On-pump Bypass Research Articles

Effects of different surgical strategies and left ventricular remodelling on the outcomes of coronary artery bypass grafting in heart failure patients with reduced ejection fraction.

Ischaemic heart failure with reduced ejection fraction (HFrEF) caused by coronary artery disease accounts for the largest proportion of heart failure cases with the worst prognosis. Coronary artery bypass grafting (CABG) is the most effective treatment for ischaemic HFrEF. On-pump and off-pump are the two surgical methods used for CABG. Whether patients with HFrEF should undergo on- or off-pump CABG is controversial in coronary heart disease surgery. The left ventricular end-systolic volume index (LVSEVI) is the gold standard for evaluating the severity of left ventricular remodelling; however, its effect on the perioperative risk and long-term survival rate of patients with HFrEF undergoing CABG remains unclear. This single centre prospective cohort analysis included 118 coronary heart disease patients with symptoms and signs of heart failure and a left ventricular ejection fraction (LVEF) of <40% who were enrolled consecutively from January 2019 to December 2023. Operative mortality, perioperative complications, and long-term survival were compared among patients treated with various LVESVIs and surgical methods. The primary outcomes were cardiac death, myocardial infarction, heart failure, stroke, and revascularization, (percutaneous coronary intervention or redo CABG) with a median follow-up of 38 ± 10 months. The 30-day postoperative mortality of 118 patients was 6.8%. Patients in the off-pump group had significantly higher perioperative mortality than those in the on-pump group (12.5% vs. 3.8%, p = 0.03). In the off-pump group, a higher proportion of patients required perioperative mechanical assistance, such as intra-aortic artery balloon pump (IABP) or extracorporeal membrane oxygenation (ECMO), compared to those in the on-pump group (IABP: 75% vs. 47.4%, p = 0.004; ECMO: 22.5% vs. 1.3%, p = 0.000). Patients in the off-pump group were more likely to have postoperative atrial fibrillation (AF) (35% vs. 14.1%, p = 0.01). In the on-pump group, the incidence of postoperative AF (25% vs. 6.5%, p = 0.02) and IABP use (62.5% vs. 36.9%, p = 0.03) were significantly higher in patients with more severe left ventricular remodelling than in those with less severe left ventricular remodelling. In the off-pump group, patients with more severe left ventricular remodelling had higher ECMO usage (38.9% vs. 9.1%, p = 0.04), incidence of postoperative AF (61.1% vs. 13.6%, p = 0.02), and perioperative mortality (22.2%). Major adverse cardiac event (MACE)-free survival rate was significantly higher in the on-pump group than in the off-pump group, and there was no significant difference in MACE free survival rates between the two groups of patients with different degrees of left ventricular remodelling. On-pump bypass is a better surgical procedure for patients with ischaemic HFrEF, especially those with severe left ventricular remodelling. Left ventricular remodelling increases perioperative mortality but has no effect on long-term survival.

Off-pump vs. on-pump bypass surgery grafting in diabetic patients with three-vessel disease: a propensity score matching study

BackgroundControversy exists regarding the advantages and risks of off-pump vs. on-pump coronary artery bypass grafting (CABG) for patients with diabetes. We therefore compare the early clinical outcomes of off-pump vs. on-pump procedures for diabetic patients with three-vessel disease.Materials and methodsWe conducted a retrospective analysis of clinical data obtained from 548 diabetic patients with three-vessel coronary artery disease who underwent isolated CABG between January 2016 and June 2020. To adjust the differences of baseline characteristics between the off-pump CABG (OPCAB) and on-pump CABG (ONCAB) groups, propensity score matching (PSM) was used. Following 1:1 matching, we selected 187 pairs of patients for further comparison of outcomes within the first 30 days after surgery.ResultsThe preoperative characteristics of the patients between the two groups were clinically comparable after PSM. The OPCAB group exhibited a significantly higher incidence of incomplete revascularization (27.3% vs. 14.4%; P = 0.002) compared with the ONCAB group. No differences were seen in mortality within 30 days between the matched groups (1.1% vs. 3.7%; P = 0.174). Notably, the OPCAB group had a lower risk of respiratory failure or infection (2.1% vs. 7.0%; P = 0.025), less postoperative stroke (1.1% vs. 4.8%; P = 0.032), and reduced postoperative ventilator assistance time (35.8 ± 33.7 vs. 50.9 ± 64.8; P = 0.005).ConclusionOPCAB in diabetic patients with three-vessel disease is a safe procedure with reduced early stroke and respiratory complications and similar mortality rate, myocardial infarction, and renal failure requiring dialysis to conventional on-pump revascularization.

