On-pump Coronary Artery Bypass Grafting Research Articles

Improved Early Outcomes With Off-Pump Coronary Artery Bypass Grafting in Patients With Left Ventricular Dysfunction: A Systematic Review and Meta-Analysis.

The ongoing debate surrounding coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass persists, particularly in individuals with left ventricular dysfunction. The objective of this study was to evaluate the safety and efficacy of these 2 strategies through a comprehensive meta-analysis of existing studies. A systematic search of PubMed, EMBASE, Web of Science, and the Cochrane Central Registry was conducted from inception to July 2023. The primary focus was on studies comparing on-pump versus off-pump CABG as the primary treatment for multivessel coronary artery disease in patients with left ventricular dysfunction (ejection fraction ≤40%), with mortality as the primary outcome. The meta-analysis included 26 studies with a total of 35,863 patients. The results revealed a significant reduction in mortality risk [risk ratio (RR), 0.75; 95% confidence interval (CI), 0.60-0.93; P = 0.009] and other perioperative morbidities associated with off-pump CABG. These included stroke (RR, 0.67; 95% CI, 0.54-0.82; P = 0.0002), myocardial infarction (RR, 0.74; 95% CI, 0.56-0.97; P = 0.03), pulmonary complications (RR, 0.71; 95% CI, 0.55-0.92; P = 0.010), postoperative transfusion (RR, 0.70; 95% CI, 0.55-0.88; P = 0.002), neurological dysfunction (RR, 0.80; 95% CI, 0.64-1.00; P = 0.05), infection (RR, 0.74; 95% CI, 0.56-0.97; P = 0.03), renal failure (RR, 0.79; 95% CI, 0.67-0.95; P = 0.010), and reoperation for bleeding (RR, 0.66; 95% CI, 0.52-0.84; P = 0.0006). However, no significant difference was observed between the 2 groups regarding postoperative atrial fibrillation (RR, 0.97; 95% CI, 0.84-1.12; P = 0.69). In conclusion, off-pump CABG demonstrates a lower perioperative mortality risk and improved overall early outcomes compared with on-pump techniques in individuals with reduced left ventricular function.

Short-term and long-term outcomes of on-pump beating-heart coronary artery bypass surgery in dialysis and non-dialysis patients: a retrospective study in a single center

BackgroundThis study aimed to evaluate the short-term and long-term outcomes of dialysis and non-dialysis patients after On-pump beating-heart coronary artery bypass grafting (OPBH-CABG).MethodsWe retrospectively reviewed medical records of 659 patients underwent OPBH-CABG at our hospital from 2009 to 2019, including 549 non-dialysis patients and 110 dialysis patients. Outcomes were in-hospital mortality, length of stay, surgical complications, post-CABG reintervention, and late mortality. The median follow-up was 3.88 years in non-dialysis patients and 2.24 years in dialysis patients. Propensity matching analysis was performed.ResultsAfter 1:1 matching, dialysis patients had significantly longer length of stay (14 (11–18) vs. 12 (10–15), p = 0.016), higher rates of myocardial infarction (16.85% vs. 6.74%, p = 0.037) and late mortality (25.93% vs. 9.4%, p = 0.005) after CABG compared to non-dialysis patients. No significant differences were observed in in-hospital mortality, complications, or post-CABG reintervention rate between dialysis and non-dialysis groups.ConclusionsOPBH-CABG could achieve comparable surgical mortality, surgical complication rates, and long-term revascularization in dialysis patients as those in non-dialysis patients. The results show that OPBH-CABG is a safe and effective surgical option for dialysis patients.

Prevention of systemic inflammatory response syndrome after emergency on-pump coronary artery bypass grafting with high-dose ascorbic acid: a prospective randomized controlled trial

