Off-pump Surgery Research Articles

Machine Learning-Based Cardiac Output Estimation Using Photoplethysmography in Off-Pump Coronary Artery Bypass Surgery

Background/Objectives: Hemodynamic monitoring is crucial for managing critically ill patients and those undergoing major surgeries. Cardiac output (CO) is an essential marker for diagnosing hemodynamic deterioration and guiding interventions. The gold standard thermodilution method for measuring CO is invasive, prompting a search for non-invasive alternatives. This pilot study aimed to develop a non-invasive algorithm for classifying the cardiac index (CI) into low and non-low categories using finger photoplethysmography (PPG) and a machine learning model. Methods: PPG and continuous thermodilution CO data were collected from patients undergoing off-pump coronary artery bypass graft surgery. The dataset underwent preprocessing, and features were extracted and selected using the Relief algorithm. A CatBoost machine learning model was trained and evaluated using a validation and testing phase approach. Results: The developed model achieved an accuracy of 89.42% in the validation phase and 87.57% in the testing phase. Performance was balanced across low and non-low CO categories, demonstrating robust classification capabilities. Conclusions: This study demonstrates the potential of machine learning and non-invasive PPG for accurate CO classification. The proposed method could enhance patient safety and comfort in critical care and surgical settings by providing a non-invasive alternative to traditional invasive CO monitoring techniques. Further research is needed to validate these findings in larger, diverse patient populations and clinical scenarios.

The Impact of Intraoperative Transit-Time Flow Measurement on Off-Pump and On-Pump Bypass Surgery Based on Three Months: A Propensity Score Matching Study

Background: The goal of this study was to investigate how transit-time flow measurement (TTFM) parameters influenced the success of coronary bypass surgeries using the on-pump coronary artery bypass (ONCAB) and off-pump coronary artery bypass (OPCAB) techniques and to compare the rates of early graft failure and major adverse cardiac and cerebrovascular events (MACCE). Methods: We retrospectively analyzed subjects who underwent coronary bypass surgery at our institution between 2017 and 2023 and compared the TTFM data of patients divided into two groups based on the surgical method: ONCAB and OPCAB. We compared the postoperative and first three months' MACCE data to assess the impact of TTFM on the two surgical methods. Results: Of the 2032 patients who underwent coronary bypass, we analyzed data from 1540 patients in the ONCAB group and 194 patients in the OPCAB group. After propensity score matching, the TTFM data of 192 patients in both groups were compared. In the ONCAB group, a mean of 3.28 ± 0.7 grafts per patient was used, while 2.22 ± 0.6 grafts were used in the OPCAB group (p = 0.001). TTFM identified problems with 19 (4.7%) grafts in the ONCAB group and 29 (8%) grafts in the OPCAB group, leading to their revision (p = 0.001). Overall, the pulsatile index (PI) values in the OPCAB group were significantly higher than in the ONCAB group. Hospital mortality was 3.1% in the ONCAB group and 2.6% in the OPCAB group (p = 0.286). MACCE and graft failure rates were similar in the first three months. Conclusions: Utilizing TTFM to assess graft quality during surgery enhances coronary bypass surgery in both ONCAB and OPCAB procedures. The enhanced results are particularly crucial for a process like OPCAB surgery, which necessitates the expertise and experience of a surgeon and is challenging to execute.

Differences in Plasma Extracellular Vesicles of Different Origin in On-Pump Versus Off-Pump Cardiac Surgery.

Coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB) causes a systemic inflammatory response that can worsen patient outcomes. Off-pump surgery has been associated with a reduced inflammatory response. The precise mechanisms and the role of extracellular vesicles (EVs) in this context are not fully understood. This study aimed to investigate the early immune response, including main T- and B-lymphocyte subsets, cytokine profiles, and plasma EVs, in patients undergoing off-pump (n = 18) and on-pump (n = 18) CABG. Thirty-six patients undergoing isolated CABG were enrolled in this randomized control study. Pre- and 24 h postoperative blood samples were analyzed for immune cell populations, cytokine levels, and plasma EV phenotyping. Off-pump CABG triggered a milder immune response than on-pump surgery. On-pump surgery led to greater changes in circulating EVs, particularly platelet- (CD62P+), endothelial- (CD31+), and B-cell-derived (CD19+), as well as platelet- and erythrocyte-derived aggregates (CD41+CD235a+). Levels of platelet-derived EVs, expressing both constitutional and activation markers (CD41+CD62P+) decreased in both groups of patients 24 h after surgery. On-pump cardiac procedures led to an increase in T-regulatory cell-derived EVs (CD73+CD39+), suggesting a potential mechanism for immune suppression compared to off-pump surgery. There were numerous correlations between EV levels and cytokine profiles following on-pump surgery, hinting at a close relationship. Leucocyte-derived EVs exhibited positive correlations with each other and with GRO but showed negative correlations with endothelial-derived EVs (CD90+ and CD31+). Additionally, CD73+ EVs demonstrated positive correlations with platelet counts and with erythrocyte-derived CD235a+ EVs. EV changes were significantly greater after on-pump surgery, highlighting a more pronounced response to this type of surgery and emphasizing the role of EVs as regulators of post-surgical inflammation.

Performance of EuroSCORE II in Octogenarians Undergoing Coronary Artery Surgery (from the KROK Registry).

Background: Octogenarians constitute the fastest-growing segment within contemporary cardiac surgery, yet precise risk assessment in this age group remains challenging. Aims: This study aimed to evaluate EuroSCORE II reliability in octogenarians undergoing isolated coronary surgery and to create an adjustment formula if necessary. Patients and Methods: All octogenarians who had isolated coronary surgery in Poland from January 2012 to December 2023, recorded in the Polish National Registry of Cardiac Surgical Procedures (KROK registry), were retrospectively assessed. EuroSCORE II's reliability was measured using the ROC curve area and observed-to-predicted mortality ratio, differentiating on-pump and off-pump cases. A nomogram was developed to enhance predictive accuracy. Results: Among 5771 octogenarians, 2729 (47.3%) underwent on-pump and 3042 (52.7%) underwent off-pump surgery. EuroSCORE II demonstrated reliability in off-pump patients (AUC:0.72, O/E ratio:0.98) but underestimated mortality for on-pump cases (AUC:0.73, O/E ratio:1.62). The lowest predicted mortality group (0.50-1.82%) showed the greatest discrepancies. Calibration was improved by adding a coefficient and creating a nomogram. Conclusions: EuroSCORE II was dependable in predicting outcomes for Polish octogenarians undergoing isolated coronary surgery. Observed mortality following on-pump surgeries was higher than expected, which was corrected by adding a coefficient to the initial EuroSCORE II calculation.

The life and work of Judson T. Chesterman, pioneering cardiac surgeon.

Judson Chesterman (1903-1987) was a surgeon working in Sheffield, United Kingdom in the mid-20th century. Born in Bath, Somerset, he attended Bristol Medical School before completing junior doctor positions around England. He developed his skills in thoracic surgery during a Fellowship with Evarts Graham (1883-1957) at Barnes Hospital, St Louis, Missouri and by the mid-1950s was also performing a large number of closed cardiac procedures. In 1955, he performed the first mitral valve replacement in the world, using a prosthesis of his own design, but the patient only survived for around 18 hours. Recognising the limitations of off-pump surgery, he visited the University of Minneapolis before building his own bypass machine and used it in two patients, the first in February 1957, one of the earliest outside the United States of America to do so. In retirement he established an osteoarchaeology laboratory and made additional contributions to that field.

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 < 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 < 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.

Effect of Ticagrelor Versus Clopidogrel After Off-Pump Coronary Artery Bypass Grafting on Postoperative Atrial Fibrillation: A Cohort Study.

