On-pump Approach Research Articles

On-Pump or Off-Pump Impact of Diabetic Patient Undergoing Coronary Artery Bypass Grafting 5-Year Clinical Outcomes.

For diabetic patients undergoing coronary artery bypass grafting (CABG), there is still a debate about whether an off-pump or on-pump approach is advantageous. A retrospective review of 1269 consecutive diabetic patients undergoing isolated, primary CABG surgery from January 1, 2013 to December 31, 2015 was conducted. Among them, 614 received non-cardiopulmonary bypass treatment during their operation (off-pump group), and 655 received cardiopulmonary bypass treatment (on-pump group). The hospitalization outcomes were compared by multiple logistic regression models with patient characteristics and operative variables as independent variables. Kaplan-Meier curves and Cox proportional-hazard regression models for mid-term (2-year) and long-term (5-year) clinical survival analyses were used to determine the effect on survival after CABG surgery. In order to further verify the reliability of the results, propensity-score matching (PSM) was also performed between the two groups. Five-year all-cause death rates were 4.23% off-pump vs. 5.95% on-pump (p = 0.044), and off-pump was associated with reduced postoperative stroke and atrial fibrillation. These findings suggest that off-pump procedures may have benefits for diabetic patients in CABG.

Outcomes following coronary artery bypass grafting with multiple arterial grafting by pump status in men and women

BackgroundMultiple arterial grafting (MAG) and off-pump surgery are strategies proposed to improve outcomes with coronary artery bypass grafting (CABG). This study was conducted to determine the impact of off-pump surgery on outcomes after CABG with MAG in men and women. MethodsThis cohort study used population-based data to identify all Ontarians undergoing isolated CABG with MAG between October 2008 and September 2019. The primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiac and cerebrovascular events (MACCE; hospitalization for stroke, myocardial infarction hospitalization or heart failure, or repeat revascularization). Analysis used propensity-score overlap-weighted cause-specific Cox proportional hazard regression. ResultsA total of 2989 women (1188 off-pump, 1801 on-pump) and 16,209 men (6065 off-pump, 10,144 on-pump) underwent MAG with a median follow-up of 5.0 years (interquartile range, 2.7-8.0) years. Compared to the on-pump approach, all-cause mortality was not changed with off-pump status (hazard ratio [HR] in women: 1.25 [95% CI, 0.83-1.88]; in men: 1.08 [95% CI, 0.85-1.37]). In women, the risk of MACCE was significantly higher off-pump (HR, 1.45; 95% CI, 1.04-2.03), with nonsignificantly increased risk observed for all component outcomes. ConclusionsIn patients undergoing CABG with MAG, this population-based analysis found no association between pump status and survival in either men or women. However, it did suggest that off-pump MAG in women may be associated with an increased risk of MACCE.

Off-Pump HeartMate 3 Left Ventricular Assist Device Implantation is Safe and Feasible for High Risk Patients

<h3>Purpose</h3> While the feasibility of off-pump HeartMate 3 left ventricular assist device (LVAD) placement has already been demonstrated, the safety of this approach has not been reported to date. <h3>Methods</h3> We retrospectively reviewed all patients who underwent Heartmate 3 LVAD implantation and identified 19 off-pump patients. These were propensity-matched with 19 on-pump cases using the following variables: age, body mass index, INTERMACS profile, and surgical approach. The study's primary objective was the safety of the off-pump technique compared to the standard on-pump approach. <h3>Results</h3> Preoperative characteristics were similar between the groups (Table 1). Most patients presented with the highest acuity INTERMACS Profile 1 (92.1%). A higher frequency of off-pump patients was supported with extracorporeal membrane oxygenation prior to LVAD implantation (31.6 vs. 89.5%, p=0.001). Intraoperatively, a higher proportion of patients in the off-pump group required packed red blood cells administration (47.4% vs. 84.2%, p=0.038). In the immediate postoperative hours, off-pump patients showed trends toward lower vasoactive-inotropic requirements. Postoperative outcomes, including all of the major complications and short-term survival (Figure 1), were comparable between the groups. <h3>Conclusion</h3> Results from our retrospective propensity-matched analysis suggest that off-pump LVAD implantation can be offered as a safe alternative for high-risk LVAD candidates.