INTRODUCTION: Emergency coronary artery bypass grafting (CABG) surgery carries a risk of postperfusion systemic inflammatory response syndrome (SIRS). The prophylactic use of high doses of ascorbic acid, which possesses an antioxidant and immunomodulatory effect, may be justified, but has not been sufficiently studied in this clinical scenario. OBJECTIVE: To determine the possibilities of preventing the systemic inflammatory response with ascorbic acid (AA) during emergency coronary artery bypass grafting under cardiopulmonary bypass (CPB). MATERIALS AND METHODS: We prospectively examined 60 patients (32 men and 28 women, aged 63 (59; 70) years who underwent CABG (3 ± 1 bypass), performed for emergency indications under CPB 95 (77; 122) min. Patients were randomly divided into two groups: patients in the main group (n = 30) were given 4 grams of AA intravenously 1 hour before the skin incision, patients in the control group (n = 30) received standard pre-operative prevention of SIRS. RESULTS: The use of AA (n = 30) was accompanied by a decrease in the incidence of SIRS (20 and 47 %; p = 0.048) and a reduction in postoperative hospitalization (9 [8; 10] and 11 [10; 16] days; p = 0.013). CONCLUSIONS: Prophylactic use of AA is safe and can reduce the frequency of individual manifestations of SIRS and the duration of postoperative hospitalization.

Relationships between Interleukin 18 -607 C/A and -137 G/C, Osteopontin -9250 C/T Genetic Polymorphisms and Systemic Inflammatory Response Syndrome in Coronary Artery Bypass Graft Surgery

Background and Objectives: Systemic inflammatory response syndrome (SIRS) is one of the most significant complications after on-pump heart surgery procedures. High cytokine levels have been shown after open-heart surgeries and a genetic predisposition seems to be an important underlying modulatory characteristic for SIRS. To investigate the association between interleukin 18 -607 C/A, interleukin 18 -137 G/C and osteopontin 9250 C/T genetic polymorphisms and SIRS in on-pump CABG patients. Materials and Methods: Two hundred consecutive elective on-pump CABG patients were recruited prospectively to the study. Genomic DNA was extracted from whole blood and genotyping was determined by sequence specific PCR or PCR-RFLP methods for related polymorphisms. Results: SIRS incidence was 60.2%, 38.1%, 18.9% on postoperative day 1, 2 and 3, respectively, in the whole study population. The SIRS rate on the second postoperative day was 13% and 43.4%, respectively, in osteopontin 9250 C/T T allele non-carriers and carriers (p = 0.004). WBC (White Blood Cell) counts were higher on day 2 and 3 in osteopontin 9250 C/T T allele carriers compared to non-carriers (day 2; 12.7 ± 4 vs. 10.5 ± 2.4 (p = 0.015), day 3; 11.8 ± 4 vs. 9.1 ± 4.7 (p = 0.035)). The average ICU stay was 3.1 ± 7.4, 1.28 ± 0.97 for IL 18-137 G/C C allele carriers and non-carriers, respectively (p = 0.003), and in the IL 18-137 G/C C allele carriers, SIRS developed in 42.2% by the second postoperative day whereas the rate was 57.8% in non-carriers (p = 0.025). Conclusions: The current research revealed a possible link between osteopontin 9250 C/T and IL18-137 G/C genetic polymorphism and SIRS and morbidity in on-pump CABG patients.

Relationship between pan-immune- inflammation value and in major cardiovascular and cerebrovascular events in stable coronary artery disease patients undergoing on-pump coronary artery bypass graft surgery

BackgroundIn this study, we aimed to evaluate the association of pan-immune-inflammation value (PIV) with major cardiovascular and cerebrovascular events (MACCE) in stable coronary artery disease patients undergoing on-pump coronary artery bypass graft (CABG) surgery.MethodsWe retrospectively analyzed data from 527 patients who underwent on-pump CABG surgery for stable coronary artery disease between June 2015 and December 2020. Patients were categorized into two groups based on MACCE development. PIV levels were calculated from blood samples taken on admission. PIV was calculated as [neutrophil count (×103/µL)×platelet count (×103/µL))×monocyte count (×103/µL)]/lymphocyte count (×103/µL). The primary endpoint was long-term major cardiovascular and cerebrovascular events (MACCE) at a median follow-up of 4.6 years.ResultsOf the included patients, 103 (19.5%) developed MACCE. PIV was higher in patients with MACCE compared to those without (470.8 [295.3-606.8] vs. 269.8 [184.3-386.4], p < 0.001). Multivariate analysis showed a significant positive association between PIV and MACCE (HR: 1.326, 95%CI:1.212–1452, p < 0.001). The cut-off value for the PIV in the estimation of MACCE was 368.28 ( AUC: 0.726 with 69% sensitivity, 71% specificity, p < 0.001).ConclusionThis study shows a significant link between high PIV levels and MACCE in stable coronary artery disease patients undergoing on-pump CABG surgery. Our findings suggest that PIV may be a valuable, routinely available, and inexpensive marker for identifying patients at increased risk of MACCE.

