time coronary artery bypass grafting (CABG). However, comparison of off-pump vs on-pump outcomes in patients undergoing redo CABG are limited in current literature. MethodsAll patients who underwent redo CABG for coronary artery disease from 2011 to 2017 at our institution were included in the study. Cox regression analysis was performed to identify variables associated with 5-year mortality and readmission. ResultsThree hundred and fifty patients underwent redo CABG; of which, 309 underwent on-pump CABG and 41 underwent off-pump CABG. Blood product transfusion (31.7% vs 58.9%; p = 0.001) and new onset atrial fibrillation (17.1% vs 35.6%; p = 0.018) were higher in the on-pump cohort. There was no difference in 30-day (2.4% vs 8.1%; p = 0.209), 1-year (4.9% vs 16.5%; p = 0.074), or 5-year mortality (31.7% vs 35.6%; p = 0.213) for off vs on pump redo CABG. There was no difference in 30-day or 1- hospital readmissions between groups. Five-year all cause readmissions (76.9% vs 55.3%; p = 0.037) was significantly higher in the off-pump redo CABG group. On multivariable analysis, on vs. off pump CABG was not significantly associated with mortality or readmission at 5 years. ConclusionThere was no short or long-term survival advantage for on-pump vs off-pump CABG despite risk adjustment. Hospital readmissions at 5-years were higher in the off-pump group.

Graft patency at 3\xa0months after off- and on-pump coronary bypass surgery: a randomized trial

PurposeCoronary artery bypass grafting (CABG) is performed either with the aid of cardiopulmonary bypass (on-pump) or without cardiopulmonary bypass (off-pump). There is a scarcity of angiographic data to support the non-inferiority of off-pump technique to on-pump technique. The objective of this study is to ascertain the non-inferiority of off-pump CABG when compared to on-pump CABG in terms of angiographically assessed graft patency at 3 months.MethodsA total of 320 patients with multivessel coronary artery disease were enrolled in a multicenter prospective randomized trial either to on-pump CABG (n = 162) or off-pump CABG (n = 158) between March 2016 through March 2017. Graft patency was evaluated by using either multidetector computerized tomographic angiography or conventional coronary angiography at 3 months. The major adverse cardiac and cardiovascular events (MACCE) were also analyzed at 3 months.ResultsThe median number of grafts per patient in off-pump was 3.00 (Q1:3.00 and Q3:4.00) vs on-pump 4.00 (Q1:3.00 to Q3:4.00), and the mean number of grafts per patient was lower in the off-pump CABG at 3.45 ± 0.75 vs 3.64 ± 0.70 in the on-pump CABG (p = 0.01). There was no significant difference in mortality at 3 months between the off-pump (0.63%) and on-pump groups (1.85%) with p value of 0.62. The cumulative combined MACCE showed significant difference between off-pump group (0.63%) and on-pump group (5.55%), p = 0.01. Follow-up angiograms were done in 239 (75%) patients with 120 off-pump and 119 in the on-pump group. The analysis was also done regarding graft patency in a graded manner—when analysis of A (excellent) grafts vs B (stenosed) grafts and O (occluded) grafts were made, there was no statistically significant difference in overall graft patency at 3 months between on-pump [376 /429 grafts (87.6%)] and off-pump [366 /420 grafts (87.1%)] groups (p = 0.82). The patency rates were similar among bypass conduits (left internal thoracic artery (ITA) in off-pump (91.4%) vs on-pump (92.9%) p = 0.66, right ITA in off-pump (82.1%) vs on-pump (81.8%) p = 0.97, radial artery in off-pump (84.4%) vs on-pump (82.6%) p = 0.81; saphenous vein in off-pump (85.8%) vs on-pump (86.3%), p = 0.86 and among 3 coronary territories.ConclusionsOff-pump CABG is non-inferior to on-pump CABG in terms of overall graft patency at 3 months and was associated with a fewer combined cumulative MACCE compared to on-pump CABG.

