On-pump Beating-heart Coronary Artery Research Articles

Comments on 'Comparison between off-pump versus on-pump beating heart CABG'.

On-pump beating heart coronary artery bypass grafting helps the surgeon in his learning curve period on off-pump heart surgery, however, it increases the risk of incomplete revascularization. Off-pump with cannulas in readiness is an alternative option.

Comparison between off-pump versus on-pump beating heart coronary artery bypass grafting.

Although coronary artery bypass grafting (CABG) is performed via three different techniques, conventional, on-pump beating heart CABG (ONBHCAB), or off-pump CABG (OPCAB), data is limited to compare ONBHCAB versus OPCAB. We retrospectively investigated postoperative cardiac biomarkers, creatine kinase-MB (CK-MB) and Troponin I (cTnI), early and late outcomes in 806 patients undergoing isolated ONBHCAB or OPCAB between February 2008 and September 2022. To eliminate the bias between different groups, propensity score matching was conducted to validate the findings. After matching, the number of each study group totaled 270 patients. In both complete and matched cohorts, early outcomes, including morbidities and mortalities, were similar. However, cTnI and CK-MB levels were significantly higher after ONBHCAB than after OPCAB with the median peak cTnI of 9.85 ng/mL versus 4.60 ng/mL and the median peak CK-MB of 48.45 ng/mL versus 17.10 ng/mL in the matched cohort, which were quite low below the threshold for values defining perioperative myocardial infarction. At follow-up of 73 ± 45 months, the overall actuarial survival rates were similar between the ONBHCAB and OPCAB patients (86 % versus 87 % at 5 years and 64 % versus 68 % at 10 years, respectively, in the matched cohort). ONBHCAB may be a comparable alternative to OPCAB with similar early and late outcomes, despite higher elevation of postoperative cardiac biomarkers. ONBHCAB provides more efficient hemodynamic support, providing a better surgical visual field, than OPCAB while reducing the risk of incomplete revascularization.

On-pump beating heart versus conventional on-pump coronary artery bypass grafting on clinical outcomes: a meta-analysis.

BackgroundA hybrid surgery method, on-pump beating heart coronary artery bypass graft (ON-BH CABG), is supposed to be a promising technology for coronary artery revascularization. Here, we conducted a comprehensive meta-analysis of the data derived from published studies on ON-BH CABG and conventional on-pump coronary artery bypass graft (C-CABG) to compare their short-term and long-term clinical outcomes.MethodsWe searched major electronic databases and 24 studies incorporating 6,862 patients (1,847 ON-BH CABG and 5,015 C-CABG) were included eventually, and 9 studies of them were focusing on high-risk patients.ResultsCompared with ON-BH CABG, C-CABG was associated with a higher risk in early mortality [odds ratio (OR), 1.45; 95% confidence interval (CI), 1.09 to 1.93; P=0.01], myocardial infarction (MI) (OR, 2.60; 95% CI, 1.41 to 4.78; P<0.01), low output syndrome (LOS) (OR, 2.56; 95% CI, 1.55 to 4.23; P<0.01), renal failure (OR, 1.84; 95% CI, 1.38 to 2.44; P<0.01). In contrast, there was no significant difference in long-term survival [hazard ratio (HR), 1.08; 95% CI, 0.81 to 1.43; P=0.60]. In systematic analysis of the studies in high-risk patients, ON-BH CABG showed a lower risk in terms of early mortality, intra-aortic balloon pump (IABP) usage, renal failure, hemodialysis, MI and pulmonary complication. No significant difference was observed in the long-term survival between ON-BH CABG and C-CABG.ConclusionsWith experienced and adept surgical team and mature ON-BH technology, ON-BH CABG may reduce the risk of postoperative death and complications in some patients. It might be an attractive alternative for high-risk patient populations.

On-pump beating-heart coronary artery bypass grafting: a literature review

Coronary artery bypass grafting techniques have been unchangeable for many years, whereas development and enhancement of myocardial protection methods in coronary bypass grafting for patients with ischemic heart disease are still actual issues of current coronary surgery. Coronary artery bypass grafting techniques include the traditional/conventional technique with cardiopulmonary bypass, aortic cross-clamping and cardioplegia, off-pump and on-pump beating heart coronary artery bypass grafting. Coronary artery bypass grafting with cardiopulmonary bypass and cardioplegia remains the most common method of coronary revascularization. However the cardiac arrest inevitably leads to global cardiac ischemia, and current cardioplegias do not prevent ischemic damage to the myocardium in all cases, especially in high-risk surgical patients. Off-pump coronary artery bypass grafting allows preventing global myocardial ischemia (due to the constant native coronary blood-flow) and avoiding possible negative consequences of cardiopulmonary bypass use. The main limitations of this technique are associated with high risk of hemodynamic instability due to low cardiac output and systolic output caused by target arteries exposition. On-pump beating heart technique is a reasonable compromise between conventional on-pump coronary artery bypass grafting, cardioplegia and off-pump procedure. It is a safe and effective technique with outcomes that are equivalent or superior to the outcomes reported for conventional coronary artery bypass grafting in patients with unstable hemodynamics, low left ventricular ejection fraction and in high-risk patients. The literature review presents the results of on-pump beating heart coronary artery bypass grafting.

