Cognitive and Cardiac Outcomes 5 Years After Off-Pump vs On-Pump Coronary Artery Bypass Graft Surgery

Abstract

for the Octopus Study Group C ORONARY ARTERY BYPASS graft (CABG) surgery effectively relieves angina but is associated with significant cerebral morbidity. 1 This has largely been attributed to the use of cardiopulmonary bypass. 1,2 Cardiopulmonary bypass requires cannulation and crossclamping of the ascending aorta, which may dislodge atheromatous macroemboli, leading to stroke. 3 Cardiopulmonary bypass also increases the permeability of the blood-brain barrier and generates microemboli, which may adversely affect cognitive function. 4,5 The incidence of cognitive decline in the first year after surgery ranges from less than 5% to more than 30%, depending both on patient characteristics and on the definition of decline that is used. 2,6 Stroke occurs in approximately 3% of patients undergoing CABG surgery. 1 The desire to avoid the perceived ill effects of cardiopulmonary bypass has led to a renewed interest in bypass surgery on the beating heart (off-pump CABG surgery). This has been stimulated by the development of cardiac stabilizers, which facilitate the construc-Author Affiliations: Departments of Anesthesiology (Drs van Dijk and Kalkman and Ms Spoor), Psychiatry (Dr Hijman), Cardiology (Drs Nathoe and Borst), and Cardiothoracic Surgery (Dr Jansen

Current outcomes of off-pump versus on-pump coronary artery bypass grafting: evidence from randomized controlled trials

“…The ROOBY trial demonstrated no difference in neurophysiological outcomes between off or on-pump groups (10). Similarly, three other randomized trials (32)(33)(34) and two systematic reviews of RCTs (35,36) failed to show any benefit with OPCAB in terms of neurocognitive function ( Tables 5,6). …”

Developmental Disability in the Young and Postoperative Cognitive Dysfunction in the Elderly After Anesthesia and Surgery: Do Data Justify Changing Clinical Practice?

“…95 Does off-pump versus on-pump make a neurocognitive difference? Several major studies have failed to detect a neurocognitive advantage to offpump, 96,97 and although Shroyer et al failed to find a statistically significant difference across their composite test battery, they did find a significant difference on one important test in favor of offpump, suggesting the possibility of a false-negative conclusion. 98 More recently, Puskas and colleagues found that ''After a mean of 7.5 years of followup, patients undergoing off-pump CABG performed better than those undergoing cardiopulmonary bypass in several neuropsychological domains.''…”

Risk Factors for the Development of Post-Operative Cognitive Dysfunction

“…For example, Evered et al found that the incidence of POCD in elderly patients on day 7 was higher after a CABG than a hip replacement, but at three months there was no difference between the two groups (Evered et al, 2011). Similarly, rates of POCD after cardiac surgery with or without CPB were not significantly different in elderly patients, one year (Jensen et al, 2006) or five years after surgery (Van Dijk et al, 2007). This was confirmed in a meta-analysis which included data of more than 900 patients (Marasco et al, 2008).…”

“…Cognitive dysfunction due to lack of normal sleep (Misra &Malow, 2008;Walker, 2008) Type of surgery POCD after minor surgery (Canet et al, 2003) POCD after major surgery (Moller et al, 1998) POCD after cardiac surgery (Pugsley et al, 1994;Newman et al, 2001;Rasmussen et al, 2001;Taggart & Westaby, 2001;Hogue et al, 2006;Jensen et al, 2006;Smith et al, 2006;Silbert et al, 2007;Van Dijk et al, 2007;Marasco et al, 2008;Evered et al, 2011) …”