Incidence and impact of silent brain lesions after coronary artery bypass grafting

ObjectiveSilent brain lesions are known to occur after coronary artery bypass grafting (CABG). The aim of this study was to seek the incidence rate, the influence of procedures, and their impact on the postoperative course. MethodsFrom July 2016 to April 2018, 104 consecutive patients undergoing elective and isolated first-time CABG (65 off-pump and 39 on-pump) were enrolled. New brain lesions were evaluated by brain magnetic resonance imaging both before and after CABG. Postoperative outcomes, including cognitive function, were compared between patients with and without brain lesions. ResultsThe overall incidence of new brain lesions was 20.1% (21/104). Excluding one symptomatic stroke case, silent brain lesions were revealed in the remaining patients. The percentage of on-pump CABG (61.9% [13/21] vs 31.3% [26/83], P = .019) and aortic clamp (52.4% [11/21] vs 24.1% [20/83], P = .014) were significantly greater in patients with brain lesions. Brain lesions were observed in 12.3% and 15.8% of patients in the off-pump and anaortic CABG. The Katz Index of Independence in Activities of Daily Living was significantly lower in patients with brain lesions (from 5.8 ± 0.9 to 5.4 ± 1.2 vs from 5.9 ± 0.5 to 5.9 ± 0.6, P = .013). In patients with new lesions, postoperative cognitive dysfunction (POCD) was observed only in multiple lesions, and the maximum size was significantly greater in patients with POCD. ConclusionsMagnetic resonance imaging of the brain frequently detected postoperative silent brain lesions after CABG in off-pump and aorta non-touch groups. Multiple and larger new brain lesions were associated with the development of POCD.

Early and long-term outcomes of coronary artery bypass surgery with and without use of heart-lung machine and with special respect to renal function - A retrospective study.

The aim of our study was to compare early and long-term outcome of patients undergoing either on-pump or off-pump coronary artery bypass grafting with special focus on impairment of renal function. Five hundred ninety-three consecutive patients undergoing coronary artery bypass grafting were retrospectively analyzed. They were assigned either to on-pump (n = 281) or to off-pump (n = 312) group. Early and long-term outcomes were analyzed with special focus on renal function. Basic demographics and preoperative characteristics did not differ between groups (p>0.05) as well as postoperative renal parameters (p>0.05). Postoperative odds ratios (OR) of off-pump group in comparison to on-pump group were higher without reaching significance in terms of incidence of gastrointestinal complications and pneumonia (OR = 2.23 and 1.61, respectively) as well as hazard ratios (HR) on long-term follow-up for mortality and incidence of myocardial infarction (HR = 1.50 and 2.29, respectively). Kaplan-Meier estimation analysis also revealed similar results for both groups in terms of mid- and long-term survival (Breslow p = 0.062 and Log-Rank p = 0.064, respectively) and for incidence of myocardial infarction (Breslow p = 0.102 and Log-Rank p = 0.103, respectively). Our study suggests that use or not use of coronary artery bypass did not influence postoperative renal function. Odds of early outcomes were similar in both groups as well as incidence of myocardial infarction and mortality in long-term follow-up.

Effects of Coronary Artery Bypass Grafting Surgery on Olfactory and Taste Functions.

Olfactory and taste sensations have a high impact on the quality of life. Impaired olfactory and taste functions may have a negative effect on physical and mental well-being, personal hygiene, and nutritional satisfaction, leading to the occurrence of depressive symptoms and impaired quality of life. Therefore, the recovery period of patients with disturbed olfactory and taste functions may be prolonged, and return to active life may be delayed. We designed this study to determine whether on-pump and off-pump coronary artery bypass grafting (CABG) surgeries have any effects on olfactory and taste functions and compare these functions between the surgical groups. A total of 60 patients, who underwent elective isolated first-time CABG, were included in this study. Patients were divided into two groups as Off-Pump and On-Pump CABG groups with 30 patients in each group. In addition to patients' primary clinical and laboratory data, olfactory and taste functions were evaluated pre- and postoperatively in both groups separately, and then these functions were compared between the groups. Olfactory functions were evaluated by the Brief Smell Identification Test, while taste functions by the Burghart Taste test. Olfactory functions significantly were disrupted in the postoperative period in patients undergoing on-pump CABG (P value < .05), while these functions significantly were not affected in patients undergoing off-pump CABG (P value > .05). During the preoperative period, advanced age and smoking were detected to be independent predictors of impaired olfactory function for the study population. During the postoperative period, smoking, amount of postoperative bleeding and serum low-density lipoprotein (LDL) level were found to be independent predictors of impaired olfactory function for just the On-Pump CABG Group. In both groups, no significant deterioration in taste functions occurred during the postoperative period (P value > .05). Our study demonstrated that olfactory function was impaired in patients, who underwent on-pump CABG in the postoperative period, and significant impairment in taste function was present in neither off-pump nor on-pump CABG patients. However, the results of our study should be supported by more comprehensive, prospective, randomized controlled trials with more extensive patient series and by further tests.