This study aimed to explore the effect of a P2Y12 inhibitor regimen on the occurrence of postoperative atrial fibrillation (POAF) after off-pump coronary artery bypass graft surgery in carriers with the cytochrome P450 family 2 subfamily C member19 loss-of-function allele. From May 2019 to November 2023, patients containing the cytochrome P450 family 2 subfamily C member19*2 or *3 allele undergoing elective first-time off-pump coronary artery bypass graft surgery including aspirin 100 mg/d and ticagrelor 180 mg/d (AT group; n=95) versus clopidogrel 75 mg/d (aspirin and clopidogrel group; n=95) were prospectively followed. The primary end point was the cumulative incidence of POAF in a week. The secondary end points were POAF burden, platelet aggregability, systemic immune-inflammation index and heart rate variability. The incidence of POAF was 21.1% in the AT group versus 41.1% in the aspirin and clopidogrel group (hazard ratio, 0.46 [95% CI, 0.27-0.76]; P=0.003). POAF burden, ADP-induced platelet aggregation and systemic immune-inflammation index was notably lower in the AT group than the aspirin and clopidogrel group. Heart rate variability data showed an increase in both high-frequency and SD of normal-to-normal RR intervals in the AT group with a decreased low-frequency/high-frequency ratio, suggesting that the sympathetic/parasympathetic activation was balanced. In patients carrying the cytochrome P450 family 2 subfamily C member19 loss-of-function allele, an AT regimen after off-pump coronary artery bypass grafting was associated with a lower incidence of POAF, paralleled by lower atrial fibrillation burden, ADP-induced platelet aggregation, lower systemic immune-inflammation index reaction, and a balanced automatic nerve system compared with an aspirin and clopidogrel regimen. Inhibiting the systemic immune-inflammation response and sustaining automatic nerve balance may underlie the therapeutic effect of POAF by a potent antiplatelet combination.

Coronary angiography was used to assess the effect of diabetes on off-pump coronary artery bypass graft patency.

This study aimed to examine the influence of diabetes on the left internal mammary artery (LIMA) and saphenous vein (SV) graft failure for 5-year follow-up. We enrolled 202 patients who underwent isolated off-pump coronary artery bypass grafting (CABG) surgery in 2014, angiographic follow-up occurred at 5 years after surgery. Angiographic outcomes in patients with or without diabetes were analyzed. Multivariate logistic regression analysis was used to identify independent predictors of graft dysfunction. A total of 66 (32.7%) patients had diabetes. Five-year rates of LIMA and SV graft failure were similar in patients with and without diabetes. In addition, in diabetics, the proportion of complete graft failure was significantly lower in the LIMA grafts (12/66, 18.2%) than in the SV grafts (57/133, 42.9%) (P = .001). In nondiabetic, the proportion of complete graft failure was also significantly lower in the LIMA grafts (28/136, 20.6%) than in the SV grafts (105/275, 38.2%) (P < .001). Multivariate logistic regression analysis showed that mean graft flow (MGF) was an independent predictor factor for LIMA (odds ratio = 1.186, 95% CI = 1.114-1.263, P < .001) and SV (odds ratio = 1.056, 95% CI = 1.035-1.077, P < .001) graft failure. Diabetes did not influence the patency of LIMA or SV grafts over a 5-year follow-up. LIMA grafts should be maximized in patients undergoing off-pump CABG surgery. Diabetes does not affect the patency of grafts CABG. Using angiography, our study proved that diabetes does not affect the patency of grafted vessels after CABG for 5 years.

The impact of incomplete revascularization on survival in minimal invasive off-pump coronary artery surgery: a propensity score analysis of 1,149 cases.

Minimally invasive concepts are increasingly influential in modern cardiac surgery. This study aimed to evaluate the effect of completeness of revascularization on clinical outcomes and overall survival in minimally invasive, thoracoscopic coronary artery bypass grafting (CABG) surgery. We retrospectively evaluated a consecutive series of 1,149 patients who underwent minimally invasive off-pump CABG with single, double, or triple-vessel revascularization between 2007 and 2018. Of these patients, 185 (16.1%) had incomplete revascularization (IR) (group I), and 964 (83.9%) had complete revascularization (CR) (group C). We used gradient boosted propensity score estimation to account for possible confounding variables. Median age was 69 years, interquartile range (IQR) 60-76 years, and median EuroSCORE II was 4, IQR 2-7. Of the 1,149 patients, 495 patients suffered from two vessel disease (VD) and 353 presented with three VD. Long-term median follow-up 5.58 (3.27-8.48) years was available for 1,089 patients (94.8%). The incidence of recurrent or persisting angina, myocardial infarction, redo-bypass surgery, and stroke during follow-up did not differ significantly between groups. During follow-up, there were 47 deaths in group I and 172 deaths in group C. The 1-, 3-, 5-, 8-, and 10-year unadjusted survival rates were 94%, 84%, 75%, 62%, and 51% for group I, and 97%, 94%, 88%, 77%, and 72% for group C, respectively (long-rank test P<0.001), favouring CR. Following risk adjustment the long-rank test P value for survival was 0.23. In minimally invasive coronary surgery, IR resulted in decreased long-term survival, but did not achieve statistical significance after risk adjustment. However, IR should only be used in carefully selected cases.