Visual Hallucinations following Coronary Artery Bypass Grafting: A Prospective Study.

Background and Objectives: After major heart surgery, some patients report visual hallucinations that cannot be attributed to psychosis or delirium. This study aimed to investigate the hallucination incidence in patients after coronary artery bypass grafting with (on-pump) and without (off-pump) extracorporeal circulation. Materials and Methods: A total of 184 consecutive patients listed for elective on- or off-pump coronary artery bypass grafting were prospectively enrolled into the study. Preoperative baseline investigations 24–48 h before surgery (t0) and postoperative follow-up 24–48 h (t1) and 5–6 days (t2) after surgery included cognitive testing and a clinical visual acuity test (Landolt rings). Patients reporting visual hallucinations were interviewed using a structured survey to record the type, timing, duration, and frequency of their hallucinations. All the patients received a neurological examination and cranial magnetic resonance imaging if indicated. Results: Of the patients in the sample, 155 patients underwent on-pump bypass surgery, and 29 patients received off-pump surgery. Of these, 25 patients in the on-pump group, but none in the off-pump group, reported transient visual hallucinations (p = 0.020), which could not be attributed to stroke, delirium, psychosis, migraine, or severely impaired vision. Significant correlations were observed for the occurrence of visual hallucinations and the amount of nicotine consumption and aortic clamp/extracorporeal circulation time. Conclusions: Transient visual hallucinations occur in a noticeable proportion of patients after on-pump heart surgery. Knowledge of the phenomenon’s benignity is important for patients to prevent anxiety and uncertainty and for treating physicians to avoid unnecessary medication and drug-induced delirium.

8-Isoprostanes and Asymmetric Dimethylarginine as Predictors of Mortality in Patients Following Coronary Bypass Surgery: A Long-Term Follow-Up Study.

Background: We previously demonstrated that enhanced oxidative stress and reduced nitric oxide bioavailability are associated with unfavorable outcomes early after coronary artery bypass grafting. It is not known whether these processes may impact long-term results. We sought to assess whether during long-term follow-up, markers of oxidative stress and nitric oxide bioavailability may predict cardiovascular mortality following bypass surgery. Methods: We studied 152 consecutive patients (118 men, age 65.2 ± 8.3 years) who underwent elective, primary, isolated on-pump bypass surgery. We measured plasma 8-iso-prostaglandin F2α and asymmetric dimethylarginine before surgery and twice after surgery (18–36 h and 5–7 days). We assessed all-cause and cardiovascular death in relation to these two biomarkers during a mean follow-up time of 11.7 years. Results: The overall mortality was 44.7% (4.7 per 100 patient-years) and cardiovascular mortality was 21.0% (2.2 per 100 patient-years). Baseline 8-iso-prostaglandin F2α was associated with cardiovascular mortality (HR 1 pg/mL 1.010, 95% CI 1.001–1.021, p = 0.036) with the optimal cut-off ≤ 364 pg/mL for higher survival rate (HR 0.460, 95% CI 0.224–0.942, p = 0.030). Asymmetric dimethylarginine > 1.01 μmol/L measured 18–36 h after surgery also predicted cardiovascular death (HR 2.467, 95% CI 1.140–5.340, p = 0.020). Additionally, elevated 8-iso-prostaglandin F2α measured at the same time point associated with all-cause mortality (HR 1 pg/mL 1.007, 95% CI 1.000–1.014, p = 0.048). Conclusions: Our findings indicate that in advanced coronary disease, increased oxidative stress, reflected by 8-iso-prostaglandin F2α before bypass surgery and enhanced asymmetric dimethylarginine accumulation just after the surgery are associated with cardiovascular death during long-term follow-up

