On-pump CABG Surgery Research Articles

The effect of ultrasound-guided bilateral single-shot erector spinae plane block on recovery after on-pump coronary bypass graft surgery: a randomized controlled study

BackgroundFast-track and ultra-fast-track anesthesia techniques can be facilitated with opioid requirements’ reduction and multi-modal analgesia techniques that include the regional anesthesia techniques. The study aimed to assess the preoperative effect of single-shot bilateral ultrasound-guided erector spinae plane block (ESPB) on the extubation time and postoperative pain of patients undergoing on-pump CABG surgery.ResultsThe ESPB group was statistically significant decreased regarding the extubation time, ICU length stay, intraoperative fentanyl, and postoperative morphine consumption than the control group (p < 0.0001 for all the previous measurement). The 1st time of rescue analgesia of the ESPB group was longer than the control group (p < 0.0001). The numerical rating score (NRS) after extubation of the ESPB group was lower at 2 and 4 h after extubation (P = ˂ 0.0001 and 0.0006 respectively) than the control group. The number of patients who required rescue analgesia after extubation was significantly decreased in the ESPB group in comparison to the control group, 2 and 4 h after extubation (P = < 0.0001 and 0.004 respectively).ConclusionsThe preoperative single-shot ultrasound-guided ESPB in patients scheduled for on-pump CABG surgery shortened the extubation time and the length of ICU, decreased intraoperative fentanyl and postoperative morphine consumption and postoperative pain scores, and prolonged 1st time of rescue analgesia without significant effect on the incidence of complications, re-intubation, or mortality.Trial registrationApproval was obtained from the Research Ethics Committee of the Faculty of Medicine (approval code of 33702/02/20) registered at February 2, 2020, and written informed consent was obtained from the patients. The trial was registered at 17 March 2020 in the Pan African Clinical Trial Registry with a unique identification number for the registry which is PACTR202003822626676.

CEREBRAL AUTOREGULATION MONITORING TO REDUCE POSTOPERATIVE NEUROLOGICAL COMPLICATIONS FROM CARDIAC SURGERY: ONGOING STUDY

<h3>Introduction and objective</h3> Disturbances of various duration of cerebral autoregulation (CA) have been documented during cardiac surgery and are associated with poor neurological outcomes. Meanwhile, patient-specific thresholds for CA are unknown. The aim of our study is to determine the influence of CA monitoring on the incidence of postoperative neurological complications in patients undergoing cardiac surgery. <h3>Design and method</h3> A prospective pilot observational study (as a part of ongoing study, funded by Lithuanian Central Project Management Agency (CPVA) grant No 01.2.2. - CPVA - K - 703 - 03 - 0025 and by EU Structural Funds) was conducted in 2021–2022. The study enrolled 30 patients undergoing elective CABG surgery with cardiopulmonary bypass (CBP). All patients were assessed for cognitive function 1 day before surgery and on the 7–10th postoperative day using MMSE-2, ACE-III tests. The CA was monitored during surgery using transcranial Doppler ultrasonography (TCD). Postoperatively delayed recovery of cognitive functions (DNR) and postoperative delirium were recorded. <h3>Results</h3> 10 patients were excluded from data analysis due to postoperative delirium, refusal to perform postoperative tests or lack of ultrasound transmission window for TCD. The average age of the rest 20 patients was 66.25± 6.87 years, most of them were men (85 % n=17). The CA monitoring data of analysed patients are presented in Table 1. <h3>Conclusions</h3> Preliminary data confirmed that temporary CA impairment occurs in all patients undergoing elective on-pump CABG surgery. TCD commonly used in clinical practice for CA evaluation has several limitations: it is highly operator dependent, and some patients have no inadequate ultrasound transmission windows. The study is ongoing, and we continue to collect the patient data, to find a better method of CA monitoring and statistically significant conclusions.