On-pump ve Off-pump Koroner Arter Bypass Greft Ameliyatı Yapılan Hastaların Cerrahi Sonuçlarının Karşılaştırılması

Aim: The aim of this study is to evaluate the clinical results of the patients undergoing off-pump and on-pump coronary artery bypass grafting (CABG) retrospectively in consideration of current literature.Material and Methods: A total of 1672 patients undergoing CABG between October 2014 and August 2016 and having a postoperative sinus rhythm were enrolled in the study. Patients who underwent an additional procedure in addition to CABG and underwent open heart surgery except CABG were excluded from the study. Off-pump CABG was applied to 783 and on-pump CABG to 889 of 1672 patients.Results: In comparison of operative data, duration of operation (p&amp;lt;0.001), number of bypasses to the coronary arteries (p&amp;lt;0.001), number of bypasses of the right coronary artery to the posterior descending artery (p&amp;lt;0.001), and diffuse coronary artery disease (p&amp;lt;0.001) were less in the off-pump CABG group and there was a statistically significant difference. In comparison of postoperative data, postoperative atrial fibrillation development (p&amp;lt;0.001), intubation time (p&amp;lt;0.001), intensive care unit stay (p&amp;lt;0.001), length of hospital stay (p&amp;lt;0.001), reexploration (p=0.006), vasopressor drug usage (p&amp;lt;0.001), positive inotropic drug usage (p&amp;lt;0.001), total drainage (p&amp;lt;0.001), blood and blood product used (p&amp;lt;0.001), and mortality rate (p=0.001) were less in the off-pump CABG group and statistically significant difference was found between groups.Conclusion: In this study, we found that off-pump CABG has many advantages. In a selected group of patients having a coronary artery disease performing CABG in beating heart would avoid the patient from morbid and mortal negative effects of cardiopulmonary bypass.

Surgical Treatment for Stand-Alone Atrial Fibrillation in North America

Surgical treatment of symptomatic atrial fibrillation has been performed for 3 decades. We reviewed trends and outcomes of surgical ablation (SA) for stand-alone atrial fibrillation using The Society of Thoracic Surgeons Adult Cardiac Surgical Database (STS-ACSD). The STS-ACSD was reviewed from 2011 to 2017 (N = 7187) for trends. Contemporary data from 2014 to 2017 (n= 3893) were used to compare three subgroups: off pump (n= 3252), on pump (n= 491), and patients with incision conversion or conversion from off pump to on pump (n = 150). Propensity score matching was conducted to balance groups. Annual growth of stand-alone SA was 7%. Median age of patients was 64 years (interquartile range, 57 to 70), and 30% were female. Overall 30-day mortality was 0.8% and perioperative stroke incidence was 0.8%. Most SA procedures were off pump (84%), with 12% greater odds for off pump per year (odds ratio [OR] 1.12, P < .001). The off-pump group had fewer biatrial SA (21% vs 71%, P < .001) and left atrial appendage obliterations (53% vs 95%, P < .001) compared with the on-pump group. After matching, uneventful off-pump SA had similar mortality (0.4% vs 0.9%, P= .292) vs on-pump SA, but reduced incidence of renal failure (0.9% vs 2%, P= .033). After risk adjustment, the conversion group had worse perioperative outcomes vs the off-pump group, including greater incidence of stroke (OR 5.37, P< .001) and operative mortality (OR 9.98, P < .001). Mortality (OR 4.69, P= .011) was also greater for conversion vs on pump. Steady growth of stand-alone SA operations was noted. Procedures performed either on pump or off pump were relatively safe. However, intraoperative conversion was associated with significantly higher morbidity and mortality. Patient selection, improvement of surgical techniques, and long-term follow-up should be emphasized to improve decision making and outcome.