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

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

Performance of left internal thoracic artery-left anterior descending artery anastomosis by residents versus attendings and coronary artery bypass grafting outcomes.

Performance of a technically sound Left Internal Thoracic Artery to Left Anterior Descending Artery (LITA-LAD) anastomosis during coronary artery bypass grafting (CABG) is critically important. We investigated CABG outcomes according to whether a resident or attending surgeon performed the LITA-LAD anastomosis using prospectively collected data from the multicenter, randomized REGROUP (Randomized Endograft Vein Perspective) Trial. This was a posthoc subanalysis of the REGROUP trial, which randomized veterans undergoing isolated on-pump CABG to endoscopic versus open vein harvest between 2014-2017. The primary endpoint was major cardiac adverse events (MACE), defined as the composite of all-cause death, nonfatal myocardial infarction, or repeat revascularization. Among 1,084 patients, 344 (31.8%) LITA-LAD anastomoses were performed by residents and 740 (68.2%) by attending surgeons. Residents (when compared to attendings) operated on fewer patients with high tercile SYNTAX scores (22.1% vs. 37.4%, p < 0.001), performed less multiarterial CABG (5.2% vs. 14.6%, p < 0.001), and performed more anastomoses to distal targets with diameters > 2.0 mm (19.0% vs. 10.9%, p < 0.001) and non-calcified landing zones (25.1% vs. 21.6%, p < 0.001). During a median observation time of 4.7 years (interquartile range 3.84-5.45), MACE occurred in 77 patients (22.4%) in the resident group and 169 patients (22.8%) in the attending group (unadjusted HR 1.00; 95% confidence interval, 0.76-1.33; p = 0.99). Outcomes persisted on adjusted analyses. Based on this REGROUP trial subanalysis, under careful supervision and with appropriate patient selection, LITA-LAD anastomoses performed by residents yields similar clinical outcomes compared to attendings.

Urgent Cardiosurgical Treatment of a Military Servant with a Moving Thrombus in the Area of the Left Ventricular Apical Aneurysm (Case Report)

Against the background of military operations, post-traumatic stress disorder, the progression of the atherosclerotic process is observed, which can lead to myocardial infarction even in young people. Left ventricular aneurysm (LVA) in military personnel is the result of untimely revascularization of an infarct-related artery, gunshot wound to the heart, chest trauma, etc. The presence of a dyskinetic area promotes formation of blood clots in the LVA cavity. LVA thrombosis is associated with an increased risk of embolism, ischemic stroke, and death.&#x0D; Case description. A 37-year-old military servant A. was urgently hospitalized to the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine with a mobile thrombus in the area of LVA, size 4.5 x 3 cm, with signs of lysis and a threat of separation according to echo data. The patient was found to suffer Q-wave myocardial infarction 5 months ago; at the time of examination there was decompensation of the condition and a decrease in the left ventricular contractility to 34%. The patient underwent urgent operation: on-pump coronary artery bypass grafting, LVA resection with thrombectomy. The duration of the operation was 7 hours, the aortic cross-clamp time was 53 minutes, the perfusion time was 93 minutes, the blood loss was 500 ml. The postoperative period was uneventful. The patient was discharged on the 7th day with improvement, the ejection fraction was 40%.&#x0D; Conclusion. The lack of an opportunity to conduct timely electrocardiography and echo for military personnel with acute chest pain reduces the chances of diagnosis and treatment of myocardial infarction within the therapeutic window, which leads to the occurrence of complicated forms of coronary heart disease, namely LVA. Echo is of crucial importance in deciding on emergency cardiac surgery for thrombosed LVA.