Simultaneous Operation on Pump Coronary Bypass Grafting and Left Hemicolectomy in Patient with Reduced Ejection Fraction

This is written so as to report the case of a 75-year-old male with a diagnosis of sigmoid adenocarcinoma accompanied by critical coronary artery disease and angina, which was subject to simultaneous surgical treatment. Was performed first an on – pump coronary artery revascularization and then a left colectomy. Our case suggests that performing an on-pump bypass in patient also with reduced ejection fraction procedure prior to cancer surgery can be a safe surgical in appropriately selected cases.

COMPARISON BETWEEN HEMODYNAMIC CHANGES OF ATRACURIUM AND CISATRACURIUM IN PATIENTS UNDERGOING CABG SURGERY

Objective: To compare the hemodynamic effects of Atracurium versus Cisatracurium in Cardiac Patients Undergoing coronary artery bypass graft Surgery.&#x0D; Study Design: Randomized controlled trial.&#x0D; Place and Duration of Study: The study was conducted at Armed Forces Institute of Rawalpindi, a tertiary care hospital, after seeking hospital ethics committee permission, from Apr 2019 to Oct 2019. Methodology: A total of 200 consecutive patients were randomized into two equal groups, group-A and group-C (100 in each group). Group-A patients were induced with 0.5mg/kg of Atracurium, followed by infusion @ 10μg/kg/min whereas group C patients received Cisatracurium @ 0.2mg/kg at induction, followed by infusion @ 2μg/kg/min during the maintainence phase. Systolic blood pressure, diastolic blood pressure, Mean arterial pressure and heart rate were noted at different intervals of both groups. Decrease in systolic blood pressure of &gt;20% from baseline or a value &lt;90 mmHg was considered as hypotension.&#x0D; Results: The mean age of patients was 57.5 ± 6.75 years and 56.52 ± 4.46 years in group A and group C respectively. Systolic and diastolic blood pressure was better maintained with cisatracurium than atracurium. Also Mean arterial pressure remained more stable with cisatracurium (p&lt;0.05), but after opening of sternum and before going on cardiopulmonary bypass, the difference was insignificant in both groups (p&gt;0.05). Heart rate remained more steady with cisatracurium (p&lt;0.05) but had insignificant difference before going on cardiopulmonary bypass (p&gt;0.05).&#x0D; Conclusion: Cisatracurium found to be more suitable drug in maintaining the stable hemodynamics and preventing fluctuations in pressure in cardiac patients undergoing on-pump bypass surgery.

Anaesthetic implications during off-pump coronary artery bypass surgery

Off-pump coronary artery bypass has emerged as a popular method of coronary revascularization to mitigate the harmful effects of cardiopulmonary bypass. It requires surgical and anaesthetic expertise for good results. Newer minimally invasive approaches to off pump coronary bypass provide attractive alternatives to conventional off pump surgery, especially in achieving better cosmetic results and early extubation. They require good perioperative pain management, with epidural and paravertebral block being good choices. Emergency conversion of off-pump bypass to on-pump bypass is associated with poor outcomes, so preventive measures to avoid it should be employed. Keywords: Off-pump coronary artery bypass, Anaesthetic implications.

Off-pump versus on-pump bypass surgery for left main coronary artery disease (EXCEL study) - is experience the unknown variable?

A post hoc analysis of the Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) data compared off-pump coronary artery bypass (OPCAB) technique with conventional coronary artery bypass grafting (CABG). It was reported that OPCAB was associated with lower rate of revascularization especially in the inferolateral wall and carried increased risk of 3-year all-cause mortality compared to on-pump CABG. However, the study does not provide any information on the experience of participating surgeons which is a key determinant of outcomes in OPCAB surgery. In the absence of this key variable, the extrapolation and applicability of this finding to the wider surgical practice, especially in countries like India and Japan, may not be accurate.

