Elsevier

The Annals of Thoracic Surgery

Volume 70, Issue 5, November 2000, Pages 1546-1550
The Annals of Thoracic Surgery

Original article: cardiovascular
Off-pump versus on-pump coronary bypass in high-risk subgroups

https://doi.org/10.1016/S0003-4975(00)01922-6Get rights and content

Abstract

Background. Cardiopulmonary bypass (CPB) has pathophysiologic sequelae that may be more severe in high-risk subsets. We wanted to determine whether off-pump coronary bypass (OPCAB) could optimize outcomes.

Methods. Our database of 242 OPCAB patients undergoing complete revascularization was compared to a base of 483 CABG patients undergoing CPB. Results were compared for the overall series and in the following high-risk subsets: 80 years of age or older, ventricular dysfunction (ejection fraction (EF) ≤ 0.25), prior neurologic event or renal failure, chronic obstructive pulmonary disease (COPD), and reoperation.

Results. In the overall series, OPCAB significantly reduced the incidence of intraoperative transfusion requirements and showed a trend toward reduced morbidity in terms of postoperative neurologic and renal complications, prolonged ventilator requirement greater than 3 days, and bleeding requiring reexploration. Mortality was less in the OPCAB group (0.4% versus 2.7%, p = not significant). Similar results were achieved in the following high-risk subgroups (n = off-pump/on-pump): 80 years of age or older (n = 28/58), EF less than or equal to 25% (n = 13/26), preoperative neurologic event (n = 25/36), preoperative renal failure (n = 27/46), COPD (n = 33/43), and reoperation (n = 28/76). OPCAB decreased the incidence of prolonged ventilation in COPD patients (0/33 [0%] versus 4/43 [9.3%] p = not significant) and decreased the incidence of renal complications in the elderly (1/28 [3.6%] versus 9/58 [15.5%] p = not significant). Off-pump coronary bypass reduced but did not eliminate neurologic events in the elderly (2/28 [7.1%] versus 8/58 [13.8%] p = not significant).

Conclusion: Off-pump coronary bypass significantly reduced the incidence of transfusion requirement compared to the CPB counterparts and had a consistent trend in reducing morbidity and mortality overall and in all high-risk subsets. Neurologic events are not eliminated in OPCAB.

Section snippets

Patients and methods

Our database of OPCAB patients undergoing complete revascularization without CPB from 1997 to 1999 was compared to our database of routine coronary artery bypass grafting (CABG) cases utilizing CPB. Various preoperative, intraoperative, and postoperative variables were studied between the groups as a whole as well as within various high-risk subgroups. These high-risk subgroups included profound ventricular dysfunction (ejection fraction ≤ 0.25 as assessed by left ventriculography or

Results

There were 242 consecutive OPCAB patients; 7 cases were done utilizing a left posterolateral thoracotomy and the remainder using a full median sternotomy approach. These were compared to 483 standard CABG patients.

Preoperative risk factors were similar between the two groups. The preoperative incidence of COPD, preoperative stroke or transient ischemic attack, and renal insufficiency for the OPCAB versus on-pump groups was 14% versus 9%, 12% versus 8.3%, and 11% versus 9.5%, respectively. The

Comment

The interaction between the inflammatory, coagulation, and fibrinolytic cascades occurring during CPB, and their contribution to end-organ injury, are complex. Studies on the beneficial physiologic effects of aprotinin reveal how these pathways are closely linked and mutually dependent [10]. Aprotinin directly inhibits plasmin, as well as inhibiting kallikrein, thus reducing the activation of complement and the formation of bradykinin, tissue plasminogen activator, and factor XIIa. This limits

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  • Repeat Coronary Artery Bypass Grafting: A Meta-Analysis of Off-Pump versus On-Pump Techniques in a Large Cohort of Patients

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    Citation Excerpt :

    Perioperative data for the OPCAB and ONCAB procedures are presented in detail in Tables S2 and S3. Twenty-one (21) studies consistently reported data regarding perioperative mortality data [10,21–23,25–29,31–42]. The 30-day mortality rate was 3.4% (n=68/2,024) and 7.4% (n=238/3,225) in the OPCAB and ONCAB repeat CABG groups, respectively.

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This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/section/atsdiscussion/

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