Optimization of cardiopulmonary bypass prime fluid to preserve microcirculatory perfusion during on-pump coronary artery bypass graft surgery: PRIME study protocol for a double-blind randomized trial

BackgroundAcute microcirculatory perfusion disturbances and organ edema are important factors leading to organ dysfunction during cardiac surgery with cardiopulmonary bypass (CPB). Priming of the CPB system with crystalloid or colloid fluids, which inevitably leads to hemodilution, could contribute to this effect. However, there is yet no optimal evidence-based strategy for this type of priming. Hence, we will investigate different priming strategies to reduce hemodilution and preserve microcirculatory perfusion.MethodsThe PRIME study is a single-center double-blind randomized trial. Patients undergoing elective coronary artery bypass graft surgery with CPB will be randomized into three groups of prime fluid strategy: (1) gelofusine with crystalloid, (2) albumin with crystalloid, or (3) crystalloid and retrograde autologous priming. We aim to include 30 patients, 10 patients in each arm. The primary outcome is the change in microcirculatory perfusion. Secondary outcomes include colloid oncotic pressure; albumin; hematocrit; electrolytes; fluid balance and requirements; transfusion rates; and endothelial-, glycocalyx-, inflammatory- and renal injury markers. Sublingual microcirculatory perfusion will be measured using non-invasive sidestream dark field video microscopy. Microcirculatory and blood measurements will be performed at five consecutive time points during surgery up to 24 h after admission to the intensive care unit.DiscussionPRIME is the first study to assess the effect of different prime fluid strategies on microcirculatory perfusion in cardiac surgery with CPB. If the results suggest that a specific crystalloid or colloid prime fluid strategy better preserves microcirculatory perfusion during on-pump cardiac surgery, the current study may help to find the optimal pump priming in cardiac surgery.Trial registrationClinicalTrials.gov NCT05647057. Registered on 04/25/2023. ClinicalTrials.gov PRS: Record Summary NCT05647057, all items can be found in the protocol.

Stroke prevention strategies for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials.

Stroke is a much-feared complication of cardiac surgery, but existing literature on preventive strategies is fragmented. Hence, a systematic review and meta-analysis of stroke prevention strategies for cardiac surgery was conducted. An electronic literature search was conducted to retrieve randomized controlled trials (RCTs) investigating perioperative interventions for cardiac surgery, with stroke as an outcome. Random-effects meta-analyses were conducted to generate risk ratios (RRs), 95% confidence intervals (95% CI), and forest plots. Descriptive analysis and synthesis of literature was conducted for interventions not amenable to meta-analysis, focusing on risks of stroke, myocardial infarction and study-defined major adverse cardiovascular events (MACE). Fifty-six RCTs (61 894 patients) were retrieved. Many included trials were underpowered to detect differences in stroke risk. Among pharmacological therapies, only preoperative amiodarone was shown to reduce stroke risk in one trial. Concomitant left atrial appendage closure (LAAC) significantly reduced stroke risk (RR = 0.55, 95% CI = 0.36-0.84, P = 0.006) in patients with preoperative atrial fibrillation, and there was no difference in on-pump versus off-pump coronary artery bypass grafting (CABG) (RR = 0.94, 95% CI = 0.64-1.37, P = 0.735). Much controversy exists in literature on the timing of carotid endarterectomy relative to CABG in patients with severe carotid stenosis. The use of preoperative remote ischemic preconditioning was not found to reduce rates of stroke or MACE. This review presents a comprehensive synthesis of existing interventions for stroke prevention in cardiac surgery, and identifies gaps in research which may benefit from future, large-scale RCTs. LAAC should be considered to reduce stroke incidence in patients with preoperative atrial fibrillation.

Effect of on-Pump and Off-Pump Coronary Artery Bypass Graft on Length of Icu Stay among Low Ejection Fraction Patients Going through Cardiac Revascularization

Background Coronary artery bypass grafting (CABG) remains a cornerstone in the management of coronary artery disease, especially for patients with severe left ventricular dysfunction. The debate between on-pump and off-pump CABG techniques centers on their impact on postoperative outcomes, particularly the length of ICU stay, which has significant implications for patient recovery and healthcare resources. Objective This study aimed to compare the effects of on-pump and off-pump coronary artery bypass grafting on the length of ICU stay among patients with severe left ventricular dysfunction undergoing cardiac revascularization, with a view to optimizing postoperative outcomes and resource utilization in this high-risk patient population. Methods A longitudinal cross-sectional study was conducted, enrolling 78 participants scheduled for CABG at a single center over one year. Participants were divided into two groups: those undergoing on-pump CABG (n=44) and those undergoing off-pump CABG (n=34). Data collection focused on demographic information, clinical characteristics, and the length of ICU stay. Statistical analysis employed SPSS v25, utilizing means, standard deviations, and Independent t-tests to compare outcomes between the two groups. Results The study revealed that patients undergoing on-pump CABG had a significantly shorter mean ICU stay (4 ± 3.9 days) compared to the off-pump CABG group (5 ± 4.4 days), with a P value of 0.01. Further stratification showed that older patients and those with comorbidities such as diabetes and hypertension experienced longer ICU stays, irrespective of the surgical technique used. Conclusion On-pump CABG is associated with shorter ICU stays compared to off-pump CABG in patients with severe left ventricular dysfunction, suggesting that the on-pump technique may be preferable for optimizing postoperative recovery and resource allocation in this patient cohort.