Preoperative Nonselective Chest Computed Tomography Prior to Primary Cardiac Surgery Results in Meaningful Change to Surgical Management: Systematic Review and Pooled Prevalence Meta-Analysis

Routine screening chest computed tomography (CT) prior to primary cardiac surgery is advocated by some surgeons due to the purported benefits of identifying significant aortic calcification that impacts ongoing management, such as performing anaortic off-pump surgery or adjusting cannulation strategy. Additionally, axial imaging can identify incidental findings that may require concomitant or staged procedures such as ascending aortic dilatation or pulmonary lesions. The objective of this study was to quantify the impact that nonselective chest CT prior to primary cardiac surgery had on subsequent management. A systematic review and pooled prevalence meta-analyses were performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Included studies performed non-selective chest CT prior to primary cardiac surgery. A total of eight studies, including 2,250 patients were included. The rate of mortality and stroke was low (1% and 2%, respectively). Calcification of the ascending aorta was identified in 15% of patients (95% confidence interval [CI] 5.0-26.0). A significant change to the surgical plan such as cannulation strategy, off-pump surgery, cancellation, or an additional procedure was required in 7% (95% CI 2.0-12.0). Clinically relevant incidental findings requiring in-patient management or follow-up were identified in 10% (95% CI 6.0-14.0). Nonselective CT chest prior to primary cardiac surgery identifies clinically relevant findings that result in a modification of the surgical plan in a significant population of patients to address the risk of stroke associated with aortic calcification as well as the identification of important incidental findings such as pulmonary lesions.

The use of transcutaneous electrical acupoint stimulation to reduce opioid consumption in patients undergoing off-pump CABG: a randomized controlled trial

BackgroundHigh doses of long-acting opioids were used to facilitate off-pump coronary artery bypass grafting procedure, which may result in opioid-related adverse events after surgery. Transcutaneous electrical acupoint stimulation (TEAS) had been reported to be effective in reducing intraoperative opioids consumption during surgery. The aim of this study is to assess whether TEAS with difference acupoints can reduce the doses of opioid analgesics.MethodsThis was a multicenter, randomized, controlled, double-blind trial. Patients underwent off-pump coronary artery bypass grafting under general anesthesia were enrolled. Eligible patients were randomly and equally grouped into sham acupuncture group (n = 105), regional acupoints combination group (n = 105), or distal–proximal acupoints combination group (n = 105) using a centralized computer-generated randomization system. Transcutaneous electrical acupoint stimulation was applied for 30 min before anesthesia induction. The primary outcome was the doses of sufentanil during anesthesia. Secondary outcomes included the highest postoperative vasoactive-inotropic scores within 24 h, intraoperative propofol consumption, length of mechanical ventilation, duration of cardiac care unit and postoperative hospital stay, incidence of postoperative complications, and mortality within 30 days after surgery.ResultsOf the 315 randomized patients, 313 completed the trial. In the modified intention-to-treat analysis, the doses of sufentanil were 303.9 (10.8) μg in the distal–proximal acupoints group, significantly lower than the sham group, and the mean difference was − 34.9 (− 64.9 to − 4.9) μg, p = 0.023. The consumption of sufentanil was lower in distal–proximal group than regional group (303.9 vs. 339.5), and mean difference was − 35.5 (− 65.6 to − 5.5) μg, p = 0.020. The distal–proximal group showed 10% reduction in opioids consumption comparing to both regional and sham groups. Secondary outcomes were comparable among three groups.ConclusionTranscutaneous electrical acupoint stimulation with distal–proximal acupoints combination, compared to regional acupoints combination and sham acupuncture, significantly reduced sufentanil consumption in patients who underwent off-pump coronary artery bypass grafting surgery.