Frequency of Respiratory Complications in Post COVID-19 Patients After Coronary Artery Bypass Grafting

Objective: To determine the frequency of post-operative pulmonary complications after (coronary artery bypass grafting)CABG surgery and to compare the respiratory complications of post COVID and comparison group &#x0D; Study Design: Analytical Cross- sectional study&#x0D; Study Place and Duration: Study was conducted in Adult Intensive Care Unit, Armed Forces Institute of Cardiology,Rawalpindi Pakistan, from Sep 2021 to Mar 2022.&#x0D; Methodology: 40 patients were selected, and divided into two groups using Non-Probability consecutive sampling. Group-A had history of COVID-19 infection and Group-B was a comparison group and had no history of COVID-19 infection. Patients presenting for elective On-Pump (coronary artery bypass grafting) CABG surgery and known history of COVID-19 were included in our study. Patients of age ranging 30 to 70 years irrespective of gender were included in the study. Any patient who had cardiopulmonary bypass time of more than 120 min, respiratory illness like asthma or Chronic Obstructive Pulmonary Disease (COPD), history of smoking, or requiring post-operative re-ventilation due to cardiac or neurological complication, were excluded from the study. After patients were received from Operation theatre, they were monitored for the respiratory complications and both groups were compared. &#x0D; Results: A total of 40 patients were included in this study having mean age 57.9±7.62 years. Most of the patient population was male 31(77.5%) and only 09(22.5%) were female patients. Study population was equally divided into two groups i.e.20(50%) in comparison group and 20(50%) in post COVID-19 group. There was no significant difference in age (p=0.714), ventilation time (p=0.068), gender (p=1.000), and re-ventilation (p=0.451) of both groups. While Intensive Care Unit stay(p=&lt;0.0001) and non-invasive ventilation (NIV) were found to be significant (p=0.007).

Analisis Biaya Operasi Teknik Off-pump CABG dibandingkan On-pump CABG Pasien BPJS Penyakit Jantung Koroner dengan Fungsi Jantung Buruk di Rumah Sakit Jantung Harapan Kita

Coronary heart disease (CHD) is a heart disease that is mainly caused by narrowing of the coronary arteries due to atherosclerosis or spam or a combination of both. In CHD patients who continued therapy, coronary artery bypass surgery can be performed Off-pump CABG or On-pump CABG, with hearts function poorly with LEF &lt; 30 % at risk and a higher complication which results in increased costs. The research is aimed to analyze the operating cost Off-pump CABG technique compared to the On-pump CABG technique in patients with BPJS coronary heart disease with poor heart function in Rumah Sakit Jantung dan Pembuluh Darah Harapan Kita on period January – December 2015. Patient sample selection is done in the installation of medical records with the diagnosis of CHD undergoing coronary artery bypass surgery technique Off-pump CABG and On-pump CABG. Data retrieval costs of pre-operatives, peri-operatives, and post-operative. This research conducted prospectively. Data were analyzed using the Kolmogorov test, Mann Whitney test, and Kruskal Wallis test. Research results obtained from a total of 70 patients with each of the 35 patients who underwent Off-pump CABG and On-pump CABG. The average cost of technique operation Off-pump CABG amounted to Rp.85,812,864. The average cost of technique operation on-pump CABG amounted to Rp.105,480,363. Operation margin amounted to Rp. 19,667,499. Mann-Whitney test shows different averages with p-value=0,006, then there is a significant difference between the two groups. Comparison of the rates for the Ina-CBGs surgery techniques Off-pump CABG an average of Rp.141,747,683, different of Rp. 55,934,819. Of the rates for the Ina-CBGs surgery techniques on-pump CABG an average of Rp. 138,782,251, different of Rp. 33,301,888. Kruskal Wallis test shows a different averages with p-value=0,000, then there is a significant difference between the two groups. Operating cost Off-pump CABG technique is lower than of On-pump CABG surgery technique. Operating cost Off-pump CABG technique and On-pump CABG lower than tariff Ina-CBGs.