Off-Pump Versus On-Pump Bypass Surgery for Left Main Coronary Artery Disease

BackgroundConcerns remain for a greater risk of incomplete revascularization and reduced survival with off-pump coronary artery bypass grafting (CABG) surgery compared with on-pump surgery particularly in patients with left main disease and extensive underlying myocardial ischemia. ObjectivesThis study sought to compare outcomes following off-pump versus on-pump surgery for left main disease by performing a post hoc analysis from the multicenter, randomized EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial. MethodsThe EXCEL trial was designed to compare percutaneous coronary intervention with everolimus-eluting stents versus CABG in patients with left main disease. CABG was performed with or without cardiopulmonary bypass (on-pump vs. off-pump surgery) according to the discretion of the operator. The 3-year outcomes in the off-pump and on-pump groups were compared using inverse probability of treatment weighting (IPTW) for treatment effect estimation. ResultsAmong 923 CABG patients, 652 and 271 patients underwent on-pump and off-pump surgery, respectively. Despite a similar extent of disease, off-pump surgery was associated with a lower rate of revascularization of the left circumflex coronary artery (84.1% vs. 90.0%; p = 0.01) and right coronary artery (31.1% vs. 40.6%; p = 0.007). After IPTW adjustment for baseline differences, off-pump surgery was associated with a significantly increased risk of 3-year all-cause death (8.8% vs. 4.5%; hazard ratio: 1.94; 95% confidence interval: 1.10 to 3.41; p = 0.02) and a nonsignificant difference in the risk for the composite endpoint of death, myocardial infarction, or stroke (11.8% vs. 9.2%; hazard ratio: 1.28; 95% confidence interval: 0.82 to 2.00; p = 0.28). ConclusionsAmong patients with left main disease treated with CABG in the EXCEL trial, off-pump surgery was associated with a lower rate of revascularization of the coronary arteries supplying the inferolateral wall and an increased risk of 3-year all-cause death compared with on-pump surgery.

Neurological outcomes after on-pump vs off-pump CABG in patients with cerebrovascular disease.

The possible association of off-pump coronary artery bypass graft (CABG) with reduced risk of postoperative stroke and enhanced benefits in high-risk patients support the hypothesis that patients with a positive history of cerebrovascular disease would benefit from off-pump coronary surgery. This study aims to investigate the impact of off-pump CABG on the incidence of postoperative neurologic events in patients with a previous history of cerebrovascular disease. From January 2015 to September 2018, 414 patients underwent isolated CABG with a previous history of transient ischemic attack (TIA) or stroke: 295 patients had on-pump CABG and 119 patients had off-pump CABG. Neurological outcomes of interest are postoperative stroke (transient or permanent), delirium requiring pharmacological treatment or a combination of both, collectively defined "Major Adverse Neurological Events" (MANE). Propensity score (PS) adjusted analysis has been used for regression models. Off-pump CABG carried a lower incidence of postoperative stroke (3.4% vs 9.8%, P = .046, PS-adjusted odds ratio 0.34 with P = .044). Postoperative delirium occurred more than twice as often in the on-pump group (11.5% vs 4.2%, P = .034, PS-adjusted odds ratio 2.78 with P = .043). The composite outcome of MANE occurred in 20.3% in the on-pump group, and in 7.6% in the off-pump group (P = .003). Other complications were similar between groups. In patients with a previous TIA or stroke, off-pump CABG is associated with a reduced risk of stroke, delirium, and postoperative adverse neurological events, compared to on-pump CABG. Patients with high neurological risk can potentially benefit from off-pump CABG, due to an overall reduction of postoperative neurological complications.

PREOPERATIVE PREDICTIVE VALUE OF ECHOCARDIOGRAPHIC CHARACTERISTICS AND CARDIOVASCULAR RISK FACTORS IN POSTOPERATIVE ATRIAL FIBRILLATION