The impact of intraoperative hypotension on postoperative acute kidney injury, mortality and length of stay following off-pump coronary artery bypass grafting surgery: a single-center retrospective cohort study

BackgroundOff-pump coronary artery bypass grafting (OPCABG) presents distinct hemodynamic characteristics, yet the relationship between intraoperative hypotension and short-term adverse outcomes remains clear. Our study aims to investigate association between intraoperative hypotension and postoperative acute kidney injury (AKI), mortality and length of stay in OPCABG patients.MethodsRetrospective data of 494 patients underwent OPCABG from January 2016 to July 2023 were collected. We analyzed the relationship between intraoperative various hypotension absolute values (MAP > 75, 65 < MAP ≤ 75, 55 < MAP ≤ 65, MAP ≤ 55 mmHg) and postoperative AKI, mortality and length of stay. Logistic regression assessed the impacts of exposure variable on AKI and postoperative mortality. Linear regression was used to analyze risk factors on the length of intensive care unit stay (ICU) and hospital stay.ResultsThe incidence of AKI was 31.8%, with in-hospital and 30-day mortality at 2.8% and 3.5%, respectively. Maintaining a MAP greater than or equal 65 mmHg [odds ratio (OR) 0.408; p = 0.008] and 75 mmHg (OR 0.479; p = 0.024) was significantly associated with a decrease risk of AKI compared to MAP less than 55 mmHg for at least 10 min. Prolonged hospital stays were linked to low MAP, while in-hospital mortality and 30-day mortality were not linked to IOH but exhibited correlation with a history of myocardial infarction. AKI showed correlation with length of ICU stay.ConclusionsMAP > 65 mmHg emerges as a significant independent protective factor for AKI in OPCABG and IOH is related to length of hospital stay. Proactive intervention targeting intraoperative hypotension may provide a potential opportunity to reduce postoperative renal injury and hospital stay.Trial registrationChiCTR2400082518. Registered 31 March 2024. https://www.chictr.org.cn/bin/project/edit?pid=225349.

Analysis of the Perioperative Course of Cardiac Surgery Patients with Coronary Artery Disease and Heart Valve Dysfunction

The aim. To analyze the perioperative course of cardiac surgery patients with coronary artery disease (CAD) and heart valve dysfunction. Materials and methods. Retrospective analysis of 41 consecutive cardiac surgery patients (mean age 61.6 ± 7.8 years) with CAD and heart valve dysfunction who were operated on and discharged from the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine. All the patients underwent standard clinical and laboratory examinations, coronary angiography, on-pump cardiosurgical intervention. Results. The patients were divided into three subgroups: patients with post-infarction left ventricular aneurysm (LVA) combined with insufficiency of atrioventricular valves, n = 15 (36.6%); those with ischemic mitral insufficiency (MI), n = 11 (26.8%); and patients with CAD combined with aortic valve disease, n = 15 (36.6%). During echocardiographic study, decreased left ventricular ejection fraction was found in patients with LVA and with ischemic MI: 33 ± 6.4% and 39.4 ± 7.8%, respectively, and in patients with aortic valve disease, left ventricular ejection fraction averaged 48.2 ± 9.9% (p &lt; 0.0001). According to the EuroSCORE II scale, the average risk was 11.8 ± 7.3%. All the patients were discussed by the heart team to choose the optimal method of cardiosurgical correction. In order to reduce the ischemic time, off-pump coronary bypass surgery was performed at the first stage, and the second stage was on-pump correction of valvular dysfunction. The average number of grafts was 2.8 ± 1.4, but the largest number of grafts was in the subgroup of ischemic MI: 4 ± 0.9 (p &lt; 0.005). Mitral valve replacement in patients with LVA was performed through LVA in 12 patients. Acute heart failure, acute renal failure often developed in patients after correction of ischemic MI (p &lt; 0.005). On the 1st day after the operation, there was an increase in average glucose values from 6.6 ± 2.8 to 10.3 ± 2.9 mmol/L (p &lt; 0.0001), a decrease in glomerular filtration rate from 72.1 ± 15.3 to 57 ± 18.8 mL/min/1.73 m2 (p = 0.0001), the above indicators returned to the initial level at discharge (p &lt; 0.0001). Conclusions. Off-pump myocardial revascularization in patients with CAD and dysfunction of the heart valves can significantly reduce the ischemic time. The method of mitral valve replacement through LVA developed in the department allowed to reduce the perfusion time (p = 0.0023) and the duration of the operation (p &lt; 0.005). Preoperative discussion of examination data of patients by the heart team, thorough preparation for cardiac surgery, timely response to changes in laboratory parameters with correction of drug treatment avoid complications.

