OPCAB Group Research Articles

Use of an objective measure of time to recovery after cardiac surgery – the STET randomised controlled trial

was censored because discharge occurred before all the criteria were met. Insufficient mobility accounted for the majority of censored observations. The median recovery time was 6 days, IQR [4,7] in the ThoraCAB group versus 5 days, IQR [4,7] in the OPCAB group (Time ratio (ThoraCAB/OPCAB) 1.03 (95%CI [0.94, 1.14], p=0.53). In contrast, the median time to discharge was 5 days in the ThoraCAB group versus 6 days in the OPCAB group.

Whether awake coronary artery bypass grafting is contrary to fast-track surgery?

We read with interest the recent paper of Go Watanabe et al [1], regarding awake off-pump coronary artery bypass grafting (OPCAB) under thoracic epidural anaesthesia (TEA). They compared 72 patients who underwent awake OPCAB under only TEA with 67 patients who underwent OPCAB under general anaesthesia (GA) and found that the time to drink water, the time to walk, and hospital stay were significantly shorter in awake OPCAB group. However, whether awake OPCAB is contrary to the concept of fast recovery surgery (FTS)? FTS using multimodal perioperative rehabilitation programs was introduced in the early 1990s, including preoperative optimization and information, ‘stress reduced’ surgery, efficient postoperative pain treatment, adjustment of perioperative care principles to existing evidence, and nursing care focusing on early mobilization and oral nutrition to enhance recovery, decrease morbidity and hospital stay [2]. The ultimate goal of FTS is to provide the ‘stress, pain and risk-free’ operation, its centre is to minimize stress. The reduction of stress during an elective surgical procedure, as characterized by attenuation of the neurohormonal response to the operation, not only provides a rational basis for increased recovery but also diminishes the risk of organ dysfunctions and complications [3]. During awake OPCAB, the tension and anxiety which will increase the patients’ stress and reduce the patient’s’ comfort and satisfaction are inevitable because the patients remain conscious. It is contrary to the concept of fast recovery surgery. We think the main benefit of awake OPCAB is achieved by the TEA, but not keeping conscious during operation. TEA recently gained popularity because of its potential beneficial effects on the perioperative stress response, analgesia and postoperative pulmonary function. Studies had shown that intraoperative use of TEA combined with GA will allow decreased use of opioids and permit earlier extubation [4], will alleviate perioperative stress and enable effective postoperative epidural analgesia which have favourable effects on pulmonary function parameters [5], and will have beneficial effects in cardiac risk patients [6]. In addition, there is a lack of evidence-based data that patients who have a risk of cerebral ischaemia or chronic pulmonary diseases are benefit from awake OPCAB. Whether it is the optimal method to use propofol or dexmedetomidine keeping patients sedation during OPCAB under TEA?

Predictors and impact of postoperative atrial fibrillation on patients’ outcomes: A report from the Randomized On Versus Off Bypass trial