On-pump beating heart coronary revascularization: Is it valid for emergency revascularization?

BACKGROUNDOn-pump beating heart coronary artery bypass grafting (CABG) may be considered as an alternative to the conventional on-pump surgery in patients presenting with acute coronary syndrome requiring emergency revascularization. This study reports our clinical experience and early outcomes with the on-pump beating heart coronary surgery on patients with acute coronary syndrome.DESIGN AND SETTINGSA retrospective study conducted from August 2009 to October, 2015, in a regional training and research hospital in Turkey.METHODSA total of 1432 patients underwent isolated CABG at our institution. A total of 316 of these patients underwent the on-pump beating heart procedure without cardioplegic arrest by the same surgeon.RESULTSThe time interval from the onset of acute myocardial infarction to CABG was 10 (2.2) hours. The mean number of grafts was 3.0 (0.6). Hospital mortality was 2.9% (9 patients). Twelve patients had low cardiac output syndromes after surgery. Eight of them had renal dysfunction but none of them needed hemodialysis. The mean intensive care unit stay was 3 (2) days and the mean hospital length of stay was 7 (4) days.CONCLUSIONWe think that the on-pump beating heart revascularization technique can be a good choice for emergency CABG of high-risk patients with a multivessel coronary artery disease.

Off-pump or on-pump beating heart: which technique offers better outcomes following coronary revascularization?

A best evidence topic was written according to a structured protocol. The question addressed was whether on-pump beating heart coronary artery bypass (BH-ONCAB) surgery has a different outcome profile in comparison to off-pump coronary artery bypass (OPCAB). A total of 205 papers were found by systematic search of which 7 provided the largest and most recent outcome analysis comparing BH-ONCAB with OPCAB, and represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results were tabulated. Reported outcome measures included mortality, stroke, myocardial infarction, renal failure, myocardial damage, change in ejection fraction, number of bypass grafts and completeness of revascularization. With the exception of one study that favoured the off-pump technique, our review did not demonstrate a statistically significant difference in terms of mortality between the groups. We did not identify a statistically significant difference in any reported morbidity outcomes. However, there was a trend towards better outcomes for the on-pump beating heart technique, despite a higher risk profile in terms of age, ejection fraction and burden of coronary disease in this group. Consistent statistically significant differences between the groups were the mean number of grafts performed and the completeness of revascularization, both of which were higher with the on-pump beating heart technique. Limitations to the current evidence include the finding that most of the current data arise from specialist off-pump surgeons or centres that would usually only carry out BH-ONCAB in the higher risk patients where the added safety of cardiopulmonary bypass is desired.

A multidisciplinary approach to unplanned conversion from off-pump to on-pump beating heart coronary artery revascularization in patients with compromised left ventricular function.

Aim. To comparably assess the perioperative risk factors that differentiate off-pump coronary artery bypass (OPCAB) grafting cases from those sustaining unplanned conversion to on-pump beating heart (ONCAB/BH) approach, in patients with left ventricular ejection fraction (LVEF) < 40%. Methods. Perioperative variables were retrospectively assessed in 216 patients with LVEF < 40%, who underwent myocardial revascularization with OPCAB (n = 171) or ONCAB/BH (n = 45) approach. The study endpoints were operative mortality (30-day) and morbidity assessed by length of intensive care unit stay (LOS-ICU), using 2 days as cut-off point. Results. Poor LVEF, increased EuroSCORE II, acute presentation, congestive heart failure, cerebrovascular disease, perioperative renal impairment, clinical status deterioration upon admission and during ICU stay, acute myocardial infarction, and low cardiac output syndrome supported by inotropes and/or balloon-pump counterpulsation were significantly related to ONCAB/BH group (P < 0.05). EuroSCORE II (P = 0.01) and LVEF (P = 0.03) were the most powerful discriminative predictors of intraoperative conversion to ONCAB/BH. Operative mortality was 2.9% in OPCAB and 6.6% in ONCAB/BH group (P = 0.224), while 23.4% participants in OPCAB and 42.2% in ONCAB/BH approach had a LOS-ICU > 2 days (P = 0.007). Conclusions. Patients with LVEF < 40% undergoing ONCAB/BH are subjected to more preoperative comorbidities and implicated ICU stay than their OPCAB counterparts, which influences adversely short-term morbidity, while operative mortality remains unaffected.