The association between cerebral blood flow variations during on-pump coronary artery bypass grafting surgery and postoperative delirium.

Postoperative delirium (POD) has a major impact on patient recovery after cardiac surgery. Although its pathophysiology remains unclear, there could be a correlation between cerebral blood flow (CBF) variations during cardio-pulmonary bypass (CPB) and POD. Our study aimed to evaluate whether variations in on-pump CBF, compared to pre-anesthesia and pre-CPB values, are associated with POD following coronary artery bypass grafting (CABG) surgery. This prospective observational cohort study included 95 adult patients undergoing elective on-pump CABG surgery. Right middle cerebral artery blood flow velocity (MCAV) was assessed using Transcranial Doppler before anesthesia induction, before CPB and every fifteen minutes during CPB. Pre-anesthesia and pre-CPB values were chosen as baselines. Individual values, measured during CPB, were converted as percentage changes relative to these baselines and named as %MCAV0 and %MCAV1, respectively. POD was assessed using the Confusion Assessment Method for ICU (CAM-ICU) during the first 48 post-operative hours and with the 3-Minute Diagnostic Interview for Confusion Assessment Method (3D-CAM) on the fifth post-surgical day. Overall POD incidence was 17.9%. At 30minutes of CPB, %MCAV0 was higher in POD group than in no-POD group (p = .05). %MCAV0 at 45minutes of CPB was significantly higher in POD group (87 (±17) %) than in no-POD group (68 (±24) %), p = .04. %MCAV1 at 30 and 45minutes of CPB were higher in POD group than in no-POD group, at the limit of statistical significance. We found %MCAV1 > 100% in POD group, but not in no-POD group. Significant differences in %MCAV0 became evident after 30minutes of CPB, whereas differences in %MCAV1 at 45 minutes of CPB were at limit of statistical significance. In POD group %MCAV1 was higher than 100% at 30 and 45minutes of CPB, which is supposed to be a sign of cerebral hyperperfusion. Monitoring CBF during CPB could have prognostic value for POD.

10-Year Mortality of Off-Pump Versus On-Pump Coronary Artery Bypass Grafting: An Updated Systematic Review, Meta-Analysis, and Meta-Regression

The longstanding debate on off-pump coronary artery bypass grafting (OPCAB) versus on-pump coronary artery bypass grafting (ONCAB) has primarily focused on short-term and mid-term outcomes, with limited attention to long-term survival. This study aims to address this gap by providing an updated analysis of 10-year mortality rates after OPCAB versus ONCAB. We have conducted a systematic review and meta-analysis, incorporating 22 studies comprising 69,449 patients. The primary end point was all-cause mortality at 10 years. Meta-regression analysis explored sources of heterogeneity. The meta-analysis revealed no significant difference in long-term all-cause mortality between OPCAB and ONCAB (hazard ratio 1.000, 95% confidence interval 0.92 to 1.08, p = 0.95). Although substantial heterogeneity existed across studies, meta-regression identified older age as a significant factor favoring OPCAB. However, patient characteristics like gender, co-morbidities, and graft numbers did not significantly influence the choice of surgical technique. In conclusion, this study challenges historical concerns regarding OPCAB's quality of revascularization and long-term survival demonstrating comparable outcomes to ONCAB in well-selected patients when performed by experienced surgeons. The results emphasize the importance of surgeon proficiency and advocate for recognizing surgical revascularization as a subspecialty.

Is Single LIMA-LAD Bypass Appropriate for OPCAB Training?

