Coronary Artery Bypass Performed Without the Use of Cardiopulmonary Bypass Is Associated With Reduced Cerebral Microemboli and Improved Clinical Results

doi:10.1378/chest.119.1.25

Chest

Volume 119, Issue 1, January 2001, Pages 25-30

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Study objectives:

Strokes and neurocognitivedysfunction have been correlated with cerebral microemboli producedduring cardiopulmonary bypass (CPB). The purpose of this study was todetermine whether, and to what extent, off-pump coronary artery bypass(OPCAB) reduces the occurrence of cerebral microemboli compared withtraditional coronary artery bypass grafting (CABG) with CPB and tocompare clinical results.

Design and patients:

Aretrospective review of 137 patients undergoing elective CABG wasperformed, 70 of whom underwent traditional CABG and 67 of whomunderwent OPCAB. Using transcranial Doppler ultrasonography, 40patients (20 CABG, 20 OPCAB) were continuously monitoredintraoperatively for the occurrence and pattern of cerebralmicroemboli.

Setting:

Private, university-affiliatedtertiary care hospitals.

Results:

There was nostatistical difference in the age, sex, or underlying comorbiditiesbetween those patients undergoing CABG and OPCAB. CABG patients didhave a slightly lower preoperative ejection fraction (50.9% vs 55.5%,p = 0.03). Despite these similar preoperative characteristics, the, OPCAB group experienced significant reductions in cerebral microemboli(27 vs 1,766, p = 0.003), transfusion requirements (29.9% vs 47.1%,p = 0.04), intubation time (3.3 vs 9.5 h, p < 0.001), ICUlength of stay (1.5 vs 2.8 days, p = 0.02), and overallhospitalization (4.9 vs 6.6 days, p = 0.01) without an increase inmortality. Fewer strokes and deaths were observed in the OPCAB group, but these trends failed to reach statistical significance.

Conclusions:

In similar patient populations, OPCAB wasassociated with significantly fewer cerebral microemboli and improvedclinical results without an increase in mortality. We believe thatthese early results support OPCAB as a viable and potentially saferalternative to traditional CABG.

Section snippets

Patient Population

A retrospective review of consecutive patients undergoingelective CABG between January 1998 and May 1999 was performed. BothOPCAB and CABG procedures were performed in consecutive patients duringthe same time period. Only patients undergoing their first cardiacrevascularization were included. Patients with significant renaldysfunction (creatinine > 2.0) or poor underlying cardiac function(ejection fraction < 20%) were excluded. To compare patientpopulations undergoing a similar number of bypass

Demographics

One-hundred thirty-seven patients met the inclusion criteria, 70undergoing traditional CABG with CPB and 67 undergoing OPCAB. OPCABpatients had a slightly higher ejection fraction than the traditional, CABG group (55.5% vs 50.9%, p = 0.03). There was no statisticaldifference in the remaining preoperative characteristics orcomorbidities between the two groups (Table 1). Despite the exclusion of CABGpatients having four or more vessels bypassed, a small butstatistically significant discrepancy in

Discussion

We believe that these early results support OPCAB as a safeand effective alternative to traditional coronaryrevascularization.¹⁸¹⁹²⁰ Eliminating CPB greatly reducesthe systemic inflammatory response associated with cardiac surgery, andtangible benefits may be realized. Decreased interstitial pulmonaryedema, surfactant degradation, and hypothermia²¹ may, inpart, account for the decreased need for postoperative mechanicalventilation after OPCAB. The damaging effects of CPB on plateletsand