Spironolactone and perioperative atrial fibrillation occurrence in cardiac surgery patients: Rationale and design of the ALDOCURE trial

BackgroundAfter artery bypass grafting (CABG), the presence of perioperative AF (POAF) is associated with greater short- and long-term cardiovascular morbidity. Underlying POAF mechanisms are complex and include the presence of an arrhythmogenic substrate, cardiac fibrosis and electrical remodeling. Aldosterone is a key component in this process. We hypothesize that perioperative mineralocorticoid receptor (MR) blockade may decrease the POAF incidence in patients with a left ventricular ejection fraction (LVEF) ≥50% who are referred for CABG with or without aortic valve replacement (AVR). Study designThe ALDOCURE trial (NCT03551548) will be a multicenter, randomized, double-blind, placebo-controlled trial testing the superiority of a low-cost MR antagonist (MRA, spironolactone) on POAF in 1500 adults referred for on-pump elective CABG surgery with or without AVR, without any history of heart failure or atrial arrhythmia.The primary efficacy end point is the occurrence of POAF from randomization to within 5 days after surgery, assessed in a standardized manner. The main secondary efficacy end points include the following: postoperative AF occurring within 5 days after cardiac surgery, perioperative myocardial injury, major cardiovascular events and death occurring within 30 days of surgery, hospital and intensive care unit length of stay, need for readmission, LVEF at discharge and significant ventricular arrhythmias within 5 days after surgery. Safety end points, including blood pressure, serum potassium levels and renal function, will be monitored regularly throughout the trial duration. ConclusionThe ALDOCURE trial will assess the effectiveness of spironolactone in addition to standard therapy for reducing POAF in patients undergoing CABG. Clinical trial registrationNCT03551548

Heart-Protective Mechanical Ventilation in Postoperative Coronary Artery Bypass Grafting Patients

Introduction: The effect of mechanical ventilation (MV) on hemodynamic parameters of cardiosurgical patients with multiple respiratory and cardiovascular risk factors may be detrimental, demanding not only lung- but heart-protective settings. Objective: This prospective study compared the hemodynamic effect and gas exchanges between several ventilator setting combination of Volume tidal, respiratory rate and end-expiratory pressure in post cardiac surgery patients. Design: Sequential study with a controlled group. Setting: Single cardiosurgical ICU. Patients: 119 patients after on-pump CABG surgery without severe hemodynamic and gas exchange disorders. Interventions: During the 1st postoperative hour (conventional ventilation) the intervention group patients ventilated with Vt 10 ml×kg-1, RR 14 /min, 5 cmH2O. During the 2nd hour, RR to 8 /min (reduced RR In the 3rd hour, Vt decreased to 6 ml×kg-1, RR returned to14 /min and increased to 10 cmH2O (low VT-high PEEP ventilation). In 24 patients from the control group MV settings in the 3rd hour did not change, so they were equal those in 2nd hour. Measurements: Respiratory mechanics, hemodynamic and arterial blood gas data. Main Results: Patients within low VT-high PEEP ventilation period had shown significantly lower alveolar ventilation and thoraco-pulmonary compliance, than during reduced RR ventilation; mean airway pressure and Vds/Vt within low VT-high PEEP ventilation were the highest, however driving pressure was lower. Vt decrease and increase on the 3rd hour did not lead to oxygenation improvement, and was characterized by the worst CO2 elimination. Hemodynamically, the significant CVP and pulmonary artery wedge pressure increase and cardiac output decrease during low VT-high PEEP ventilation were revealed; in 23.2% patients catecholamine therapy was initiated. In contrast, control group patients demonstrated no significant respiratory and hemodynamic changes without low VT-high PEEP ventilation. Conclusions: In postoperative cardiosurgical patients, MV with Vt 6 ml×kg-1 and 10 cmH2O is characterized by significantly worse oxygenation and elimination of CO2, and a less favorable hemodynamic profile than ventilation with Vt 10 ml×kg-1 and 5 cmH2O. Funding: No funding. Declaration of Interest: No competing interest. Ethical Approval: In prospective study approved by the local Ethics Committee of Almazov National Medical Research Centre included 119 on-pump CABG patients’ data during 2016-2017 years.