The study objective was to determine the predictors of postoperative atrial fibrillation (POAF) in patients randomized to conventional coronary artery bypass graft (on-pump coronary artery bypass [ONCAB]) versus beating heart coronary surgery (off-pump coronary artery bypass [OPCAB]). The subgroup of 2103 patients (of 2203 enrollees) in the Randomized On Versus Off Bypass trial with no POAF was studied (1056 patients in the ONCAB group and 1047 patients in the OPCAB group). Univariate and multivariate analyses were used to identify the predictors of POAF and the impact of POAF on outcomes. Use of ONCAB versus OPCAB was not associated with increased rates of POAF. Older age (P < .0001), white race (P < .001), and hypertension (P < .002) were predictors of POAF on multivariate analysis. In general, POAF led to a higher rates of reintubation (ONCAB: 6.3% vs 0.8% no POAF, P < .001; OPCAB: 7.4% vs 1.8% no POAF, P < .0001) and prolonged ventilatory support (ONCAB: 7.1% vs 2.3% no POAF, P = .001; OPCAB: 9.2% vs 3.4% no POAF, P = .0003). The rate of any early adverse outcome was higher in patients with POAF (all patients: 10% POAF vs 4.7% no POAF, P < .0001; ONCAB: 9% POAF vs 4.3% no POAF, P = .008; OPCAB: 11% POAF vs 5.1% no POAF, P = .001). The 1-year all cause mortality was higher with POAF for both groups (ONCAB: 5.4% POAF vs 2% no POAF, P = .009; OPCAB: 5.1% POAF vs 2.6% no POAF, P = .07). POAF was independently associated with early composite end point (odds ratio [OR], 2.23; confidence interval [CI], 1.55-3.22; P < .0001), need for new mechanical support (OR, 3.25; CI, 1.39-7.61; P = .007), prolonged ventilatory support (OR, 2.93; CI, 1.89-4.55; P < .0001), renal failure (OR, 5.42; CI, 1.94-15.15; P = .001), and mortality at 12 months (OR, 1.94; CI, 1.14-3.28; P = .01). In the Randomized On Versus Off Bypass trial, the strategy of revascularization did not affect the rate of POAF. Age, race, and hypertension were predictors of POAF. POAF was independently associated with a higher short-term morbidity and higher 1-year mortality rates.

Hybrid Coronary Revascularization Versus Off-Pump Coronary Artery Bypass Grafting for the Treatment of Multivessel Coronary Artery Disease

Hybrid coronary revascularization (HCR) combines a minimally invasive (3-cm anterolateral thoracotomy), sternal-sparing, off-pump left internal mammary artery-left anterior descending (LIMA-LAD) coronary artery anastomosis with percutaneous coronary intervention (PCI) to non-LAD coronary arteries. We compared outcomes of HCR versus traditional off-pump coronary artery bypass grafting (OPCAB) for the treatment of multivessel coronary artery disease (CAD). Between October 8, 2003 and April 23, 2010, 147 patients with multivessel coronary disease were treated with HCR at a US academic center. These were matched 4:1 to 588 contemporaneous patients treated with multivessel OPCAB by sternotomy using an optimal matching algorithm with 8 preoperative variables: age, gender, ejection fraction, presence of diabetes, myocardial infarction (MI), number of diseased vessels, left main coronary artery disease, and Society of Thoracic Surgeons (STS) predicted risk of mortality (PROM) score. In-hospital major adverse events (MACCE) and the need for repeated revascularization during follow-up were compared between groups. All-cause mortality was determined using the Social Security Death Index (SSDI). Matching produced groups with similar coronary anatomy and statistically similar preoperative risk factors. The incidence of MACCE was similar between groups (3/147 HCR versus 12/588 OPCAB). During a median 3.2 years of follow up, the need for repeated revascularization was higher for HCR than for OPCAB (18/147 [12.2%] versus 22/588 [3.7%]; p < 0.001). The incidence of blood transfusion was higher for the OPCAB group. Estimated 5-year survival was similar between groups (OPCAB, 84.3% versus HCR, 86.8%; p = 0.61). Hybrid coronary revascularization is a minimally invasive treatment for multivessel CAD. Although repeated revascularization was greater with HCR, both in-hospital and midterm outcomes were comparable with those of traditional OPCAB. Further investigation into the comparative effectiveness of this alternative strategy is warranted.

Off-Pump Coronary Artery Bypass in Patients With Left Ventricular Dysfunction: A Meta-Analysis