Hospitalization costs related to long-term management of patients undergoing CABG (PRIORITY project)

Abstract Background Identifying potential tools that could help improving the standard of care and lead to a better allocation of economic resources represents a main objective of research in public health. Using data from the PRIORITY cohort, this study aims to describe inpatients costs after a discharge for isolated coronary artery bypass surgery (CABG). Methods The PRIORITY project was designed to evaluate the long-term outcomes of 2 large multicenter cohort studies on CABG conducted between 2002-04 and 2007-08. For each patient discharged alive after a CABG intervention, costs of hospitalizations were estimated as the sum of costs of all the admissions occurred during 3 years of follow-up. NHS reimbursement rates were used as standard costs (in Euros). Inpatients costs were analysed according to their baseline risk factors. Results Among the 7363 patients included in this analysis, the median 3-year hospitalization costs were 4341€ (IQR: 1865-11699). Median costs were around 4.000€ for subjects alive at the end of follow up but higher for patients dying within 1 (about 8.600€) and 2-3 years of follow up (about 20.000€). The presence of comorbidities (such as diabetes and cancer) lead to higher median hospitalization costs while the on-pump approach was associated to lower median cost. Sixteen per cent of patients were at zero cost having no re-hospitalizations during the 3 years of follow-up (97% alive). Subjects at zero cost received more frequently on-pump approach, had a lower frequency of cancer, arteriopathy and ictus, but a higher frequency of angina and infarction. Conclusions Inpatient costs after isolated CABG are affected by preoperative comorbidities and by operative variables that could be removed or managed. Identifying independent risk factors for re-hospitalization will lead to the definition of a preoperative clinical and decision-making path that will bring both a clinical advantage for the patient and an optimization of costs for the NHS. Key messages Inpatient costs after isolated CABG are affected by preoperative comorbidities and operative characteristics like the on-pump approach. Appropriate management of operative approaches mainly based on operator preferences can have important implications in terms of healthcare costs.

Mitral valve surgery combined with on-pump versus off-pump myocardial revascularization: A prospective randomized analysis with midterm follow-up.

The aim of the study was to compare results off-pump coronary artery bypass (OPCAB) combined mitral valve reconstruction (MVR) with standard on-pump approach. From January 2014 to December 2017, a total of 53 patients received a combined myocardial revascularization and MVR for multivessel coronary artery disease (CAD) complicated by severe ischemic mitral regurgitation (IMR). All the subjects were divided into two groups: group I: 27 patients, received OPCAB + MVR, and group II (control group): 26 patients with on-pump myocardial revascularization (ONCAB) + MVR. The aortic cross-clamp (ACC) and cardio-pulmonary bypass (CPB) times were longer in group II, 47.0 (44.0; 55.0) vs 94.5 (89.75; 105.5) minutes, P < .05 and 70.0 (63.0; 77.0) vs 138.5 (127.0; 157.5) minutes, P < .05, respectively. Evaluation of major clinical events showed that the implementation of the off-pump stage of myocardial revascularization in patients with severe IMR did not lead to significant changes in the mortality and postoperative complications. Furthermore, its use did not affect the volume of blood loss and need for blood transfusion, the duration of mechanical ventilation, the need for inotropic therapy, as well as the duration of the patient's resuscitation and the total duration of hospitalization, with the one exception: the troponin-T level increase in the OPCAB + MVR group was less than in the ONCAB + MVR group. OPCAB combined MVR in patients with CAD and severe IMR can be performed with shorter CPB and ACC times, and lower troponin-T level after surgery, without reducing the risk of surgical complications.