Epicardial Electrical Isolation of the Right Atrial Appendage on the Beating Heart With an Infrared Coagulator

To determine the clinical efficacy of application of infrared energy to the beating heart as a means of creating electrical blocks, an original infrared coagulator (KIRC-119; Phomec Inc, Tokyo, Japan) was applied to the atrium of a patient with atrial fibrillation. A postoperative electrophysiologic study was performed to confirm its efficacy. The coagulator was applied epicardially to the beating heart concomitant with an on-pump beating heart coronary artery bypass graft procedure. Sinus rhythm was restored during the operation, and the electrophysiologic study revealed that a bidirectional block had been created on the right atrial appendage. The infrared coagulator may facilitate performance of the epicardial Maze procedure on the beating heart.

Invited Commentary

Invited Commentary

A Randomised Trial of On-pump Beating Heart Coronary Artery Bypass Surgery and Warm Blood Cardioplegia in Patients with Impaired Left Ventricular Function Using Cardiac Magnetic Resonance Imaging and Biochemical Markers

A Randomised Trial of On-pump Beating Heart Coronary Artery Bypass Surgery and Warm Blood Cardioplegia in Patients with Impaired Left Ventricular Function Using Cardiac Magnetic Resonance Imaging and Biochemical Markers

Beating heart revascularization with or without cardiopulmonary bypass: evaluation of inflammatory response in a prospective randomized study

Objective On-pump beating heart coronary artery surgery provides the opportunity to examine the isolated effect of cardiopulmonary bypass. This prospective randomized study compares the early clinical outcomes and inflammatory response of patients undergoing elective on-pump and off-pump beating heart coronary artery bypass grafting. Method and patients Thirty-seven consecutive patients undergoing elective coronary artery bypass grafting were recruited from a pool of 73 patients, with 19 patients randomized to on-pump beating heart surgery and 18 patients to off-pump coronary bypass surgery. Intraoperative events and postoperative outcomes were recorded. Plasma levels of interleukin-6, interleukin-8, and interleukin-10, tumor necrosis factor-alpha, and vascular cell adhesion molecule-1 were measured before the operation, intraoperatively, after the operation, and 4, 24, and 48 hours thereafter. Results There was no significant difference in clinical outcomes between the 2 groups. The operating time was longer and consumption of platelets was greater for the on-pump beating heart group. There was no postoperative mortality or major complication in either group. There was significant elevation in the levels of interleukin-6, interleukin-8, and interleukin-10 and tumor necrosis factor-alpha during and immediately after the operations in the on-pump beating heart group when compared with the off-pump group. Levels of interleukin-8 ( P = .01) and tumor necrosis factor-alpha ( P = .0004) remained significantly elevated 4 hours after the operation in the on-pump beating heart group. The level of vascular adhesion molecule dropped significantly during the operation but was elevated 4 hours ( P = .026) after the operation in the on-pump beating heart group. Conclusion The use of cardiopulmonary bypass alone without global myocardial ischemia secondary to aortic crossclamping and cardioplegic cardiac arrest can trigger intense inflammatory responses.

Febrile Seizures

Coronary artery disease (CAD) is commonly associated with abdominal aortic aneurysms (AAAs) in elderly patients. When severe CAD requiring coronary artery bypass grafting (CABG) is associated with an impending AAA in a high-risk patient, the options for the suitable timing of CABG and AAA repair strategy (one-stage or two-stage) are still being debated.An 87-year-old man with non-ST-segment elevation myocardial infarction and a giant abdominal aortic aneurysm was transferred to our centre. Coronary angiography revealed triple-vessel coronary disease, and computed tomography confirmed a giant infrarenal fusiform abdominal aortic aneurysm 9 cm in maximal diameter. We simultaneously performed endovascular aneurysm repair prior to on-pump beating-heart coronary artery bypass grafting. The postoperative course was uneventful, and the patient was discharged on the 15th postoperative day.Combined endovascular aneurysm repair and on-pump beating heart coronary artery bypass grafting in a one-stage operation is a promising strategy to improve therapeutic efficiency in octogenarians. More studies are needed to compare the efficacy and safety of one-stage and two-stage operations to treat concomitant coronary artery disease and aortovascular pathology in the high-risk octogenarian patients.