In symptomatic multivessel disease with left ventricular dysfunction, coronary artery bypass surgery (CAB) is the conventional approach. This study assesses outcomes in patients with left ventricular dysfunction undergoing coronary artery bypass with (on-pump; ONCAB) and without cardiopulmonary bypass (off-pump; OPCAB). A systematic literature search was performed and data were extracted for the following outcomes of interest: 30-day, midterm, and late-term mortality, myocardial infarction, and completeness of revascularization. Random effects meta-analysis was used to aggregate the data. Sensitivity, heterogeneity, and publication bias were assessed. Analysis of 23 nonrandomized studies revealed 7,759 patients, of whom 2,822 received OPCAB and 4,937 underwent ONCAB. Early mortality was significantly lower in the OPCAB group (odds ratio 0.64, 95% confidence interval 0.51 to 0.81) with no significant heterogeneity between the studies. This finding was supported by subgroup analysis that included assessment of studies only including patients with poor left ventricular function. Based on 13 studies, there was no difference in mortality at the midterm, and based on 4 studies there was no significant difference when comparing late-term mortality. Analysis of four studies revealed the OPCAB group was associated with significantly less complete revascularization. Off-pump CAB may be associated with lower incidence of early mortality in patients with impaired left ventricular function, although the method of handling the conversion-related mortality in each study is uncertain and may challenge these results. Incomplete revascularization provided by the OPCAB group occurred more often, although its impact was not reflected in the clinical outcomes but may explain why the early advantage in mortality was not continued to the late term.

On-pump and off-pump coronary artery bypass grafting in patients with left main stem disease: A propensity score analysis

This study compared safety and efficacy between off-pump coronary artery bypass grafting (OPCAB), a relatively new technique, and conventional on-pump coronary artery bypass grafting (CCAB) in patients with left main stem disease. In a retrospective, observational, cohort study of prospectively collected data on 2375 consecutive patients with left main stem disease undergoing isolated CABG (1297 OPCAB, 1078 CCAB) between April 1996 and December 2009 at the Bristol Heart Institute, 548 patients undergoing OPCAB were matched with 548 patients undergoing CCAB by propensity score. After propensity matching, groups were comparable in preoperative characteristics. Relative to CCAB, OPCAB was associated with lower in-hospital mortality (0.5% vs 2.9%; P = .001), incidence of stroke (0% vs 0.9%; P = .02), postoperative renal dysfunction (4.9% vs 10.8%; P = .001), pulmonary complications (10.2% vs 16.6%; P = .002), and infectious complications (3.5% vs 6.2%; P = .03). The OPCAB group received fewer grafts than did the CCAB group (2.7 ± 0.7 vs 3 ± 0.7; P = .001) and had a lower rate of complete revascularization (88.3% vs 92%; P = .04). In multivariable analysis, cardiopulmonary bypass was confirmed to be an independent predictor of in-hospital mortality (odds ratio, 5.74; P = .001). Survivals at 1, 5, and 10 years were similar between groups (OPCAB, 96.8%, 87.3%, and 71.7%; CCAB, 96.8%, 88.6%, and 69.8%). OPCAB in patients with left main stem disease is a safe procedure with reduced early morbidity and mortality and similar long-term survival to conventional on-pump revascularization.

Clinical significance of intestinal type fatty acid binding protein in patients undergoing coronary artery bypass surgery

The aim of this study was to determine whether serum levels of intestinal type fatty acid binding protein (I-FABP) are related to intestinal ischemia in patients undergoing coronary bypass surgery. The study was planned as prospective, observational. Elective coronary artery bypass candidate patients between ages of 50 and 70 were consecutively included in the study. Thirty-five patients scheduled for cardiopulmonary bypass (CPB) were identified as the CPB group and 16 patients not scheduled for CPB were identified as the off-pump coronary artery bypass surgery (OPCAB) group. The variables between and within the groups were analyzed with Student's t, Mann-Whitney U, Friedman and Wilcoxon tests respectively. In both CPB and OPCAB groups, I-FABP level at the end of the operation was significantly higher than that noted at the beginning of the operation (p<0.005). In the CPB group, there was a significant drop in I-FABP from the end of the operation to each of the postoperative time points (12(th) hour and 24(th) hour) (respectively p<0.001, p<0.001). In the OPCAB group, the I-FABP levels at both postoperative time points were lower than that at the end of the operation (p<0.001), and the level at 24-hour post-surgery was significantly lower than at both the end-of-operation I-FABP value (p<0.001) and the 12-hour post-surgery I-FABP value. Since we have not observed any intestinal ischemia through our research, slight changes of I-FABP measurements make us believe that I-FABP would be a valuable way to monitor for intestinal ischemia in patients who undergo cardiac surgery.