Off- vs. On-Pump Coronary Artery Bypass Grafting Long-Term Survival is Driven by Incompleteness of Revascularisation

Off-pump coronary artery bypass grafting (CABG) negates the requirement for extracorporeal circulation used with the traditional on-pump approach. However, off-pump CABG is technically more challenging and may theoretically lead to less complete revascularisation. Recent data suggests a prognostic benefit for traditional on-pump CABG, but the mechanism for this remains unclear. We hypothesised that the inferior outcomes with off-pump CABG could be driven by the need for repeat revascularisation, with this benefit only becoming clear at long-term follow-up. We therefore evaluated short, medium and long-term outcomes of patients undergoing revascularisation with on vs. off-pump CABG. Electronic databases were searched to identify suitable randomised controlled trials enrolling ≥100 patients in each arm. Clinical outcomes were extracted at 30-days, 12-months or >4years. The primary outcome was long-term all-cause death, while secondary outcomes included 30-day, 12-month and >4-year cardiac death, stroke, myocardial infarction or revascularisation. Thirteen (13) studies comprising 13,234 patients were included. Off-pump CABG was associated with an increased risk of all-cause death (Odds Ratio [OR] 1.18, 95% confidence interval [CI] 1.02-1.32, p=0.01) and repeat bypass surgery (OR 2.57, 95%CI 1.23-5.39, p=0.01) at long-term follow-up. A significant, increased requirement for revascularisation in off-pump was seen at 12-month follow-up (OR 1.59, 95%CI 1.09-2.33, p=0.02). No differences were noted between groups at 30-days, 12-months and >4years for myocardial infarction or stroke. Off-pump CABG is associated with significantly higher rates of all-cause mortality rate at long-term follow-up. These outcomes demonstrate a temporal relationship that may be driven by a greater requirement for repeat revascularisation at 1- and 5-year follow-up. CRD42018102019 (PROSPERO).

Off-Pump Versus On-Pump Impact: Diabetic Patient 5-Year Coronary Artery Bypass Clinical Outcomes

For diabetic patients who require coronary artery bypass graft (CABG) operation, controversy persists whether an off-pump or an on-pump approach may be advantageous. This US-based, multicenter, randomized, controlled trial, Department of Veterans Affairs Randomization On versus Off Bypass Follow-up Study, compared diabetic patients' 5-year clinical outcomes for off-pump versus on-pump procedures. From 2002 to 2008, 835 medically treated (ie,oral hypoglycemic agent or insulin) diabetic patients underwent either off-pump (n= 402) or on-pump (n=433) CABG. Five-year primary end points included all-cause death and major adverse cardiovascular events (MACE; composite included all-cause death, myocardial infarction, or repeat revascularization). Secondary 5-year end points included cardiac death and MACE-related components. With baseline risk factors balanced, outcomes were evaluated by using a p value less than or equal to 0.01; nonsignificant trends were reported for p values greater than 0.01 and less than or equal to 0.15. Five-year all-cause death rates were 20.2% off pump versus 14.1% on pump (p= 0.0198). No differences were seen in MACE (32.6% off-pump approach versus 28.6% on-pump approach, p= 0.216), repeat revascularization (12.4% off-pump approach versus 11.8% on-pump approach, p= 0.770), and nonfatal myocardial infarction (12.7% off-pump approach versus 10.4% on-pump approach, p= 0.299). Cardiac death trended worse with off-pump CABG (9.0%) than with on-pump CABG (6.25%, p= 0.137). Sensitivity analyses that removed conversions confirmed these findings. With a 6.1% absolute difference, a strong trend toward improved 5-year survival was observed with on-pump CABG for medically treated diabetic patients. No off-pump advantage was found for any 5-year end points. A future clinical trial now appears warranted to rigorously compare off-pump versus on-pump longer term outcomes for diabetic patients.

Complete arterial revascularization using bilateral internal mammary artery in T-graft technique for multivessel coronary artery disease in on- or off-pump approach: does gender lose its historical impact on clinical outcome?