Objective: Postoperative atrial fibrillation (POAF) is the most common arrhythmia in patients after isolated coronary artery bypass grafting (CABG).With a reported incidence between 10% and 40%, it is associated with an increased morbidity, mortality and prolonged hospitalization which is very often followed by an increased hospital-related complications and costs.The aim of this study was to identify significant preoperative predictors for non-valvular POAF in patients undergoing CABG. Design and method: Retrospective study included 226 consecutive patients revascularized at Clinic of Cardiac Surgery, Clinical Center of Serbia, during the four months’ period. Patients were divided in two groups: on-pump (N: 176) and off-pump (N: 50). In both groups, we investigated the association of demographic characteristics (gender, age), echocardiographic characteristics (left ventricular systolic function, preoperative size of the left atrium and left ventricle) and cardiovascular risk factors (arterial hypertension, diabetes, hyperlipidemia) with the occurrence of non-valvular POAF, using the Logistic regression analysis. Exclusion criteria were severe MR and preoperative AF. Results: The incidence of POAF was 23.45% (on-pump: 22.2%, off-pump: 28%; p > 0.05). There were statistically significant differences between two study groups considering: left ventricular systolic function (X2 = 12,896; p < 0,001), preoperative size of the left atrium (X2 = 13,046; p < 0,001) and left ventricle (EDD:t = 3,439; p = 0,001, ESD: t = 3,162; p = 0,002) and presence of diabetes mellitus (X2 = 6,841; p = 0,009). In the off-pump group, an independent preoperative predictor of POAF was preoperative size of left atrium (OR 34.000; 95% CI 1.479–781.787; p: 0.027). Paradoxically, an independent inverse relationship of preoperative arterial hypertension and the risk of POAF was documented in the on-pump group(OR 0.088; 95% CI 0.009–0.874; p: 0.038), most likely due to the more frequent preoperative use of beta-blockers in patients with a history of hypertension. Conclusions: We found that patients with very enlarged left atrium (>5 cm) had significantly higher risk of POAF. Independent preoperative predictors for POAF are preoperative size of left atrium in off-pump and arterial hypertension in on-pump revascularized patients.

PREOPERATIVE PREDICTIVE VALUE OF HYPERTENSION, ECHOCARDIOGRAPHIC CHARACTERISTICS AND OTHER CARDIOVASCULAR RISK FACTORS IN POSTOPERATIVE ATRIAL FIBRILLATION

Objective: Postoperative atrial fibrillation (POAF) is the most common arrhythmia in patients after isolated coronary artery bypass grafting (CABG). The incidence is between 10% and 40%, and is associated with an increased morbidity, mortality and prolonged hospitalization. The aim of this study was to identify significant preoperative predictors for non-valvular POAF in patients undergoing CABG. Design and method: We included 226 consecutive patients, revascularized at Cardiac Surgery Clinic, Clinical Center of Serbia, during the four months’ period. Patients were divided in two groups: on-pump (N: 176) and off-pump (N: 50). In both groups, we investigated the association of demographic characteristics (gender, age), echocardiographic characteristics (left ventricular systolic function, preoperative size of the left atrium and left ventricle) and cardiovascular risk factors (arterial hypertension, diabetes, hyperlipidemia) with the occurrence of non-valvular POAF, using the logistic regression analysis. Exclusion criteria were severe MR and preoperative AF. Results: The incidence of POAF was 23.45% (on-pump: 22.2%, off-pump: 28%; p > 0.05). There were statistically significant differences between two study groups considering: left ventricular systolic function (p < 0,001), preoperative size of the left atrium (p < 0,001) and left ventricle (p = 0,001, ESD: p = 0,002) and presence of diabetes mellitus (p = 0,009). In the off-pump group, an independent preoperative predictor of POAF was preoperative size of left atrium (p: 0.027). Paradoxically, an independent inverse relationship of preoperative arterial hypertension and the risk of POAF was documented in the on-pump group (p: 0.038), most likely due to the more frequent preoperative use of beta-blockers in patients with a history of hypertension. Conclusions: We found that patients with very enlarged left atrium (>5 cm) had significantly higher risk of POAF. Independent preoperative predictors for POAF are preoperative size of left atrium in off-pump and arterial hypertension in on-pump revascularized patients.

Long Term Outcomes of The Off-Pump and On-Pump Coronary Artery Bypass Grafting In A High-Volume Center

Coronary artery bypass grafting (CABG) remains the most frequent surgery in the practice of an adult cardiac surgeon and the most frequently performed cardiac surgical procedure worldwide. Despite the ongoing debates regarding the superiority or inferiority of off-pump coronary artery bypass grafting, it still comprises 15–30% of all CABG cases varying in different national registries. We performed a propensity matched study of 302 consecutive CABG patients,143 off -pump cases performed by the four experienced off-pump surgeons and the on-pump CABG cases performed by those surgeons and four other experienced coronary surgeons. The five year follow up was performed and data collected comprised of mortality, rehospitalization due to cardiac origin, repeated revascularization, myocardial infarction and cerebrovascular accident. Overall, the off-pump group of patients had a higher risk profile than the patients in the on-pump group. After matching, fewer differences were found between the groups. Propensity score matching analysis showed no difference in long-term survival as well as MACCE and repeated revascularization. The higher risk profile of the patients subjected to OPCAB and the comparable survival to lower risk CPB patients in this series indicate that in experienced hands, OPCAB is a valuable option in this important subgroup of patients.