A significant impact of surgeons' experience on outcomes of off-pump coronary artery bypass (OPCAB) has been recognized through previous large-scale studies. However, a safe, effective, and concrete OPCAB training was yet to be identified. We evaluate a safety of our OPCAB training model with single left internal mammary artery (LIMA)-left anterior descending artery (LAD) as a reasonable first step. Between January 2010 and June 2019, 180 patients with an isolated single coronary bypass of the LAD using LIMA as an in situ graft via median sternotomy fulfilled the inclusion criteria. Coronary arterial bypass under cardiopulmonary bypass (CPB), utilizing other graft material, minimal invasive direct coronary arterial bypass through left-sided thoracotomy, and multiple diseased coronary artery disease were excluded. The primary outcome is an early postoperative outcome (major adverse cardiac and cerebrovascular events [MACCEs]: myocardial infarction, coronary re-revascularization, stroke, acute renal failure, and all causes of death) between residents in training under supervision (group 1: n = 63) and experienced surgeons (group 2: n = 117). Trainees were already experienced in on-pump coronary artery bypass grafting. Preoperative variables were comparable. There was no significant difference in the rate of MACCEs between the two groups including hospital mortality (p = 1.000), perioperative myocardial infarction (p = 0.246), stroke (p = 0.655), and acute renal failure (p = 0.175). The early postoperative outcome of off-pump LIMA to the LAD performed by trainees was comparable to those by experienced surgeons. Single LIMA-LAD was safely performed by trainees under supervision without CPB. In order to master OPCAB technique, single LAD bypass might be a reasonable first step to get into touch with the technical characteristics of this special procedure.

Prognostic factors of surgical management for heart failure patients with reduced left ventricular ejection fraction

ObjectivesThere are many available pharmaceutical and surgical management for Coronary artery disease (CAD) patients. However, coronary artery bypass grafting (CABG) is the preferred treatment modality for CAD patients with low ejection fraction (EF) in view of the more favorable outcomes. This study aimed to determine the associated factors of poor outcomes post-CABG for heart failure patients with reduced left ventricular ejection fraction who underwent on-pump and off-pump CABG. MethodsA retrospective review of CAD patients who underwent isolated on-pump CABG (ONCAB) or off-pump CABG (OPCAB) in Beijing Anzhen Hospital Affiliated with Capital Medical University from January 2013 to March 2021. Only those with confirmed reduced left ventricular ejection fraction (LVEF) ≤40% on preoperative echocardiography were included. By analyzing the clinical and surgical data, postoperative mortality and morbidity, as well as major cardiovascular and cerebrovascular adverse events (MACCE) as endpoints, certain risk factors of the postoperative complications were identified. ResultsOut of the 500 patients, 64 developed MACCE, of which 14 (13.6%) occurred in the ONCAB group and 50 (14.0%) in the OPCAB group. Univariate COX regression analysis showed that age ≥65 years, history of diabetes, and preoperative renal insufficiency were independent risk factors for postoperative primary endpoint events in CAD patients with heart failure with reduced ejection fraction (HFrEF). Following the multivariate COX regression analysis, in addition to the above three risk factors, a history of previous percutaneous coronary angiography (PCI) intervention was also a risk factor for the occurrence of the primary endpoints post-CABG. ConclusionBased on the analysis, significant predictors of post-CABG MACCE in patients with HFrEF included being older than 65 years old, having diabetes, preoperative renal insufficiency, and having previous PCI.

Effect of on-pump vs. off-pump coronary artery bypass grafting in patients with non-dialysis-dependent severe renal impairment: propensity-matched analysis from the UK registry dataset.