Comparative Analysis of Dexmedetomidine and Propofol Based Sedation Regimens on Anaesthetic Requirements in Cardiac Surgery with On-pump Cardiopulmonary Bypass

Comparative Analysis of Dexmedetomidine and Propofol Based Sedation Regimens on Anaesthetic Requirements in Cardiac Surgery with On-pump Cardiopulmonary Bypass

Concordance between administrative data and clinical review for mortality in the randomized on/off bypass follow-up study (ROOBY-FS)

The optimal methodology to identify cardiac versus non-cardiac cause of death following cardiac surgery has not been determined. The Randomized On/Off Bypass Trial was a multicenter, randomized, controlled clinical trial of 2203 patients (February 2002-May 2008) comparing 1-year cardiac outcomes between off-pump and on-pump bypass surgery. In 2013, the Veterans Affairs (VA) Cooperative Studies Program funded a follow-up study to assess 5-year outcomes including mortality. Deaths were identified and confirmed using the National Death Index (NDI), VA Vital Status file, and medical records. An Endpoints Committee (EC) reviewed patient medical records and classified each cause of death as cardiac, non-cardiac, or unknown. Using pre-determined ICD-10 codes, NDI death certificates were independently used to classify deaths as cardiac or non-cardiac. Cause of death was compared between the NDI and EC classifications and concordance measured, using Kappa statistics. Of the 297 5-year deaths identified by the NDI and/or VA vital status file and confirmed by the EC, 219 had adequate patient records for EC cause of death determination. The EC adjudicated 141 of these deaths as non-cardiac and 78 as cardiac, while the NDI classified 150 as non-cardiac and 69 as cardiac; agreement was 77.6% (kappa 0.500; P < 0.001). Since concordance between EC and NDI cause of death classifications was only moderate, caution should be exercised in relying exclusively on NDI data to determine cause of death. A hybrid approach, integrating multiple information sources, may provide the most accurate approach to classifying cause of death.

Myocardial injury in diabetic patients with multivessel coronary artery disease after revascularization interventions

BackgroundDiabetic patients may be more susceptible to myocardial injury after coronary interventions. Thus, the aim of this study was to assess the release of cardiac biomarkers, CK-MB and troponin, and the findings of new late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) in patients with type 2 diabetes mellitus after elective revascularization procedures for multivessel coronary artery disease (CAD).MethodsPatients with multivessel CAD and preserved systolic ventricular function underwent either elective percutaneous coronary intervention (PCI), off-pump or on-pump bypass surgery (CABG). Troponin and CK-MB were systematically collected at baseline, 6, 12, 24, 36, 48 and 72 h after the procedures. CMR with LGE was performed before and after the interventions. Patients were stratified according to diabetes status at study entry. Biomarkers and CMR results were compared between diabetic and nondiabetics patients. Analyses of correlation were also performed among glycemic and glycated hemoglobin (A1c) levels and troponin and CK-MB peak levels. Patients were also stratified into tertiles of fasting glycemia and A1c levels and were compared in terms of periprocedural myocardial infarction (PMI) on CMR.ResultsNinety (44.5%) of the 202 patients had diabetes mellitus at study entry. After interventions, median peak troponin was 2.18 (0.47, 5.14) and 2.24 (0.69, 5.42) ng/mL (P = 0.81), and median peak CK-MB was 14.1 (6.8, 31.7) and 14.0 (4.2, 29.8) ng/mL (P = 0.43), in diabetic and nondiabetic patients, respectively. The release of troponin and CK-MB over time was statistically similar in both groups and in the three treatments, besides PCI. New LGE on CMR indicated that new myocardial fibrosis was present in 18.9 and 17.3% (P = 0.91), and myocardial edema in 15.5 and 22.9% (P = 0.39) in diabetic and nondiabetic patients, respectively. The incidence of PMI in the glycemia tertiles was 17.9% versus 19.3% versus 18.7% (P = 0.98), and in the A1c tertiles was 19.1% versus 13.3% versus 22.2% (P = 0.88).ConclusionsIn this study, diabetes mellitus did not add risk of myocardial injury after revascularization interventions in patients with multivessel coronary artery disease.Trial Registration Name of Registry: Evaluation of cardiac biomarker elevation after percutaneous coronary intervention or coronary artery bypass graft; URL: http://www.controlled-trials.com.ISRCTN09454308

Risk Factors of On-Pump Conversion during Off-Pump Coronary Artery Bypass Graft.