Off-pump versus on-pump redo coronary artery bypass grafting: A propensity score analysis of long-term follow-up

ObjectiveRedo coronary artery bypass grafting (CABG) is associated with an increased early mortality reported up to 16%. The aim of this study was to analyze the early and long-term results after redo CABG with special focus on the feasibility and safety of the off-pump technique in the setting of a high-volume off-pump CABG center. MethodsFrom January 2006 to June 2015, isolated redo CABG was performed in 304 patients (179 = on-pump redo CABG, 125 = off-pump redo CABG). We used propensity score matching with 14 preoperative variables to adjust for differences in baseline characteristics between the on-pump redo CABG and the off-pump redo CABG groups. After 1:1 matching we selected 108 pairs for each group. Mean follow-up rate was 4.01 years. ResultsThe final sample was 83.9% men (n = 225) with a mean age of 69.77 ± 8 years. After propensity score matching there was a significant difference in the total number of grafts performed in favor of on-pump redo CABG (P = .011), whereas 66.7% (72 out of 108) of off-pump redo CABG patients received total arterial grafts. Off-pump redo CABG patients had a lower rate of postoperative renal failure necessitating dialysis (4.6% vs 0%; P = .06), required less recovery time in the intensive care unit (1.33 ± 1.03 days vs 4.4 ± 7.98 days; P < .001) and were discharged more quickly (10.08 ± 5.35 days vs 14.1 ± 10.6 days; P = .001). Off-pump redo CABG led to better long-term survival (log-rank test, P = .086). ConclusionsIn our study, patients undergoing off-pump redo CABG had fewer postoperative complications, achieved faster recovery, and had better long-term survival. Hence, off-pump redo CABG is safe and feasible.

Intermittent on-pump beating-heart coronary artery bypass grafting-a safer option.

On-pump beating-heart coronary artery bypass grafting represents a merger of standard on and off-pump techniques and is thought to benefit patients by coupling the dual absence of cardioplegic arrest (conventional coronary surgery), with the hemodynamic instability during manipulation seen in off-pump surgery. However, the clinical benefits are still under discussion. We improvised on the standard on-pump beating-heart surgeries by introducing use of "intermittent" bypass as and when required. This study involved 108 patients. "Intermittent" on-pump-beating heart coronary artery bypass grafting was done using suction stabilizer and placing aortic and venous cannula, electively in all patients (group 1) who were supported by pump intermittently (n = 54). Retrospective data of patients who underwent off-pump surgery electively by the same surgeon (group 2, n = 54) was collected. There was a significant advantage in the number of grafts performed for the lateral surface (circumflex branches) using the new technique compared to conventional technique (68vs22). Similarly, significant advantage was also noted in terms of total number of grafts along with shorter operating times. There were no mortalities in the new group compared to the off-pump group and blood loss was also lesser. "Intermittent" on-pump coronary revascularization is a technically reliable method of coronary revascularization taking advantage of the off-pump and conventional on-pump techniques while considerably eliminating the disadvantages of both. It has shown its superiority in safety, number of grafts, blood loss, operating time and perioperative course.

Clinical Outcome of CABG on Off-pump Beating Heart and On-pump Beating Heart: Experience in Ibrahim Cardiac Hospital &amp; Research Institute (ICHRI)