P07-2 - Preconditioning effect of Remifentanil on myocardium in patients undergoing on-pump cabg surgery

P07-2 - Preconditioning effect of Remifentanil on myocardium in patients undergoing on-pump cabg surgery

Total antioxidant stress and total oxidant stress levels in geriatric patients with open heart

The aim at this study is to compare the association with oxidative stress with the patients over and below the age of 65, who underwent an open heart surgery. In our prospective and a single-center study, 45 patients, undergoing an elective isolated on-pump CABG and heart-valve surgery, were included. The patients were divided into two groups, including Group I (at the age of 65 over) and Group II (at the age of 65 and below). The serum total oxidant status (TOS) and total antioxidant status (TAS) values were assessed in the patients, by taking blood at the first hour before and after the pump. There is no statisti-cally significant diffrences between preoperative and postoperative TAS and TOS values within the groups. However, the postoperative TOS value in Group I is statistically greater than Group II. TAS and TOS in organism is affected by many factors. Futher controlled studies are needed on this topic.

Morphological and Functional Changes in the Brain in the Long-Term Period after On-Pump Cabg

Purpose: evaluation of brain substance’s morphological state and dynamics of cerebral tissue perfusion in patients undergoing on-pump CABG surgery compared preoperative and late postoperative period.Materials and methods. The study included 14 male patients who underwent on-pump CABG surgery. CT and PCT with intravenous bolus radiopaque drug in the cubital vein conducted to all patients in the preoperative period. Cranio-ventricular index, width III ventricle was measured. The presence and degree leukoaraiosis, the presence of cysts, areas of gliosis, CBF, CBV, TTP in symmetric cortical and subcortical regions was recorded. CT and PCT repeat after 5 years.Results.In preoperative period III ventricle width was 6.8 ± 1.4 mm; cranio-ventricular index = 4.9 ± 1.3. It were found cysts on the level of the basal ganglia in two cases (14%). Leukoaraiosis detected in four patients (28%). PCT in the preoperative period noted the absence of blood flow asymmetry, reducing blood flow to the frontal lobes, in the area of the junction of the parietal, temporal and occipital lobes. Significant expansion of the III ventricle 8.5 ± 2.5 mm, reducing cranio-ventricular index 3.6 ± 0.5, increasing the number of cysts and glial changes in 6 (43%) cases, leukoaraiosis in 8 (57%) cases, a significant increase in TTP in the index of the thalamus (11.5 ± 2.1 sec) was determined after the operation.Conclusions.Сhronic cerebral ischemia revealed progression of manifestations in the late postoperative period in patients undergoing on-pump CABG. The identified changes are not a direct result of on-pump CABG, because similar changes observed in patients with atherosclerotic lesions of the microvasculature and damage the blood-brain barrier and also in patients without cardiac surgery.

Effect of Remote Ischemic Preconditioning on Intestinal Ischemia-Reperfusion Injury in Adults Undergoing On-Pump CABG Surgery: A Randomized Controlled Pilot Trial