On-pump coronary artery bypass (ONCABG) grafting in patients with a pre-existing poor renal reserve is known to carry significant morbidity and mortality. There is limited controversial evidence on the benefit of off-pump coronary artery bypass (OPCABG) grafting in these high-risk groups of patients. We compared early clinical outcomes in propensity-matched cohorts of patients with non-dialysis-dependent pre-operative severe renal impairment undergoing OPCABG vs. ONCABG, captured in a large national registry dataset. All data for patients with a pre-operative creatinine clearance of less than 50 mL/min who underwent elective or urgent isolated OPCABG or ONCABG from 1996 to 2019 were extracted from the UK National Adult Cardiac Surgery Audit (NACSA) database. Propensity score matching was performed using 1:1 nearest neighbor matching without replacement using several baseline characteristics. We investigated the effect of ONCABG vs. OPCABG in the matched cohort using cluster-robust standard error regression. We identified 8,628 patients with severe renal impairment undergoing isolated CABG, of whom 1,142 (13.23%) underwent OPCABG during the study period. We compared 1,141 propensity-matched pairs of patients undergoing OPCABG vs. ONCABG. The median age of the matched population was 78 years in both groups, with no significant imbalance post-matching in the rest of the variables. There was no difference between OPCABG and ONCABG in in-hospital mortality rates, post-operative dialysis, and stroke rates. However, the return to theatre for bleeding or tamponade was higher in ONCABG vs. OPCABG (P > 0.02); however, OPCABG reduced the total length of stay in the hospital by 1 day (P = 0.008). After double adjustment in the matched population using cluster-robust standard regression, ONCABG did not increase mortality compared to OPCABG (OR, 1.05, P = 0.78), postoperative stroke (OR, 1.7, P = 0.12), and dialysis (OR, 0.7, P = 0.09); however, ONCABG was associated with an increased risk of bleeding (OR, 1.53, P = 0.03). In this propensity analysis of a large national registry dataset, we found no difference in early mortality and stroke in patients with pre-operative severe renal impairment undergoing OPCABG or ONCABG surgery; however, ONCABG was associated with an increased risk of return to theatre for bleeding and an increased length of hospital stay.

Off-pump versus on-pump coronary artery bypass grafting in elderly patients at 30 days: a propensity score matching study

Abstract Background Elderly patients are at increased risk of perioperative morbidity and mortality after conventional on-pump coronary artery bypass grafting (ONCABG). This study was to determine whether such high-risk population would benefit from off-pump coronary artery bypass grafting (OPCABG). Methods A retrospective analysis was performed on patients aged 65 years or older who underwent isolated coronary artery bypass grafting for the first time in Wuhan Union Hospital from January 2015 to January 2021. We used propensity score matching to adjust for differences in baseline characteristics between the ONCABG and OPCABG groups. Morbidity and mortality within 30 days after surgery were compared between the two groups. All operations were performed by experienced cardiac surgeons. Results A total of 511 patients (ONCABG 202, OPCABG 309) were included. After 1:1 matching, the baseline characteristics of the two groups were comparable (ONCABG 173, OPCABG 173). The OPCABG group had higher rate of incomplete revascularization (13.9% vs. 6.9%; P = .035) than the ONCABG group. However, OPCABG reduced the risk of postoperative renal insufficiency (15.0% vs. 30.1%; P = .001) and reoperation for bleeding (0.0% vs. 3.5%; P = .030). There were no significant differences in early postoperative mortality, myocardial infarction, stroke, and other outcomes between the two groups. Conclusions OPCABG is an alternative revascularization method for elderly patients. It reduces the risk of early postoperative renal insufficiency and reoperation for bleeding.

Accuracy of a zero-heat-flux thermometer in cardiac surgery, a prospective, multicentre, method comparison study

Accurate measurement of core temperature is of utmost importance during on-pump cardiac surgery, for detection of hypothermia before cardiopulmonary bypass (CPB), guidance of temperature management on CPB, active rewarming on CPB and guidance of warming therapy after CPB. Most temperature measurement methods are known to become inaccurate during rapid changes in core temperature and suffer from delayed detection of temperature changes. Zero-heat-flux temperature (ZHF) measurement from the lateral forehead may be an alternative, non-invasive method quantifying the core temperature. A prospective, observational, multicentre study was conducted in one hundred patients scheduled for on-pump coronary artery bypass grafting. Core temperatures were measured every minute by two zero-heat-flux thermometer (SpotOn™) and a bladder thermometer and a pulmonary artery catheter (PAC) in the period after induction of anesthesia until CPB. Accuracy and precision of both methods were compared against core temperature measured in the pulmonary artery using the method of Bland and Altman. A high accuracy (around 0.1 °C) and a very good precision (Limits of agreement (LoA) − 0.6; 0.4 °C) were found between zero-heat-flux thermometer and core temperature measured by PAC. Among the two ZHF thermometers the bias was negligible (− 0.003 °C) with narrow LoA of − 0.42 °C and 0.41 °C. In contrast, bias between bladder temperature and PAC temperature was large (0.51 °C) with corresponding LoA of − 0.06 °C and 1.1 °C. ZHF thermometers are in contrast to bladder temperature a reliable core temperature monitor in cardiac surgery during the period after induction of anestesia until CPB. The zero-heat-flux method can provide clinicians reliably with continuous and non-invasive measurements of core temperature in normothermic and mild hypothermic temperature ranges and therefore can be helpful to guide temperature management.