Effects of Balanced Versus Saline-based Solutions on Acute Kidney Injury in Off-pump Coronary Artery Bypass Surgery: A Randomized Controlled Trial

To determine whether balanced solutions can reduce the incidence of acute kidney injury after off-pump coronary artery bypass surgery compared with saline. Randomized controlled trial. Single tertiary care center. Patients who underwent off-pump coronary artery bypass surgery between June 2014 and July 2020. Balanced solution-based chloride-restrictive intravenous fluid strategy. The primary outcome was acute kidney injury within 7 postoperative days, as defined by the 2012 Kidney Disease: Improving Global Outcomes Clinical Practice Guideline. The incidence of acute kidney injury was 4.4% (8/180) in the balanced group and 7.3% (13/178) in the saline group. The difference was not statistically significant (risk difference, -2.86%; 95% confidence interval [CI], -7.72% to 2.01%; risk ratio, 0.61, 95% CI, 0.26 to 1.43; p = 0.35). Compared with the balanced group, the saline group had higher levels of intraoperative serum chloride and lower base excess, which resulted in a lower pH. In patients undergoing off-pump bypass surgery with a normal estimated glomerular filtration rate, the intraoperative balanced solution-based chloride-restrictive intravenous fluid administration strategy did not decrease the rate of postoperative acute kidney injury compared with the saline-based chloride-liberal intravenous fluid administration strategy.

Comparison of Postoperative Anxiety, Depression, Somatization, and Somatosensory Perception Levels of Patients After Off-Pump and On-Pump Coronary Artery Bypass Graft Surgery

Comparison of Postoperative Anxiety, Depression, Somatization, and Somatosensory Perception Levels of Patients After Off-Pump and On-Pump Coronary Artery Bypass Graft Surgery

Comparison of outcomes between off-pump and on-pump coronary artery bypass graft surgery using collaborative targeted maximum likelihood estimation

There are some discrepancies about the superiority of the off-pump coronary artery bypass grafting (CABG) surgery over the conventional cardiopulmonary bypass (on-pump). The aim of this study was estimating risk ratio of mortality in the off-pump coronary bypass compared with the on-pump using a causal model known as collaborative targeted maximum likelihood estimation (C-TMLE). The data of the Tehran Heart Cohort study from 2007 to 2020 was used. A collaborative targeted maximum likelihood estimation and targeted maximum likelihood estimation, and propensity score (PS) adjustment methods were used to estimate causal risk ratio adjusting for the minimum sufficient set of confounders, and the results were compared. Among 24,883 participants (73.6% male), 5566 patients died during an average of 8.2 years of follow-up. The risk ratio estimates (95% confidence intervals) by unadjusted log-binomial regression model, PS adjustment, TMLE, and C-TMLE methods were 0.86 (0.78–0.95), 0.88 (0.80–0.97), 0.88 (0.80–0.97), and 0.87(0.85–0.89), respectively. This study provides evidence for a protective effect of off-pump surgery on mortality risk for up to 8 years in diabetic and non-diabetic patients.

Early Postoperative Iatrogenic Acute Type-A Aortic Dissection Following Off-pump Coronary Artery Bypass Graft Surgery: An Uncommon Complication of a Common Surgery

Complications of cardiac surgery include iatrogenic acute aortic dissection (IAAD), which occurs in 0.04%–0.06% of cases and has poorer results than spontaneous dissection. IAADs generated by thoracotomy are often associated with severe cardiovascular conditions, such as advanced atherosclerosis with three or more coronary artery lesions and persistent heart failure due to multivalvular heart disease. It is possible to experience this complication following any kind of cardiac surgery, including off-pump coronary artery bypass grafting (OPCAB) as well as following endovascular operations. We encountered early postoperative IAAD following OPCAB, which necessitated high-risk reoperation with dismal outcomes. Death rates could be reduced with better access to timely diagnosis and adequate treatment. Avoiding, diagnosing, and treating this potentially fatal complication requires tremendous effort from every member of the heart team.