Cardiopulmonary bypass (CPB) surgery commonly threatens the heart and remote organs with ischemia-reperfusion injury. Transient episodes of ischemia to nonvital tissue, known as remote ischemic preconditioning (RIPC), is thought to help local and remote vital organs to withstand subsequent ischemic insults. Prospective, randomized, double-blinded control trial. Tertiary referral academic teaching hospital. Thirty patients undergoing elective CPB surgery INTERVENTION: RIPC was achieved via three 5-minute cycles of upper limb ischemia using a blood pressure cuff or control (sham cuff). Primary outcome was the occurrence of intestinal injury, as measured by an increase in intestinal fatty acid binding protein (I-FABP). Secondary outcomes included incidence of gastrointestinal complications and duration of intensive care unit (ICU) stay. RIPC did not affect serum IFABP levels at the end of surgery and on the first postoperative day (p = 0.697 and p = 0.461, respectively). For all patients, mean I-FABP levels significantly increased at the end of surgery and decreased to under baseline levels on the first postoperative day (from a mean [± standard deviation] baseline value of 764 ± 492 pg/mL to 2,002 ± 974 pg/mL and decreased to 568 ± 319 pg/mL, p < 0.001). All patients remained clinically absent of gastrointestinal complications until hospital discharge. Duration of ICU stay was not correlated with I-FABP levels at the end of surgery. Neither duration of CPB nor duration of aortic clamping significantly correlated with postoperative I-FABP levels. These findings suggest that RIPC does not affect intestinal injury in patients undergoing CPB surgery. In patients undergoing cardiac surgery, intestinal injury appears to be moderate and transient without any clinical relevant complication.

Six-years survival and predictors of mortality after CABG using cold vs. warm blood cardioplegia in elective and emergent settings.

BackgroundThe aim of this study was to determine whether intermittent warm blood cardioplegia (IWC) is associated with comparable myocardial protection compared to cold blood cardioplegia (ICC) in patients undergoing elective vs. emergent CABG procedures.MethodsOut of 2292 consecutive patients who underwent isolated on-pump CABG surgery using cardioplegic arrest either with ICC or IWC between January 2008 and December 2010, 247 consecutive emergent patients were identified and consecutively matched 1:2 with elective patients based on gender, age (<50 years, 50–70 years, >70 years) and ejection fraction (<40 %, 40–50 %, >50 %). Perioperative outcomes and long-term mortality were compared between ICC and IWC strategies and predictors for 30-day mortality and perioperative myocardial injury were identified in both elective and emergent subgroups of patients.ResultsPreoperative demographics and baseline characteristics, logistic Euroscore, CPB-time, number of distal anastomoses and LIMA-use were comparable. Aortic cross clamp time was significantly longer in the IWC-group regardless of the urgency of the procedure (p = 0.05 and p = 0.015 for emergent and elective settings). There were no significant differences regarding ICU-stay, ventilation time, total blood loss and need for dialysis. The overall 30-day, 1-, 3- and 6-year survival of the entire patient cohort was 93.7, 91.8, 90.4 and 89.1 %, respectively, with significantly better outcomes when operated electively (p < 0.001) but no differences between ICC and IWC both in elective (p = 0.857) and emergent (p = 0.741) subgroups. Multivariate analysis did not identify the type of cardioplegia as a predictor for 30-day mortality and for perioperative myocardial injury. However, independent factors predictive of 30-day mortality were: EF < 40 % (OR 3.66; 95 % CI: 1.79–7.52; p < 0.001), atrial fibrillation (OR 3.33; 95 % CI: 1.49-7.47; p < 0.003), peripheral artery disease (OR 2.51; 95 % CI: 1.13–5.55; p < 0.023) and COPD (OR 0.26; 95 % CI: 1.05–6.21; p < 0.038); predictors for perioperative myocardial infarction were EF < 40 % (OR 2.04; 95 % CI: 1.32–3.15; p < 0.001), preoperative IABP support (OR 3.68; 95 % CI: 1.34-10.13; p < 0.012), and hemofiltration (OR 3.61; 95 % CI: 2.22–5.87; p < 0.001).ConclusionAlthough the aortic cross clamp time was prolonged in the IWC group our results confirm effective myocardial protection under IWC, regardless of the urgency of the procedure. We suggest that intermittent warm cardioplegia in emergent CABG setting is a low-cost alternative and safe. It is associated with similar long-term outcomes both in elective and emergent settings compared to intermittent cold cardioplegia.