BackgroundOff-pump coronary artery bypass grafting (OPCABG) procedures can avoid the complications of an on-pump bypass. However, some cases unexpectedly require conversion to cardiopulmonary bypass during OPCABG. The risk factors associated with a sudden need for cardiopulmonary bypass were analyzed.MethodsThis retrospective study included 283 subjects scheduled for OPCABG from 2001 to 2010. These were divided into an OPCABG group and an on-pump conversion group. Preoperative, operative, and postoperative variables were compared between the 2 groups.ResultsOf the 283 patients scheduled for OPCABG, 47 (16%) were switched to on-pump coronary artery bypass grafting (CABG). The mortality of the both the OPCABG and on-pump conversion groups was not significantly different. The major risk factors for conversion to on-pump CABG were congestive heart failure (CHF) (odds ratio [OR], 3.5; p=0.029), ejection fraction (EF) <35% (OR, 4.4; p=0.012), and preoperative beta-blocker (BB) administration (OR, 0.3; p=0.007). The use of intraoperative (p=0.007) and postoperative (p=0.021) inotropics was significantly higher in the conversion group. The amount of postoperative drainage (p<0.001) and transfusion (p<0.001) also was significantly higher in the conversion group. There were no significant differences in stroke or cardiovascular complications between the groups over the course of short-term and long-term follow-up.ConclusionPatients who undergo OPCABG and have CHF or a lower EF (<35%) are more likely to undergo on-pump conversion, while preoperative BB administration could help prevent conversions from OPCABG to on-pump CABG.

Outcome of Cardiac Rehabilitation Following Off-Pump Versus On-Pump Coronary Bypass Surgery.

BACKGROUND:A few studies have compared the cardiac rehabilitation (CR) outcome between those who undergo conventional on-pump bypass surgery and off-pump surgery. We compared this outcome among the patients differentiated by the On-pump and off-pump surgical procedures about cardiovascular variables and psychological status.METHODS:This longitudinal study recruited 318 and 102 consecutive patients who had undergone CABG (on-pump surgery, n = 318 and off-pump surgery, n = 102) and been referred to the CR clinic.RESULTS:The off-pump surgery patients had more improvement in their metabolic equivalents (METs) value. The physical and mental components of health-related quality of life (QOL) (based on SF-36 questionnaire) as well as depression-anxiety (based on Costello-Comrey Depression and Anxiety Scale) were notably improved in the two study groups after the CR program, while changes in the QOL components scores and also depression-anxiety score were not different between the off-pump and on-pump techniques.CONCLUSIONS:Regarding QOL and psychological status, there were no differences in the CR outcome between those who underwent off-pump bypass surgery and those who underwent on-pump surgery; nevertheless, the off-pump technique was superior to the on-pump method on METs improvement following CR.

Simultaneous Beating Heart Coronary Artery Bypass Surgery and Modified Radical Mastectomy

Concomitant surgeries for unrelated diseases can be performed to minimize the risks associated with surgery and general anesthesia. In treating a male patient with breast cancer and severe coronary artery disease, we used the beating heart technique for a coronary artery bypass graft to avoid the negative effects of on-pump bypass on the possible acceleration of tumor growth. In this report, we present a unique case of concomitant off-pump coronary artery bypass graft surgery and modified radical mastectomy in a 56-year-old man.