Free radical reaction products and antioxidant capacity in beating heart coronary artery surgery compared to conventional bypass

Oxygen-derived free radicals are important agents of tissue injury during ischemia and reperfusion. The aim of this study was to investigate changes in protein and lipid oxidation and antioxidant status in beating heart coronary artery surgery and conventional bypass and to compare oxidative stress parameters between the two bypass methods. Serum lipid hydroperoxide, nitric oxide, protein carbonyl, nitrotyrosine, vitamin E, and β-carotene levels and total antioxidant capacity were measured in blood of 30 patients undergoing beating heart coronary artery surgery (OPCAB, off-pump coronary artery bypass grafting) and 12 patients undergoing conventional bypass (CABG, on-pump coronary artery bypass grafting). In the OPCAB group, nitric oxide and nitrotyrosine levels decreased after reperfusion. Similarly, β-carotene level and total antioxidant capacity also decreased after anesthesia and reperfusion. In the CABG group, nitric oxide and nitrotyrosine levels decreased after ischemia and reperfusion. However, protein carbonyl levels elevated after ischemia and reperfusion. Vitamin E, β-carotene, and total antioxidant capacity decreased after ischemia and reperfusion. Significantly decreased nitration and impaired antioxidant status were seen after reperfusion in both groups. Moreover, elevated protein carbonyls were found in the CABG group. The off-pump procedure is associated with lower degree of oxidative stress than on-pump coronary surgery.

Process Review of a Departmental Change from Conventional Coronary Artery Bypass Grafting to Totally Arterial Coronary Artery Bypass and Its Effects on the Incidence and Severity of Postoperative Stroke

We evaluated the process of changing from conventional coronary artery bypass grafting (CABG) to totally arterial off-pump coronary artery bypass (TOPCAB) at a single heart center in Germany. We (1) used multivariate statistical methods to assess real-time monitoring of OPCAB effects, (2) conducted a case review to assess preventable deaths and identify areas of improvement, (3) conducted a team survey, and (4) evaluated benchmarking results. All surgeons and assistants (n = 18) at this center were involved and were guided by the department head and one of the consultants, who was trained in this procedure in 2004 at the Leuven OPCAB school. The frequency of OPCAB operations increased abruptly in 2005 from 5% to 43% and then increased gradually to 67% (n = 546) by 2008 (total, 1781 OPCAB cases and 1563 on-pump cases). The in-hospital and 30-day mortality rates for OPCAB surgeries (n = 10 [0.6%] and 21 [1.2%], respectively) were lower than for on-pump surgeries (n = 27 [1.7%] and 26 [1.7%], respectively). Stroke rates were also lower for OPCAB surgeries (7 cases [0.4%] versus 15 cases [1%]). The lower risk of stroke in the OPCAB group was significant (P < .05) after risk adjustment. Monitoring curves and case reviews demonstrated a preventable death percentage of at least 30%. The attitude of the team was mostly positive because of the promising results (eg, fewer strokes, increasing TOPCAB popularity, and a top national rank). The change from conventional CABG to TOPCAB was effective in decreasing the incidence and severity of stroke, in developing a team routine and a positive team attitude, and in producing excellent benchmarking results. The presence of a training and communication deficiency at the beginning of the study suggested an area for further improvement. After 6 years TOPCAB had largely replaced conventional CABG.

Minimally invasive coronary artery bypass grafting via a small thoracotomy versus off-pump: a case-matched study☆☆☆

