Clampless Off-Pump Versus Conventional Coronary Artery Revascularization

Abstract

Background-This study aimed to assess if clampless off-pump coronary artery bypass grafting (CABG) decreases risk-adjusted mortality, stroke rate, and morbidity in unselected patients in comparison to conventional CABG. Methods and Results-Between July 2009 and November 2010, data of 1282 consecutive patients undergoing isolated CABG were prospectively recorded. In 30.8% (nϭ395), clampless off-pump revascularization was used, either with the PAS-Port automated central venous anastomosis system (nϭ310) or as total arterial revascularization without central anastomoses (nϭ85). Propensity score (PS) matching was performed based on 15 preoperative risk variables to correct for selection bias. In-hospital mortality and stroke rate as primary end point, as well as major complications and follow-up outcome of clampless off-pump (lessOPCAB) and conventional CABG (cCABG) were compared in 394 matched patient pairs (total: 788 patients). The clampless off-pump technique decreased the in-hospital rate of death (odds ratio, 0.25; 95% confidence interval, 0.05-1.18, Pϭ0.080) and stroke (odds ratio, 0.36; 95% confidence interval, 0.13-0.99, Pϭ0.048) significantly. Complications such as low cardiac output syndrome, prolonged ventilation and rethoracotomy were also reduced by lessOPCAB. Over a 2-year follow-up period overall survival, cerebrovascular and major adverse event rate were significantly lower in the lessOPCAB group, while the repeat revascularization rate was comparable. Conclusions-In a retrospective PS-matched analysis, clampless off-pump CABG lowers mortality, stroke rate and other morbidity in an unselected group of patients with coronary artery disease. (Circulation. 2012;126[suppl 1]:S176 -S182.)

2018 ESC/EACTS Guidelines on myocardial revascularization

“…491 Harvesting of the whole radial artery pedicle, together with the intraluminal and subadventitial injection of vasodilators, are useful steps to prevent spasm. [508][509][510] In cases of off-pump surgery, devices that allow a clampless procedure may help reduce the incidence of cerebral vascular complications.…”

“…518,[520][521][522][523] For some surgeons, off-pump surgery is associated with inferior early and late graft patency rates, and possibly compromised long-term survival; however, aortic no-touch/clampless off-pump procedures in the hands of highly trained teams appear to be associated with a reduced risk of early morbidity, such as stroke, and fewer transfusions. [508][509][510][524][525][526][527][528] In the subgroup of patients with end-stage CKD, there is some evidence that off-pump surgery is associated with lower in-hospital mortality and less need for new renal replacement therapy. 529 A summary of these technical aspects can be found in Figure 8.…”

Strategies for the coronary surgeon to remain “competitive and co-operative” in the PCI era

“…14 Borgermann et al compared clampless OPCAB (anaortic/ aortic no touch OPCAB) with conventional CABG by a propensity matched analysis and reported lower incidence of stroke and mortality with the clampless off pump technique. 15 In a subgroup analysis of SYNTAX trial the incidence of stroke in the conventional CABG arm at 3 years follow up was compared with that of anaortic OPCAB arm. The percentage of stroke was trending towards a lower but nonsignificant value with the aortic no touch technique (1.3% in the no touch group vs 3.4% in the SYNTAX group).…”

Letter by Salzberg et al Regarding Article, “Should Off-Pump Coronary Artery Bypass Grafting Be Abandoned?”

“…However, the available randomized, controlled trials were underpowered to detect significant differences between rarely occurring parameters such as stroke or death and importantly suffered from high selection and exclusion biases. Even more important is the fact that available randomized, controlled trials so far have primarily focused only on low-risk (Randomized On/Off Bypass [ROOBY; NCT00032630] or Coronary Artery Bypass Surgery Off or On Pump Revascularization Study [CORONARY; NCT00463294]) or elevated-risk (German Off Pump Coronary Artery Bypass in Elderly Study [GOPCABE; NCT00719667]) but not high-risk patients in whom the benefits of OPCAB have been repeatedly reported to be most apparent.3 The high conversion rates (12% in ROOBY, 7.9% in CORONARY, and 5% in GOPCABE) may suggest that some of the participating surgeons were inexperienced because expert centers report conversion rates between 2% and 4%, [2][3][4] which significantly affects long-term outcome.Second, Dr Lazar points out the important relation between incomplete revascularization and worse long-term outcomes. However, incomplete revascularization is not a shortcoming of OPCAB.…”

“…3 The high conversion rates (12% in ROOBY, 7.9% in CORONARY, and 5% in GOPCABE) may suggest that some of the participating surgeons were inexperienced because expert centers report conversion rates between 2% and 4%, [2][3][4] which significantly affects long-term outcome.…”