Background: To avoid harmful effect of cardiopulmonary bypass (CPB) used in off-pump coronary artery bypass graft (CABG) surgery, cardiac surgeons are now inclined to on-pump beating heart surgery (ONBEAT). However, the superiority of ONBEAT over Off-pump has not yet been conclusively established. This study compares the outcomes between off-pump and on pump beating heart CABG surgery.&#x0D; Methods: A total 249 consecutive patients who underwent non-emergency, primary isolated CABG from January 2014 to December 2017 by a single surgeon were included. The selected patients were assigned to either OPCAB group (Patients who received Off-pump beating heart CABG surgery, n=193) or to ONBEAT group (patients who received On-pump beating heart CABG surgery, n=56). The clinical outcomes were investigated and compared.&#x0D; Result: Forty percent of the patients were in their 5th decade of life. A male predominance was also observed. The two study groups were almost identical in terms of age and sex (p=0.983 and p=0.153 respectively). None of the conventional risk factors of ischemic heart disease (smoking, diabetes, hypertension and dyslipidaemia) were any different between the study groups (p &gt; 0.05). Cerebrovascular disease, recent MI, congestive heart failure and left main disease were significantly higher in the on-pump beating heart group compared to those in the off-pump beating heart group (p &lt; 0.05). The left ventricular ejection fraction (LVEF) was significantly lower in the former group than that in the latter group (p= 0.007). Both groups required 3 grafts on an average. Two patients in the on-pump group required Intra-Aortic Balloon Pump (IABP) support as opposed to none in the off-pump group (p=0.050). The mean cardiopulmonary bypass (CPB) time was 105.8 ± 46.5 in the on-pump group. Fourteen patients (25%) from off-pump group needed urgent switching to on-pump group. Postoperative drainage in the first 24 hours was significantly voluminous in the on-pump group (p &lt; 0.001). The incidence of pneumonia, respiratory failure, arrhythmia, renal failure requiring haemodialysis and perioperative MI were significantly higher in the on-pump group (p &lt; 0.001, p &lt; 0.001, p=0.037, p &lt; 0.001 and p=0.050 respectively). The patients with prolonged mechanical ventilation were also more in the on-pump group. The left ventricular ejection fraction (LVEF) was much lower and Intensive Care Unit (ICU) stay was longer in the on-pump group compared to those in the off-pump group (p &lt; 0.001). The incidence of in-hospital mortality was also higher in the former group (p=0.037).&#x0D; Conclusion: OPCAB was associated with lower operative morbidity compared to ONBEAT cardiac surgery. However, the increased morbidity in ONBEAT group might have been influenced by a sizable proportion of patients from OPCAB group being switched to ONBEAT group due to their haemodynamic deterioration and frequent ventricular fibrillation. But on-pump CABG can be performed safely on high risk patients. Use of cardiopulmonary bypass and elimination of cardioplegic arrest may be beneficial to hemodynamically unstable patients.&#x0D; Ibrahim Card Med J 2017; 7 (1&amp;2): 15-22

Energy expenditure measured using indirect calorimetry after elective cardiac surgery in ventilated postoperative patients: A prospective observational study

Summary Background & aims Resting energy expenditure (REE) following cardiac surgery is not determined. We conducted this prospective observational study to clarify this, comparing REE to basal energy expenditure (BEE) estimated using the Harris-Benedict equation (HBE). Methods Consecutive patients who underwent cardiac surgery (coronary artery bypass graft sursgery, valve surgery, and total arch replacement) in our hospital from September 2013 to March 2015 were included. Patients who were Results We enrolled 47 patients. Mean age, body weight, and height were 73 ± 10 years (mean ± standard deviation), 55 ± 10 kg, and 155 ± 10 cm, respectively. BEE was 1147 ± 148 kcal/day. The average REE during ventilation was 1314 ± 148 kcal/day (23.9 ± 6.8 kcal/kg/day), significantly higher than estimated BEE (114 ± 35% BEE, p Conclusions REE was 1314 ± 148 kcal/day (23.9 ± 6.8 kcal/kg/day), or 1.14 times higher than the estimated BEE, in postoperative cardiac surgery patients. The average REE was not significantly different between the on-pump and off-pump groups.