The minimally invasive coronary artery bypass grafting (MICS CABG) operation performed via a small thoracotomy has not previously been examined in a direct comparison to sternotomy off-pump coronary artery bypass grafting (OPCAB). We matched, according to age, gender, left ventricular function, and median number of distal anastomoses, 150 patients who underwent MICS CABG via small left thoracotomy, and 150 patients who received sternotomy OPCAB. All operations were performed by the same surgeon. There was no perioperative mortality (0/300). In the MICS CABG group, pump assistance was used in 28/150 (19%) patients, and conversion to sternotomy occurred in 10/150 (6.7%) patients. In the OPCAB group, conversion to on-pump occurred in 3/150 (2.0%) patients. There were four (2.7%) reoperations for bleeding and one (0.7%) for anastomotic revision in each group. The median hospital length of stay was 5 days for MICS CABG (average 5.4), and 6 days for OPCAB (average 7.2) (P=0.02). New-onset atrial fibrillation occurred in 35 (23%) MICS CABG patients and in 42 (28%) OPCAB patients (P=0.3). No wound infection occurred with MICS CABG versus six (4.0%) with OPCAB (P=0.03). A self-limiting left pleural effusion developed in 22 (15%) MICS CABG patients and in six (4.0%) OPCAB patients (P=0.002). The median time to return to full physical activity was 12 days in MICS CABG patients versus >5 weeks in OPCAB patients (P<0.001). MICS CABG is a valuable alternative for patients in need of multivessel CABG. The operation appears at least as safe as OPCAB, and associated with shorter hospital length of stay, less wound infections, and faster postoperative recovery than OPCAB.

High Mobility Group Box 1 Levels in On and Off-Pump Cardiac Surgery Patients

High mobility group box 1 (HMGB1), which has properties similar to those of proinflammatory cytokines, is released from activated immune cells and necrotic cells. It is known that cardiopulmonary bypass (CPB) induces systemic inflammation and aortic cross-clamping induces myocardial ischemia. This study was conducted to clarify whether HMGB1 is released in CPB-supported cardiac surgery in comparison to off-pump coronary artery bypass grafting (OPCAB) where CPB is not used.Nineteen adult patients undergoing cardiac surgery involving CPB (CPB group) and 5 OPCAB patients (OPCAB group) were included in this study. Plasma concentrations of proinflammatory cytokines including HMGB1 were measured before, during, and after cardiac surgery. The plasma HMGB1 level was significantly increased at one hour after aortic declamping in the CPB group and at 30 minutes after revascularization in the OPCAB group. The peak HMGB1 level was slightly higher in the CPB group than that in the OPCAB group. These values decreased toward baseline value after surgery in both groups. TNF-α and IL-1β were not detectable throughout the study period in either group. IL-6 and IL-10 increased after aortic declamping in the CPB group and after coronary revascularizations in the OPCAB group.Based on these results, we conclude that the major factor involved in the increase in HMGB1 level might be myocardial ischemia/reperfusion during cardiac surgery. Activation of immune cells, altered tissue perfusion, and pulmonary ischemia and reperfusion could be additional factors that increase the HMGB1 level in CPB-supported cardiac surgery.

Activation of Coagulation and Fibrinolysis after Off-Pump Coronary Artery Bypass Grafting with or without Endotracheal General Anesthesia

: In this study, we measured the activity of coagulation and fibrinolysis and clarified the presence of certain differences between off-pump coronary artery bypass grafting (OPCAB) cases and awake off-pump coronary artery bypass grafting (AOCAB) cases to evaluate whether AOCAB is actually safe from the viewpoint of coagulability. : 8 underwent OPCAB and 6 underwent AOCAB. The following factors inducing coagulation and fibrinolysis were measured for upto 5 days after the operation: platelet counts, prothrombin time, activated partial thromboplastin time, fibrinogen, fibrin degeneration products, d-dimer, thrombin-antithrombin III complex (TAT), α2-plasmin inhibitor-plasmin complex, prothrombin fragment 1, 2 (F1+2), thrombomodulin, β-thromboglobulin (β-TG), and platelet factor-4. : At 5 days after the operation, fibrin degeneration products, d-dimer, α2-plasmin inhibitor-plasmin complex, and F1+2 levels of the OPCAB group were significantly higher compared with their baseline values and those of the AOCAB group. At 5 days after the operation, thrombin-antithrombin III complex levels of the OPCAB group were significantly higher than those of the AOCAB group. Fibrinogen levels of the OPCAB group were significantly higher than their baseline values at 3 days after the operation (POD3) and 5 days after the operation (POD5). : In this study, the hypercoagulable state at POD5 was suggested in the patients in the OPCAB group, but not in those in the AOCAB group. Further study is necessary to confirm these results, and future studies would evaluate the potential benefit of AOCAB procedure from the viewpoint of perioperative coagulability.