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Introduction: Patients requiring an on-pump bypass procedure may benefit from limiting the volume of crystalloid and colloid administration. The objective of this retrospective study was to compare mortality and clinical outcomes in patients receiving standard concentration cardioplegia (4:1 blood to crystalloid) with those observed in patients receiving Master Follower concentrated cardioplegia (16:1 and 32:1 blood to crystalloid). Methods: Retrospective analysis of adult patients who underwent CABG-only procedures between January 2010 and December 2011 at a single academic medical center were assessed. Fifty patients who received Master Follower and fifty who received standard cardioplegia were selected randomly for inclusion. The primary outcome was all-cause mortality at 30 days after the procedure. Secondary outcomes included the presence of neurologic dysfunction (encephalopathy, transient ischemic attack, and/or cerebrovascular accident), pulmonary dysfunction (ventilator time), cardiac complications (myocardial infarction, atrial fibrillation, requirement of intra-aortic balloon pump, and/or time on critical medications), renal dysfunction (acute kidney injury), ICU length of stay, and quantity of fluid received (cardioplegia volume, crystalloid volume, colloid volume, and/or packed red blood cells). Results: The Master Follower cardioplegia group received a reduced volume of cardioplegia (p<0.001), crystalloid (p=0.047), colloid (p=0.035), and packed red blood cells (59 units vs. 112 units, overall) as compared to the standard cardioplegia group. There were no statistically significant differences between the groups in relation to mortality, ICU length of stay, or organ dysfunction. Conclusions: Master Follower concentrated cardioplegia is as safe as standard concentration cardioplegia for CABG-only procedures.

On-pump coronary artery bypass in moyamoya disease: A case report

A 54-year-old female with pre-existing idiopathic moyamoya disease developed chest pain with acute myocardial infarction. Coronary angiography detected occluded and stenotic lesions in the coronary arteries. Right coronary artery stenosis was treated by balloon angioplasty and stenting. Because of the restenosis, on-pump cardiopulmonary bypass was performed. The operation was uneventful and no perioperative cerebral ischemic episode occurred. The conclusion is that on-pump cardiopulmonary bypass preserving intraoperative hemodynamic parameters at an optimal level is a safe procedure in a patient with moyamoya disease.

Evaluation of graft flow between on-pump and off-pump coronary artery bypass grafting

Background: Coronary artery bypass grafting (CABG) is an effective method to afford sufficient blood flow for that ischemic myocardium. Off-pump coronary bypass surgery (OPCAB) has been rediscovered and refined to avoid cardiopulmonary bypass. However, it’s a high technique demanding skill. And evaluation of the blood flow should be reliable. Transit time flow measurement (TTFM) is introduced to evaluate graft flow and anastomosis patency intraoperatively. The accuracy of graft flow depends on how to explain the parameters of TTFM. Here, we introduce our experiences on the explanation of TTFM parameters. Objective: We compared the graft patency of off-pump coronary artery bypass grafting with those of on-pump coronary artery bypass grafting by intraoperative transit time flow measurement (TTFM). Methods: Three hundred patients were divided into off-pump group and on-pump group. TTFM was routinely performed for assessment of graft patency during operation. Revision of the grafts depends on the TTFM findings. Results: One patient in OPCAB group was converted to conventional CABG group due to ventricular fibrillation. One patient died of multiple organ failure 21 days post-operation. Seven grafts were revised based on unsatisfactory TTFM findings. There was no statistical difference in the variables between the two groups except for anastmosis to right coronary artery. Conclusions: Off-pump surgery can provide the same flow of grafts as that of on-pump surgery. TTFM is an effective tool to decide if a well-function graft is or not, and it allows for revision of failure graft during operation. Keywords: Backward flow percentage, coronary artery bypass grafting, pulsatile index, revascularization, transit time flow measurement

Stay off-pump and do not touch the aorta!