Higher rates of mortality and morbidity have been reported in women undergoing coronary artery bypass grafting (CABG) compared with men. Different revascularization techniques (on-pump and off-pump) might influence this outcome. We retrospectively analysed 3445 consecutively recruited patients (all comers) undergoing complete arterial CABG (CACABG) at a single centre between January 2000 and December 2012. CACABG was performed in all patients using bilateral skeletonized internal mammary artery in T-graft technique, either on-pump (n = 2216) or off-pump (n = 1229). Early results (30-day) and long-term follow-up data were analysed with respect to gender-specific outcome. Women were older than men in both groups (P < 0.001), and men had a higher body mass index (on-pump: P < 0.001; off-pump: P = 0.02) compared with women. Men displayed a higher extent of coronary artery disease (P < 0.001) and an overall lower ejection fraction (P < 0.001) when undergoing on-pump CABG. No gender differences were observed for late survival (P = 0.74 vs P = 0.52) in on-pump and off-pump procedures, respectively. Late follow-up revealed a higher rate of FitzGibbon A graft patency in men undergoing the on-pump approach (P = 0.006). CACABG using bilateral internal mammary artery in T-graft technique showed excellent early and long-term results. No significant gender-specific differences were observed in both groups undergoing CACABG with respect to 30 days mortality and morbidity as well as late survival. However, late follow-up revealed a higher graft patency in men undergoing the on-pump approach, compared to women.

Translating trials to clinical practice in cardiac surgery

Three randomized clinical trials have added data to the debate about whether off-pump CABG surgery has any advantages over the on-pump approach. A growing consensus is emerging; however, understanding the conflicting results of these trials, and how they might apply to clinical practice, requires careful attention to trial design.

Response to Letter Regarding Article, “Off-Pump Versus On-Pump Coronary Artery Bypass Graft Surgery: Differences in Short-Term Outcomes and in Long-Term Mortality and Need for Subsequent Revascularization”

To the Editor: We read with great interest the recent report by Hannan et al1 on the short-term benefits of off-pump coronary artery bypass graft surgery compared with the standard on-pump approach on in-hospital/30-day mortality and perioperative complication rates. The 3-year follow-up proved comparable outcomes, excluding a lower rate of freedom from revascularization for the off-pump surgery group. The topic is certainly extremely interesting, especially nowadays, when less invasive approaches, such as off-pump coronary surgery and percutaneous coronary interventions, are acquiring dominant roles in the treatment of ischemic heart disease.2 However, we believe that this …

Letter by Bollati et al Regarding Article, “Off-Pump Versus On-Pump Coronary Artery Bypass Graft Surgery: Differences in Short-Term Outcomes and in Long-Term Mortality and Need for Subsequent Revascularization”

To the Editor: We read with great interest the recent report by Hannan et al1 on the short-term benefits of off-pump coronary artery bypass graft surgery compared with the standard on-pump approach on in-hospital/30-day mortality and perioperative complication rates. The 3-year follow-up proved comparable outcomes, excluding a lower rate of freedom from revascularization for the off-pump surgery group. The topic is certainly extremely interesting, especially nowadays, when less invasive approaches, such as off-pump coronary surgery and percutaneous coronary interventions, are acquiring dominant roles in the treatment of ischemic heart disease.2 However, we believe that this …