Protective Effects of Danhong Injection against Cerebral Damage during On-Pump Coronary Artery Bypass Graft Surgery.

To explore the protective effects of Danhong injection against cerebral damage during on-pump coronary artery bypass graft surgery and its mechanism. Methods. Fifty patients scheduled for on-pump CABG surgery were randomly divided into Danhong injection group (group D) and control group (group C). Group D was given Danhong injection while group C was given the same volume of normal saline when the artery was cut open. Jugular bulb blood right before the operation began (T1), when body temperature rewarming to 36°C (T2), 30 min after the termination of cardiopulmonary bypass (T3), and 6 hrs after the termination of CPB (T4) was collected. The superoxide dismutase activity by using xanthine oxidase method and concentration determination of malondialdehyde were examined. Results. In group C, SOD activity was less at T2–T4 than at T1. It was also less active comparatively in group D at T2–T4. The MDA concentration increased in both groups but was more obvious in group C. Levels of TNF-α, IL-6, IL-8, and IL-10 increased in both groups C and D at T3 and T4, compared to T1. Conclusions. Danhong injection shows significant protective effects against cerebral damage during on-pump coronary artery bypass graft surgery.

Assessment of RBC transfusion volume and its effect on postoperative pulmonary complications in on-pump CABG patients

This study was purposed to investigate the effect of the transfused RBC amount on pulmonary complications after on-pump CABG surgery, and to explore the influencing factors on RBC transfusion volume. 292 adult patients receiving on-pump CABG surgery were divided into non-RBC transfusion group (n = 71), 1-4 U RBC transfusion group (n = 144) and >4 U RBC transfusion group (n = 77). Adjusted multivariable regression analysis was performed to examine the correlation between transfused RBC amount and the odds of pulmonary complications, and multivariable linear regression was used to analyze the influencing factors on RBC transfusion volume. The results showed that compared the three groups, there was the significant difference in postoperative pulmonary complications (1.4% vs 14.6% vs 24.7%, P < 0.001). A stronger and graded correlation was found between transfused RBC amount and pulmonary complications in on-pump CABG patients, the adjusted odds were increased to 1.251 (95% CI: 1.120-1.398, P < 0.001), and influencing factors on RBC transfusion volume were as follows: age (B:0.102; 95% CI: 0.046-0.157, P < 0.001), sex (B:1.825; 95% CI: 0.692-2.957, P = 0.002), preoperative Hct (B:-36.044; 95% CI:-47.724--25.163, P < 0.001), CPB time (B: 0.031; 95% CI:0.013-0.050, P = 0.001) and acute myocardiac infarction (B:2.769; 95% CI: 1.295-4.243, P < 0.001). It is concluded that the transfused RBC amount is related with postoperative pulmonary complications, and the influencing factors on RBC transfusion volume include preoperative Hct, age, acute myocardiac infarction, sex and CPB time.

901 Importance of Risk Stratification to Explain International Variations in Results of the Coronary Trial (Off-Pump Vs. On-Pump Cabg Surgery) — the Canadian Results

901 Importance of Risk Stratification to Explain International Variations in Results of the Coronary Trial (Off-Pump Vs. On-Pump Cabg Surgery) — the Canadian Results

Overall safety of on-pump and off-pump CABG surgery is similar

Overall safety of on-pump and off-pump CABG surgery is similar

Single Dose Inamrinone in Terminal Warm Cardioplegia in On-Pump Coronary Artery Bypass Patients