Correlation between high-sensitivity cardiac troponin I, lactate levels, and clinical outcomes in on-pump coronary artery bypass grafting

Background: On-pump coronary artery bypass graft (CABG) causes myocardial damage and hypoperfusion. However, it is unknown how varied timings of combining serum high-sensitivity cardiac troponin I (hs-cTnI) and lactate levels in on-pump CABG surgery would affect clinical outcomes. Objectives: This study aims to evaluate serum hs-cTnI and lactate levels and their influence on postoperative clinical outcomes in patients with on-pump CABG. Materials and methods: Eleven coronary artery disease (CAD) patients were included for on-pump CABG surgery. The biomarkers were collected at four stages of onpump CABG: before sternotomy (T0, pre-cardiopulmonary bypass (pre-CPB)), 5 minutes before aortic cross-clamp of CPB (T1, preaortic cross-clamp), after aortic cross-clamp (T2, postaortic cross-clamp), and 24 hrs post-surgery in an intensive care unit (T3, ICU at 24 hrs). Results: Correlation analysis revealed that during the study period, average hs-cTnI is positively associated with lactate levels (r=0.775, p=0.005). However, 24 hours after surgery, lactate levels return more quickly than hs-cTnI levels. The average hs-cTnI and lactate levels were positively correlated with CPB time and aortic clamp time. Regarding clinical outcomes, average hs-cTnI, and lactate levels were positively associated with a length of ICU stay (r=0.717 and 0.612, p=0.013 and 0.045, respectively). However, only the lactate levels were associated with ventilator support time (r=0.674, p=0.023). Conclusion: We demonstrated that hs-cTnI and lactate levels are important markers of myocardial injury in association with hypoperfusion during on-pump CABG, and it could be used to monitor the postoperative outcome.

Serum CIRP increases the risk of acute kidney injury after cardiac surgery.

Acute kidney injury (AKI) is a frequent perioperative complication. The underlying mechanisms of cardiac surgery-associated AKI are still not completely elucidated. Cold-induced RNA-binding protein (CIRP) has been subsequently found to be regulated by various stress conditions. During cardiac surgery and cardiopulmonary bypass (CPB), the host is subjected to hypothermia and inadequate organ perfusion, resulting in an upregulation of CIRP secretion. The aim of this study is to evaluate the role of elevated extracellular CIRP level as a contributing factor in the development of AKI. A total of 292 patients who underwent cardiac surgery were retrospectively enrolled and their serum samples were collected preoperative and postoperative. Demographic data, intraoperative data, in-hospital outcomes, and the occurrence of AKI were also collected for the patients. The correlation between CIRP and intraoperative procedures, as well as its association with postoperative outcomes were analyzed. In multivariable analysis, higher ΔCIRP (p = 0.036) and body mass index (p = 0.015) were independent risk factors for postoperative AKI. Meanwhile, patients with postoperative AKI exhibited lower survival rate in 2-year follow-up (p = 0.008). Compared to off-pump coronary artery bypass grafting surgery, patients who underwent on-pump coronary artery bypass grafting, valve surgery, aortic dissection and other surgery showed higher ΔCIRP, measuring 1,093, 666, 914 and 258 pg/mL, respectively (p < 0.001). The levels of ΔCIRP were significantly higher in patients who underwent CPB compared to those who did not (793.0 ± 648.7 vs. 149.5 ± 289.1 pg/mL, p < 0.001). Correlation analysis revealed a positive correlation between ΔCIRP levels and the duration of CPB (r = 0.502, p < 0.001). Patients with higher CIRP levels are at greater risk of postoperative AKI (OR: 1.67, p = 0.032), especially the stage 2-3 AKI (OR: 2.11, p = 0.037). CIRP secretion increases with prolonged CPB time after cardiac surgery, and CIRP secretion is positively correlated with the duration of CPB. Cardiac surgeries with CPB exhibited significantly higher levels of CIRP compared to non-CPB surgeries. Elevation of CIRP level is an independent risk factor for the incidence of AKI, especially the severe AKI, and were associated with adverse in-hospital outcomes.