Activation of coagulation and fibrinolysis after off-pump coronary artery bypass grafting with or without endotracheal general anesthesia.

: In this study, we measured the activity of coagulation and fibrinolysis and clarified the presence of certain differences between off-pump coronary artery bypass grafting (OPCAB) cases and awake off-pump coronary artery bypass grafting (AOCAB) cases to evaluate whether AOCAB is actually safe from the viewpoint of coagulability. : 8 underwent OPCAB and 6 underwent AOCAB. The following factors inducing coagulation and fibrinolysis were measured for upto 5 days after the operation: platelet counts, prothrombin time, activated partial thromboplastin time, fibrinogen, fibrin degeneration products, d-dimer, thrombin-antithrombin III complex (TAT), α2-plasmin inhibitor-plasmin complex, prothrombin fragment 1, 2 (F1+2), thrombomodulin, β-thromboglobulin (β-TG), and platelet factor-4. : At 5 days after the operation, fibrin degeneration products, d-dimer, α2-plasmin inhibitor-plasmin complex, and F1+2 levels of the OPCAB group were significantly higher compared with their baseline values and those of the AOCAB group. At 5 days after the operation, thrombin-antithrombin III complex levels of the OPCAB group were significantly higher than those of the AOCAB group. Fibrinogen levels of the OPCAB group were significantly higher than their baseline values at 3 days after the operation (POD3) and 5 days after the operation (POD5). : In this study, the hypercoagulable state at POD5 was suggested in the patients in the OPCAB group, but not in those in the AOCAB group. Further study is necessary to confirm these results, and future studies would evaluate the potential benefit of AOCAB procedure from the viewpoint of perioperative coagulability.

A prospective randomized study to evaluate the renal impact of surgical revascularization strategy in diabetic patients

Acute kidney injury (AKI) is a major postoperative complication following cardiac surgery. Diabetes mellitus is a major cause of nephropathy and end-stage renal failure. We aimed to evaluate the occurrence of adverse renal outcomes, in diabetic patients, between on-pump (CPB) and off-pump (OPCAB) coronary artery bypass graft (CABG). Seventy-one diabetic patients (36 and 35 patients in the CPB and OPCAB groups, respectively) were enrolled in a prospective randomized study. Renal tubular and glomerular functions, were monitored preoperatively and over five consecutive days. There was no significant difference between the groups in terms of age, gender, New York Heart Association class, Canadian Cardiovascular Society functional classification of angina grade and number of CABG. Intensive care unit stay, duration of intubation, hospital stay and bleeding were significantly higher in the CPB group. No significant differences in plasmatic creatinine, urinary creatinine, creatinine clearance, proteinuria or osmolality were detected. A significant rise in urinary albumine excretion occurred in both groups peaking on the operative day; for the on-pump CABG group (10±5 vs. 48±57; P=0.015) and for the OPCAB group (11±6 vs. 37±59; P=0.04). Values were less important in the OPCAB group and return to the baseline was faster than in the CPB group. OPCAB attenuates sub-clinical AKI, in diabetic patients.

“Anaortic” Off-Pump Coronary Artery Bypass Grafting Significantly Reduces Neurological Complications Compared to Off-Pump and Conventional On-Pump Surgery with Aortic Manipulation

Most studies comparing off-pump coronary artery bypass grafting (OPCAB) with conventional on-pump coronary artery bypass grafting (ONCAB) include patients with aortic manipulation in the OPCAB group. Performing OPCAB without aortic manipulation, i.e., "anaortic" OPCAB (anOPCAB), may improve neurological outcome. We reviewed the perioperative data of all isolated CABG patients at two metropolitan hospitals for the period from January 2002 to December 2007. Multiple logistic regression analysis was performed to determine whether the type of procedure was an independent predictor of adverse neurological outcome. Out of a total of 3699 consecutive patients, 1346 were anOPCAB, 600 OPCAB and 1753 ONCAB cases. Neurological complications occurred in 0.9 % of all patients. Compared to the anOPCAB group, there was a statistically significant higher odds for neurological complications in the OPCAB group [odds ratio (OR) 7.01, 95 % confidence interval (CI) 1.4-35.0, P = 0.0175] and in the ONCAB group (OR 12.33, 95 % CI 2.9-52.2, P = 0.0007). In this series "anaortic" OPCAB surgery significantly decreases the risk of neurological complications compared to both ONCAB and OPCAB with aortic manipulation. If possible, we advocate avoiding aortic manipulation in OPCAB surgery.