Comparison of intestinal ischemia after on-pump versus off-pump coronary artery bypass grafting surgery

Background/aim Acute mesenteric ischemia (AMI), one of the gastrointestinal system complications, which occurs following cardiac surgery, is challenged in the literature with a diminished incidence of AMI by heart surgery without cardiopulmonary bypass (CPB) or with pulsatile CPB. This study aims to compare the incidence and mortality rate of mesenteric ischemia in a series of consecutive patients undergoing coronary artery bypass grafting (CABG) through on-pump and off-pump techniques.Materials and methods This study included patients who underwent CABG between 1 January 2010 and 31 June 2016. All patients were divided into two groups: Group 1 comprised 6396 CABG patients operated on with the off-pump technique. Group 2 included 1210 patients who received CABG with the on-pump technique. Preoperative data were collected on the studied variables. Postoperative data included the development of intestinal ischemia and in-hospital mortality.Results Of 7606 consecutive CABG patients, a total of 31 (0.4%) developed intestinal ischemia. The incidence of postoperative mesenteric ischemia was 0.28% in Group 1 and 1.07% in Group 2 (P = 0.000). The survival rates after AMI were 61.1% in Group 1 (off-pump) and 7.7% in Group 2 (on-pump) (P = 0.003). Time from the first occurrence of nonspecific GI complaints to laparotomy was similar in the off-pump and on-pump groups and had no effect on mortality.Conclusions: With regard to the incidence of mesenteric ischemia and survival after laparotomy, off-pump CABG patients revealed significant improvement compared with those operated on with the on-pump technique.

Coronary Artery Bypass in Young Patients-On or Off-Pump?

A definitive conclusion regarding whether on-pump or off-pump coronary artery bypass is preferable in young patients is lacking. The aim of our study was to perform a long-term comparison of the two approaches in young patients. We analyzed the National Health Insurance Research Database, using data for patients between 18 and 45 years of age who had undergone isolated coronary artery bypass between 2001 and 2011. The study endpoints were: all-cause death, major adverse cardiac and cerebrovascular events, and repeat revascularization within 30 days, 1 year, 5 years, and the entire 10-year follow-up period. A total of 344 patients received off-pump surgery and 741 patients received on-pump surgery. Preoperative characteristics and comorbidities were similar in both groups, and all-cause mortality was almost equal (p = 0.716). The 5-year survival rates were 93.9% and 92.2% in the off-pump and on-pump groups, respectively, and the 10-year survival rates were 86.3% and 82.1%, respectively. The repeat revascularization rate was significantly lower in the on-pump group (p = 0.0407). Both the on-pump and off-pump methods offer equally good long-term outcomes in terms of mortality and major adverse cardiac and cerebrovascular events. However, the need for repeat revascularization is a concern in the long term after off-pump surgery.

Effect of cardiopulmonary bypass versus off-pump coronary artery bupass grafting on platelet inhibition rate and Aspirin resistance after coronary artery bypass grafting surgery

Objective To investigate the effect of cardiopulmonary bypass(CPB)on platelet inhibition rate(INHAA)and Aspirin resistance(AR)after coronary artery bypass grafting(CABG)surgery. Methods A total of 114 patients undergoing CABG surgery were divided into two groups: on-pump group(n=54)and off-pump group(n=60). Aspirin treatment(100 mg/d)was paused 7 days before surgery and continued 6 hours after surgery.INHAA was detected and calculated by using thrombelastography(TEG)at 6 hours after taking the last dose of aspirin before surgery(T0), 12 hours(T1), 5 days(T2), 10 days(T3)and 15 days(T4)after surgery respectively.The incidence of AR was calculated. Results There was no significant difference in the overall INHAA between the two groups of on vs.off-pump(F=0.336, P=0.563), while the differences of INHAA index at each time point was statistically significant between two groups of on vs.off-pump(F=95.519, P=0.000). There was an interaction effect of timing and grouping(F=15.500, P=0.000). In comparison of INHAA between the two groups of on vs.off-pump at each time point, INHAA was higher in on-pump group than in off-pump group at T1(P 0.05). In the on-pump group, the total difference of INHAA at different time points was significant(P 0.05). In comparison of AR incidence after CABG surgery between two groups of on vs.off-pump at each time point, the incidence of AR was lower in on-pump group than in off-pump group at T1(P 0.05). Conclusions The increase of platelet inhibition rate and aspirin resistance occurs in early period after CABG surgery.The platelet inhibition rate is higher and aspirin resistance rate is lower in on-pump group than in off-pump group at 12 h after surgery, and the platelet inhibition rate is lower at 5 days after CABG surgery in on-pump group than in off-pump group.CPB has little effect on the platelet inhibition rate and on the incidence of AR after 5 days of CABG surgery. Key words: Coronary artery disease; Extracorporeal circulation; Platelet aggregation inhibitors