Circulating neuropeptide Y as a biomarker in postoperative atrial fibrillation cases administered off-pump coronary bypass Graft surgery

Background and aimsPostoperative atrial fibrillation (POAF) is considered the most prevalent irregular heart rhythm after heart surgery. The cardiac autonomic nervous system significantly affects POAF, and neuropeptide Y (NPY), an abundant neuropeptide in the cardiovascular system, is involved in this autonomic regulation. The current work aimed to examine the potential association of NPY with POAF in individuals administered isolated off-pump coronary artery bypass grafting. MethodsFrom January 1 to May 31, 2020, we examined consecutive cases administered successful isolated off-pump coronary artery bypass grafting with no previously diagnosed atrial fibrillation (AF). Clinical characteristics and plasma samples were collected before surgery. NPY was quantified by enzyme-linked immunosorbent assay (ELISA) in peripheral blood, and POAF cases were identified through a 7-day Holter monitoring. ResultsAmong 120 cases with no previously diagnosed AF, 33 (27.5 %) developed POAF during hospitalization. Median NPY levels were markedly elevated in the POAF group in comparison with the sinus rhythm group (31.72 vs. 27.95, P = 0.014). Multivariable logistic regression analysis revealed age (OR = 1.135, 95%CI 1.054–1.223; P = 0.001), left atrial size (OR = 1.136, 95%CI 1.004–1.285; P = 0.043), and NPY levels in peripheral blood (OR = 1.055, 95%CI 1.002–1.111; p = 0.041) independently predicted POAF. Additionally, NPY levels were positively correlated with high-frequency (HF) (r = 0.2774, P = 0.0022) and low-frequency (LF) (r = 0.2095, P = 0.0217) components of heart rate variability. ConclusionIn summary, this study demonstrates an association between elevated NPY levels in peripheral blood before surgery and POAF occurrence.

Clinical outcomes of on-pump versus off-pump coronary-artery bypass surgery: a meta-analysis.

The ongoing debate regarding off-pump coronary artery bypass grafting (CABG) and on-pump CABG has endured for over three decades. Although numerous randomized controlled trials (RCTs) and meta-analyses have been reported, new evidence has emerged. Therefore, an updated and comprehensive meta-analysis to guide clinical practice is essential. A comprehensive search for eligible articles published after 2000, reporting RCTs involving at least 100 patients and comparing off-pump CABG with on-pump CABG, was performed throughout the databases including Embase, Ovid Medline, and Web of Science. The primary interested outcomes included the short-term incidence of stroke and long-term mortality. The primary analysis utilized fixed-effect model with the inverse variance method. The Grade of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the certainty of evidence. After thorough screening, 39 articles were included, consisting of 28 RCTs and involving a total of 16090 patients. Off-pump CABG significantly reduced the incidence of short-term stroke (1.27 vs. 1.78%, OR: 0.74, P =0.03, high certainty). However, it was observed to be associated with increased mid-term coronary reintervention (2.77 vs. 1.85%, RR: 1.49, P <0.01, high certainty) and long-term mortality (21.8 vs. 21.0%, RR: 1.09, P =0.02, moderate certainty). Off-pump CABG significantly reduces the short-term incidence of stroke, but it also increases the incidence of mid-term coronary reintervention. Moreover, it may increase long-term mortality.

Evaluating the Efficacy of the Erector Spinae Plane Block as a Supplementary Approach to Cardiac Anesthesia during Off-Pump Coronary Bypass Graft Surgery via Median Sternotomy: A Randomized Clinical Trial.

Background: Pain control after off-pump coronary artery bypass graft (OPCAB) facilitates mobilization and improves outcomes. The efficacy of the erector spinae plane block (ESPB) after cardiac surgery remains controversial. Methods: We aimed to investigate the analgesic effects of ESPB after OPCAB. Precisely 56 patients receiving OPCAB were randomly divided into ESPB and control groups. The primary outcome was visual analog scale (VAS) pain scores at 6, 12, 24, and 48 h postoperatively. Secondary outcomes were the dose of rescue analgesics in terms of oral morphine milligram equivalents, the dose of antiemetics, the length of intubation time, and the length of stay in the intensive care unit (ICU). Results: The VAS scores were similar at all time points in both groups. The incidence of severe pain (VAS score > 7) was significantly lower in the ESPB group (50% vs. 15.4%; p = 0.008). The dose of rescue analgesics was also lower in the ESPB group (19.04 ± 18.76, 9.83 ± 12.84, p = 0.044) compared with the control group. The other secondary outcomes did not differ significantly between the two groups. Conclusions: ESPB provides analgesic efficacy by reducing the incidence of severe pain and opioid use after OPCAB.