One of the major drawbacks in contemporary on-pump coronary artery bypass surgery is the inherent risk of intraoperative stroke. In addition, neurophysiological dysfunction and neurobehavioural changes have been reported in variable frequencies following on-pump bypass surgery. Cardiopulmonary bypass (CPB) causes a systemic inflammatory response, haemodilution, change in vascular resistance, absence of pulsatile flow, and large volume shifts. As a result, temporary cerebral oedema can be seen in magnetic resonance imaging (MRI) studies early after on-pump bypass surgery and has been identified as the substrate for what was termed ‘pump head’ in the past. Refinements of CPB circuits using biocompatible surfaces, the use of less traumatic oxygenators, and the addition of filters as well as the establishment of standardized perfusion protocols have improved the results of on-pump surgery. Despite these advances, CPB remains one major source for gaseous microembolization.1,2 Retransfusion of shed mediastinal blood during on-pump surgery has long been recognized as an additional source of embolization by fat particles and activation and derangement of the clotting cascade. Manipulation of the ascending aorta such as partial or total clamping and cannulation required for installation of CPB can cause additional solid emboli especially in the presence of atherosclerotic disease.3,4 Numerous studies have shown embolic showers in transcranial Doppler during cannulation and clamping and declamping manoeuvres. The release of particulate emboli correlates in particular with the release of the aortic cross-clamp.5 Gerriets et al. have reported a randomized controlled trial to demonstrate the impact of two different methods to decrease the embolic load during on-pump bypass surgery with partial aortic clamping in a … *Corresponding author. Tel: +41 44 255 32 98, Fax: +41 44 255 32 98, Email: volkmar.falk{at}usz.ch

Application of prophylactic gel-pads for transcutaneous pacing in patients with complete right bundle-branch block with axis deviation when surgical procedures are performed: 10-year experience from a single Japanese university hospital

This retrospective study aimed to determine whether prophylactic transcutaneous pacing is required for patients with complete right bundle-branch block (CRBBB) and axis deviation (AD), so-called bifascicular block, when surgical procedures are performed under general or local anesthesia. The authors reviewed 34 063 anesthesia cases that took place at Nara Medical University Hospital during a 10-year period (1996-2005). The anesthesia records of all identified patients having CRBBB or bifascicular block were retrospectively reviewed and the incidence of block progression to complete heart block or bradycardia requiring temporary transcutaneous pacing served as the primary endpoint. As a secondary endpoint, the incidence of block progression to complete heart block or bradycardia requiring only medical treatment was checked. Seventy of the 34 063 patients (0.2%) had CRBBB with AD. Only 1 patient with CRBBB with left AD, who underwent on-pump aorto-coronary bypass grafting surgery, developed complete heart block at the resumption of heartbeat. None of the other 69 patients, except for this cardiac case, developed complete heart block during surgery. Based on this analysis of 70 cases, prophylactic gel-pad electrode application in patients with CRBBB and AD does not appear to be necessary during surgical procedures.

Surgical volume and outcomes of off-pump coronary artery bypass graft surgery: Does it matter?

Coronary artery bypass grafting performed off-pump has emerged in recent years as a less morbid alternative to on-pump bypass grafting. However, the impact of hospital volume on the outcomes of off-pump relative to on-pump bypass grafting has not been evaluated. We conducted a retrospective study of patients undergoing off-pump (n = 26,011) and on-pump (n = 99,344) coronary artery bypass grafting during 2000 through 2004 in 124 California hospitals, using the California Patient Discharge Database. Generalized linear mixed models were used to compare in-hospital mortality and postoperative complications in patients undergoing on-pump versus off-pump bypass grafting, accounting sequentially for differences in patient characteristics and hospital-level effects. The relative mortality and complication rates for patients undergoing on-pump versus off-pump coronary bypass were evaluated across hospital volume quartiles. Mean length of stay was lower for patients who underwent off-pump compared with on-pump bypass grafting (8.7 vs 9.6 days; P < .001), as were unadjusted mortality and complication rates (2.2% vs 3.3%; 10.1% vs 11.6%, respectively; P < .001). For hospitals in the highest percent off-pump bypass quartile, adjusted mortality and complication rates for patients having off-pump bypass were significantly lower than for the on-pump group (odds ratio [OR] = 0.50; 95% confidence intervals [CI], 0.41-0.61; OR = 0.73; 95% CI, 0.66-0.81, respectively; P < .001); by contrast, for hospitals in the lowest percent off-pump bypass quartile, mortality and complications were similar in off-pump and on-pump groups (OR = 1.10; 95% CI, 0.75-1.63; OR = 0.92; 95% CI, 0.72-1.16, respectively; P > .05). Outcomes were significantly better for off-pump compared with on-pump coronary artery bypass grafting. Although the benefit of off-pump bypass grafting increased as the relative use of the procedure at a hospital increased, off-pump bypass grafting can be safely implemented across numerous hospitals.