Five-Year Follow-Up of a Randomized Comparison Between Off-Pump and On-Pump Stable Multivessel Coronary Artery Bypass Grafting. The MASS III Trial

Coronary artery bypass graft surgery with cardiopulmonary bypass is a safe, routine procedure. Nevertheless, significant morbidity remains, mostly because of the body's response to the nonphysiological nature of cardiopulmonary bypass. Few data are available on the effects of off-pump coronary artery bypass graft surgery (OPCAB) on cardiac events and long-term clinical outcomes. In a single-center randomized trial, 308 patients undergoing coronary artery bypass graft surgery were randomly assigned: 155 to OPCAB and 153 to on-pump CAB (ONCAB). Primary composite end points were death, myocardial infarction, further revascularization (surgery or angioplasty), or stroke. After 5-year follow-up, the primary composite end point was not different between groups (hazard ratio 0.71, 95% CI 0.41 to 1.22; P=0.21). A statistical difference was found between OPCAB and ONCAB groups in the duration of surgery (240±65 versus 300±87.5 minutes; P<0.001), in the length of ICU stay (19.5±17.8 versus 43±17.0 hours; P<0.001), time to extubation (4.6±6.8 versus 9.3±5.7 hours; P<0.001), hospital stay (6±2 versus 9±2 days; P<0.001), higher incidence of atrial fibrillation (35 versus 4% of patients; P<0.001), and blood requirements (31 versus 61% of patients; P<0.001), respectively. The number of grafts per patient was higher in the ONCAB than the OPCAB group (2.97 versus 2.49 grafts/patient; P<0.001). No difference was found between groups in the primary composite end point at 5-years follow-up. Although OPCAB surgery was related to a lower number of grafts and higher episodes of atrial fibrillation, it had no significant implications related to long-term outcomes. Clinical Trial Registration-URL: http://www.controlled-trials.com. Unique identifier: ISRCTN66068876.

Clinical study of Coronary artery bypass grafting in the elderly

Objective To explore the characteristics of operation,curative effects and operative management in elderly patients of age older than 70 years with coronary heart disease receiving coronary artery bypass grafting.Methods 108 elderly patients of age older than 70 years with coronary heart disease were divided into two groups:OPCAB group(n = 76) and CCABG group (n = 32) The clinical curative effects, early postoperative mortality and complications of the two groups were compared and analyzed respectively. Results OPCAB group was better than CCABG group in these series(P ＜ 0.05): The early postoperative mortality (5.8%, 11.2%)、 myocardial infarction (2.9%, 10.6%), respiration failure(8.7%, 17.5%), pulmonary complications: (11.8%, 31.5%) 、complication of CNS:(1.8% ,9.8%) 、acute renal failure(1.8% ,6.2%) ,the time of intubation: (9.3 ±4.5), (25.4 ±7.5) h,ICU stay(3.1 ± 1.8) ,(7.1 ±2.9) d,hospital stay(15.5 ±8.6) ,(26.4 ±8.6)d. Conclusion OPCAB could reduce operative mortality and complication, it should be the first option for the surgery of elder patients with coronary heart disease;surgical skills and correct perioperative management were the key factors to assure surgical outcome. Key words: Coronary artery bypass grafting; Cardiac surgery procedures

Off-Pump Coronary Bypass Surgery Is Safe in Patients with a Low Ejection Fraction (≤25%)