Invited commentary

Over the past decade, there has been considerable interest in altering the traditional on-pump approach to sewing coronary artery bypass grafts in a still bloodless field with maximum exposure. Presumed advantages are to avoid the deleterious effects of the heart-lung machine and to allow for a more rapid recovery related to less invasive approaches. These techniques include off-pump coronary artery bypass graft (OPCAB) surgery, minimally invasive direct coronary artery bypass graft (MIDCAB) surgery, and variations using robotic technology. We have also seen the reintroduction of sutureless connectors for both proximal and distal anastomoses. Radial artery grafts and skeletonized internal thoracic arteries are increasingly popular conduits. The introduction of these modalities has been academically stimulating and technically challenging. While perioperative benefit or lack of benefit is readily apparent, the ability to achieve long-term graft patency must be reassessed with each newly introduced technique on an individual and institutional basis. The strength of the manuscript by Hol and colleagues is the pointing out of the need for patency feedback, both short term and long term. The authors present data showing the utility of intraoperative angiography in saving a small number of grafts that were already occluded or likely to occlude early postoperatively. Only 4.2% of grafts were revised. However, there was a significantly higher revision rate in the OPCAB and MIDCAB groups compared with the on-pump group. The authors state that the higher OPCAB and MIDCAB revision rates may be related to a learning curve. However, the study was done over an 8-year period, and presumably some of the OPCAB and MIDCAB procedures were performed after a significant amount of experience was gained. Therefore, it is doubtful that a learning curve is the entire reason for the higher revision rate in these subgroups. Although patency rates at 1-year follow-up were not statistically different, there was a concerning trend toward lower patency rates in the OPCAB group for both saphenous vein grafts and left internal thoracic artery grafts. The 90% 1-year patency for left internal thoracic artery to left anterior descending artery grafts is less than acceptable. This patency rate was in the face of 9.4% of the original left internal thoracic artery to left anterior descending artery grafts requiring revision. This manuscript adds to the concern that long-term patency of OPCAB grafts may be less than with on-pump revascularization. I congratulate the authors on their use of angiographic control to compare newly introduced techniques with the traditional approach. This approach should be standard of care as we continue our attempts to improve the outcomes of surgical coronary revascularization.

Chronologic distribution of stroke after minimally invasive versus conventional coronary artery bypass

ObjectivesWe sought to investigate whether the chronologic distribution of the onset of stroke occurring after coronary artery bypass graft surgery (CABG) without cardiopulmonary bypass (off-pump CABG) is different from the conventional on-pump approach (CABG with cardiopulmonary bypass). BackgroundOff-pump CABG has been associated with a lower stroke rate, compared with conventional on-pump CABG. However, it is unknown whether the chronologic distribution of the onset of stroke is different between the two approaches. MethodsWe evaluated the chronologic distribution of postoperative stroke in patients undergoing CABG from June 1996 to August 2001 (n = 10,573). Preoperative risk factors for stroke were identified using the Northern New England preoperative estimate of stroke risk. Multivariate logistic regression analysis was used to determine the independent predictors of early stroke and to delineate the association between the surgical approach and the chronologic distribution of the onset of stroke. ResultsStroke occurred in 217 patients (2%, n = 10,573). A total of 44 (20%) and 173 (80%) of these patients had stroke after off-pump CABG and on-pump CABG, respectively. The median time for the onset of stroke was two days (range 0 to 11 days) after on-pump CABG versus four days (range 0 to 14 days) after off-pump CABG (p < 0.01). On-pump CABG was associated with a higher risk of early stroke (odds ratio 5.3, 95% confidence interval 2.6 to 10.9; p < 0.01) compared with off-pump CABG. ConclusionsCompared with off-pump CABG, on-pump CABG is associated with an earlier onset of postoperative stroke during the recovery phase, suggesting different mechanisms in the pathogenesis of stroke between the two surgical approaches.

Surgical steps toward complete revascularization in off-pump coronary bypass.

Surgical techniques aimed at complete myocardial revascularization without the use of cardiopulmonary bypass are described. Between January 1998 and June 2000, coronary artery bypass was performed in 3,003 patients; an off-pump technique was used in 676 and cardiopulmonary bypass was employed in 2,327. Patient characteristics, demography, and preoperative risk factors of the two groups were compared retrospectively, and differences in operative variables and postoperative outcomes were analyzed. Using a commercially available suction stabilization device and the surgical and anesthetic techniques described herein, off-pump coronary revascularization was accomplished with results comparable to the on-pump approach.