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Preoperative treatment with clopidogrel and ticagrelor on bleeding complications in off-pump coronary artery bypass grafting
2022, Thrombosis Research
Dual antiplatelet therapy (DAPT) consisting of acetylsalicylic acid and clopidogrel or ticagrelor increased bleeding complications in patients undergoing coronary artery bypass grafting (CABG). We aimed to compare the bleeding risks between patients treated with clopidogrel and ticagrelor preoperatively and investigate the influence of discontinuation of clopidogrel and ticagrelor on bleeding risk in off-pump CABG (OPCABG).
We conducted a retrospective analysis of patients with DAPT who underwent OPCABG. The propensity score matching was performed given the baseline differences between clopidogrel- and ticagrelor-treated patients. Bleeding was assessed by chest tube drainage volume and universal definition of perioperative bleeding.
This study included 836 patients. Five hundred and fifty patients were treated with clopidogrel and 286 patients treated with ticagrelor before surgery. After matching, 275 patients treated with clopidogrel and 275 patients with ticagrelor were included. There were no significant differences in bleeding between clopidogrel and ticagrelor group. Patients who discontinued clopidogrel before surgery <3 d had a higher risk of severe perioperative bleeding compared with those who discontinued ≥5 d (16.4 % vs. 5.0 %, P = 0.045). By contrast, the risk of severe perioperative bleeding was comparable among patients who discontinued ticagrelor for <3 d, ≥3–5 d and ≥5 d preoperatively (16.2 % vs. 9.1 % vs. 10.1 %, P = 0.317). The multivariable analysis confirmed that time since discontinuation (<3 d vs. ≥5 d: OR = 2.732, 95 % CI: 1.332–5.605, P = 0.006) but not the types of P2Y₁₂ receptor antagonist was an independent predictor for severe perioperative bleeding.
There were no significant differences in severe perioperative bleeding between clopidogrel and ticagrelor groups. Discontinuation of clopidogrel <3 d before OPCABG increased the risk of severe perioperative bleeding.
Comparing S-100 beta protein levels and neurocognitive functions between patients undergoing on-pump and off-pump coronary artery bypass grafting
2013, Journal of Surgical Research
In the present study, we aimed to investigate the effects of off-pump coronary artery bypass grafting and on-pump cardiopulmonary bypass on the serum S-100 beta (S-100B) protein levels and neurocognitive functions of the patients.
Sixty-four patients undergoing coronary artery bypass grafting (CABG) were enrolled in the study and were divided into two groups: off-pump (group I, n = 24) and on-pump CABG (group II, n = 40) group. Serum S-100B levels were measured before and 0, 6, and 24 h after the operation. Neurocognitive function tests were done preoperatively and were repeated in the postoperative period as well.
Serum S-100B levels were similar between the two groups preoperatively. However, median S-100B levels at 0, 6, and 24 h after the surgery were found to be significantly lower in the off-pump CABG group than in the on-pump group. The preoperative neurocognitive functions of the patients were similar between the two groups, whereas neurocognitive function was found to be significantly impaired postoperatively in the on-pump group in comparison with the off-pump CABG group.
We concluded that off-pump CABG is associated with decreased serum S100 protein levels and less impairment on neurocognitive functions compared with the on-pump group.
Comparison of frequency of postoperative stroke in off-pump coronary artery bypass grafting versus on-pump coronary artery bypass grafting versus percutaneous coronary intervention
2012, American Journal of Cardiology
The stroke rate after coronary artery bypass grafting (CABG) compared to percutaneous coronary intervention (PCI) is generally considered high because cardiopulmonary bypass and aortic manipulations are often associated with cerebrovascular complications. However, an increasing number of CABGs performed without cardiopulmonary bypass (OPCAB) may improve those outcomes. Of 6,323 patients with multivessel and/or left main coronary artery disease, 3,877 patients underwent PCI, 1,381 conventional on-pump CABG, and 1,065 OPCAB. Median follow-up was 3.4 years. Stroke types were classified as early (onset of stroke within 24 hours after revascularization), delayed (within 30 days), and late (after 30 days). Propensity score analysis showed that the incidences of early, delayed, and late stroke did not differ between PCI and OPCAB (0.65, 95% confidence interval 0.08 to 5.45, p = 1.00; 0.36, 0.10 to 1.29, p = 0.23; 0.81, 0.52 to 1.27, p = 0.72, respectively). In contrast, incidence of early stroke after on-pump CABG was higher than after OPCAB (7.22, 1.67 to 31.3, p = 0.01), but incidences of delayed and late stroke were not different (1.66, 0.70 to 3.91, p = 0.50; 1.18, 0.83 to 1.69, p = 0.73). In conclusion, occurrence of stroke was not found to differ in patients after PCI versus OPCAB regardless of onset of stroke. Occurrence of early stroke after OPCAB was lower than that after on-pump CABG, yet occurrences of delayed and late strokes were similar for the 3 revascularization strategies.
Historical development of minimised cardiopulmonary bypass
2012, Minimized Cardiopulmonary Bypass Techniques and Technologies
This chapter discusses the history of the development of technologies for minimising the cardiopulmonary bypass (CPB) system while addressing issues of perfomance, safety and convenience. Technologies that moderate complications of CPB include membrane-based oxygenator materials, surface modification, active filtration, autotransfusion, novel pumping systems and many other pharmacological interventions and clinical techniques. Factors affecting safe deployment of mini-bypass systems include concern over passage of air through the system and the need for a team-focused approach to safe perfusion delivery. These factors are discussed with reference to general perfusion concepts.
Clinical relevance of transcranial Doppler in a cardiac surgery setting: embolic load predicts difficult separation from cardiopulmonary bypass
2024, Journal of Cardiothoracic Surgery
Off-pump vs. on-pump bypass surgery grafting in diabetic patients with three-vessel disease: a propensity score matching study
2023, Frontiers in Cardiovascular Medicine

View all citing articles on Scopus

: Supported by a grant from the Hawaii Community Foundation (grant961573) and the Pacific Health Research Institute.

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Chest

Clinical InvestigationsSURGERYCoronary Artery Bypass Performed Without the Use of Cardiopulmonary Bypass Is Associated With Reduced Cerebral Microemboli and Improved Clinical Results

Study objectives:

Design and patients:

Setting:

Results:

Conclusions:

Section snippets

Patient Population

Demographics

Discussion

Am J Cardiol

Neurocardiology

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Cerebral disorders after open-heart operations

N Engl J Med

An 11-year evolution of coronary arterial surgery (1968–1978)

Ann Surg

Neurologic complications of coronary artery bypass grafting: case-control study

Neurology

Central nervous system complications of coronary artery bypass graft surgery: prospective analysis of 421 patients

Stroke

Postoperative stroke in cardiac and peripheral vascular disease

Ann Surg

Clinical Investigations
SURGERY
Coronary Artery Bypass Performed Without the Use of Cardiopulmonary Bypass Is Associated With Reduced Cerebral Microemboli and Improved Clinical Results