A severely decreased ejection fraction (EF) of < or =25% is an established risk factor for a worse outcome after heart surgery and therefore has been incorporated into the EuroSCORE risk-stratification model. We compare clinical outcomes after off-pump coronary artery bypass grafting (OPCAB) and on-pump coronary artery bypass grafting in patients with a severely compromised EF. We compared 112 patients with a low EF (< or =25%) who underwent myocardial revascularization between 2003 and 2008. Forty-four patients underwent OPCAB (group A), and 68 patients underwent on-pump surgery (group B). We compared demographics, intraoperative parameters, intraoperative outcomes, and the completeness of revascularization for the 2 groups. Demographic and EuroSCORE data were comparable for groups A and B. The 2 groups appeared to be similar with respect to mortality rate during the first 30 days (2.2% and 8.8%, respectively; P = .11) and the rate of major complications such as stroke (2.2% and 2.9%, respectively; P = 0.83). The patients in group A had fewer pulmonary complications (7% versus 25%, P < .01), received fewer blood transfusions (15.9% versus 47.0%, P < .01), required fewer postoperative pacing procedures (atrial, 11.4% versus 39.7%; ventricular, 13.6% versus 47.1%; P < .01), and had fewer wound infections (2.2% versus 16.1%, P = .02). The numbers of diseased vessels were comparable, and although the OPCAB patients received more arterial grafts (1.05 +/- 0.43 versus 0.84 +/- 0.37, P < .01), the total number of grafts per patient was lower among these patients (2.50 +/- 0.88 versus 3.53 +/- 0.92, P = .03). Similarly, complete revascularization was achieved less frequently within this group (80% versus 94%, P = .02). A standardized OPCAB approach in patients with a severely decreased EF is safe and may benefit this subset of patients with respect to fewer postoperative complications. Although complete revascularization is the optimal approach for these patients, they benefit from avoiding cardiopulmonary bypass.

A 3-Year Clinical Outcome After Percutaneous Coronary Intervention Using Sirolimus-Eluting Stent and Off-Pump Coronary Artery Bypass Grafting for the Treatment of Diabetic Patients With Multivessel Disease

There are few data to compare the long-term efficacy of sirolimus-eluting stent (SES) and off-pump coronary artery bypass grafting (OPCAB) for diabetic patients with multivessel disease (MVD). In a single-center non-randomized registry, 208 diabetic patients with MVD were examined (SES group: n=92, OPCAB group: n=116). The occurrence of major adverse cardiac and cerebrovascular events (MACCE, defined as all-cause death, non-fatal myocardial infarction, cerebrovascular event, and repeat revascularization) was compared between the 2 groups. Fasting blood glucose level, type of diabetic treatment and the prevalence of diabetic major vascular complications were similar between groups. The SES group had a significantly higher prevalence of 2-vessel disease and a significantly lower prevalence of 3-vessel disease compared with the OPCAB group. During the follow-up period (mean: 42+/-8 months), the rate of revascularization was significantly higher in the SES group than the OPCAB group (21% vs 6.9%, P=0.003). On the other hand, there was a significant higher occurrence of cerebrovascular events in the OPCAB group. Finally, the cumulative MACCE was similar between the 2 groups (27% vs 23%, P=0.492). At the 3-year clinical follow-up, the prevalence of MACCE in diabetic patients with MVD was comparable between the SES and the OPCAB groups.

Assessment of oxidative stress in coronary artery bypass surgery: comparison between the global index OXY-SCORE and individual biomarkers

The performances of the OXY-SCORE, a summary index of oxidative stress, and of its individual components (plasma malondialdehyde (MDA), oxidized and reduced glutathione, individual antioxidant capacity, α- and γ-tocopherol and urinary isoprostanes) were assessed in 47 patients undergoing coronary surgery, randomly assigned to cardiopulmonary bypass (CPB) or off-pump procedure (OPCAB) associated with less oxidative stress. The ability of the OXY-SCORE to classify correctly the patients was high (area under the ROC curve 0.90). Only free MDA showed a similar performance, but it was insensitive to the minor variations of the oxidative balance in the OPCAB group.