Background: Phosphodiesterase inhibitors (PDI) are used in cardiac surgery to improve and stabilize cardiac function after surgery. The aim of this study is to evaluate changes in hemodynamics and early outcomes when PDI (Inocor/inamrinone) is given in terminal warm blood cardioplegia to on-pump CABG only patients and compare results with patients who did not receive the drug. Material and methods: From April 2003 through September 2004 241 pts underwent elective on-pump CABG only surgery. 141 pts received Inocor in the terminal warm blood cardioplegia (Group 1) and 100 pts did not (Group 2). Results: Demographic data, preoperative EuroSCORE risk scores and operative details were similar. Of pts preoperatively in sinus rhythm (SR) 80.15% in Group 1 and 69.79% in Group 2 regained spontaneous SR (p = 0.07) after release of crossclamp. Inotropic support was needed in 5 pts in Group 1 and in 12 pts in Group 2, p = 0.02. Post cardiopulmonary by-pass (CPB) IABP support was needed for 4 pts in Group 2 and none for Group 1 pts, p = 0.01. There was no operative mortality in either Group and hospital/30 day mortality was similar (3/2.13% vs 3/3.00%, p = 0.69). There were no statistical difference in stay in postoperative intensive care unit (p = 0.15), total hospital stay (p = 0.07), appearance of postoperative atrial fibrillation (p = 0.23) or appearance of postoperative kidney injury (p = 0.27). Post CPB cardiac index improved 16.90% in Group1but decreased 1.49% in Group 2, p < 0.0001. Mean arterial pressure decreased 7.46%in Group 1 pts and 5.08% in Group 2 pts, p = 0.002, but no pts in either Group needed medication for too low blood pressure. Systemic vascular resistance decreased 28.40% in Group 1 and 9.02% in Group 2, p < 0.0001. Conclusions: Inamrinone in terminal warm blood cardioplegia (hot shot) is safe and effective way to improve and stabilize cardiac function after on-pump CABG surgery but does not affect short-term outcomes.

Cirurgia de revascularização miocárdica com circulação extracorpórea versus sem circulação extracorpórea: uma metanálise

There are controversies about the possible benefits of off pump coronary artery bypass grafting (OPCABG) compared to on-pump coronary artery bypass grafting (ONCABG). For a better perspective on this important issue, we performed a meta-analysis of randomized controlled trials, comparing the two techniques. The objective of this study was to verify which technique applied in Coronary Artery Bypass Surgery, OPCABG or ONCABG, provides better results through a meta-analysis of published randomized trials comparing the two techniques. We carried out a computer-based literature search in PubMed, Embase, B-on and Science Direct from March 2009 to January 2010. The studies covered were recovered according to predetermined criteria. A systematic review of randomized clinical trials was performed in order to evaluate the differences between the two revascularization techniques (OPCABG versus ONCABG) regarding mortality and morbidity. Selected studies did not include patients at high risk and long-term longitudinal evaluations. The meta-analysis focused on nine randomized clinical trials, corresponding to a total of 75,086 patients, and compared OPCABG to ONCABG. Regarding mortality, a reduction of 18% in the risk of cardiovascular mortality (OR: 0.82, 95%CI: 0.70 to 0.98, p = 0.03) and 27% in the risk of stroke postoperatively (OR: 0.73, 95%CI: 0.63 to 0.85, p = 0.0001) were observed, both in favor of OPCABG. Concerning the occurrence of complications associated with the procedure, no significant differences were found between the two surgical techniques, particularly with regard to the occurrence of kidney complications (OR: 0.97, 95%CI: 0.84-1.14, p = 0, 74) and sepsis (OR 0.98, 95%CI: 0.64-1.51, p = 0.93, respectively). Off-pump CABG significantly reduces the occurrence of major cardiovascular events (mortality and CVA) compared to on-pump CABG surgery.

Is vasoplegic syndrome more prevalent with open-heart procedures compared with isolated on-pump CABG surgery?

Postoperative vasoplegic syndrome (PVS) is a frequent complication and can affect the early postoperative course. Our study investigated the incidence and risk factors of PVS after on-pump isolated coronary artery grafting bypass (CABG) and on-pump open-heart surgery. A total of 629 patients underwent on-pump cardiac surgery from November 21, 2005, to June 9, 2006, at our institution. Of those, 334 patients underwent on-pump isolated CABG and 295 patients had open-heart surgery. PVS was defined based on the recognized criteria. Multivariate logistic regression analysis was used to identify the risk factors for PVS. The overall incidence of PVS was 11.7%. The incidence in isolated on-pump CABG surgery was 6.9% and 17.0% in open-heart surgery (P<.01). In multivariate analysis, isolated CABG reduced by half the incidence of PVS [odds ratio (OR)=0.45, P=.02]; preoperative left ventricular ejection fraction (EF) <35% was identified as an independent predictor of PVS (OR=2.1, P=.01), and a protective effect of female gender for PVS was observed (OR=0.4, P=.01). The association between angiotensin-converting enzyme inhibitors and other preoperative medical treatments was not confirmed by our study. In conclusion, PVS occurred less often after isolated CABG surgery than after open-heart surgery. Advanced age and low preoperative EF strongly predicted PVS.

On-pump or off-pump CABG surgery—under the spotlight

The ROOBY investigators found off-pump CABG surgery to be significantly inferior to on-pump surgery with regard to 1 year mortality, revascularization, or new myocardial infarction. This unexpected finding could be related to the fact that most of the participating surgeons were experienced in on-pump CABG surgery, but relatively inexperienced in the off-pump procedure.

Early neurological complications after coronary artery bypass grafting and valve surgery in octogenarians☆

To determine the incidence and risk factors for neurological events complicating cardiac surgery, and the implications for operative outcome in octogenarians. Of 6791 who underwent primary on-pump CABG and/or valve surgery from 1998 through 2006, 383 were aged > or =80 years. Neurological complications, classified as reversible or permanent, were investigated by head CT scan in patients who did not recover soon after an event. There were more females (47% vs 26%, p<0.0001) among octogenarians (n=383, median age 82 years) than among younger patients (n=6408, median age 66 years). Controlled heart failure, NYHA class III/IV and chronic obstructive pulmonary disease were more prevalent in octogenarians while preoperative myocardial infarction was predominant in younger patients. Octogenarians were at higher operative risk (median EuroScore 6 vs 2, p<0.0001). Operative procedures differed between octogenarians and younger patients (p<0.0001); respective frequencies were 45% vs 77% for CABG, 26% vs 10% for AVR, and 23% vs 6% for AVR+CABG. Mortality was higher for octogenarians (8.9% vs 2.1, p<0.0001). Early neurological complications observed in 3.9% of the entire study population were mostly reversible (3.2%). Age > or =80 years (odds ratio [OR] 2.82, 95% confidence interval [CI] 1.89-4.21, p<0.0001), prior cerebrovascular disease (OR 2.23, 95% CI 1.56-3.18, p<0.0001), AVR+CABG (OR 2.92, 95% CI 1.60-5.33, p<0.0001) and MVR+CABG (OR 4.77, 95% CI 2.10-10.85, p<0.0001) were predictive of neurological complications. More octogenarians experienced neurological events (p<0.0001): overall 12.8% vs 3.4%, reversible 11.5% vs 2.8%, permanent 1.3% vs 0.6%. Among octogenarians, neurological complication was associated with elevated operative mortality (18% vs 8% for those without neurological complication, p=0.03), and prolonged ventilation, intensive care stay and hospitalisation. Predictors of neurological complications in octogenarians were blood and/or blood product transfusion (OR 3.60, 95% CI 1.56-8.32, p=0.003) and NYHA class III/IV (OR 7.6, 95% CI 1.47-39.70, p=0.02). Octogenarians undergoing on-pump CABG and/or valve repair/replacement are at higher risk of neurological dysfunction, from which the majority recover fully. The adverse implications for operative mortality and morbidity, however, are profound. Blood product transfusion which has a powerful correlation with neurological complication should be reduced by rigorous haemostasis with parsimonious use of sealants when appropriate.