Cognitive Outcome After On- and Off-Pump Coronary Artery Bypass Grafting Surgery: A Systematic Review and Meta-Analysis

Kennedy, Ewan D.; Choy, Kevin; Alston, R. Peter; Shao-yun, Chen; Farhan-Alanie, Muhamed M; Anderson, Jamie E.; Ang, Yun Lin; Moore, Deborah E.; MacKenzie, Sam A.; Sykes, Robert

doi:10.1053/j.jvca.2012.11.008

Cited by 49 publications

(41 citation statements)

References 42 publications

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“…Although our study was not powered for this outcome and no correction was made for multiple testing, this is in keeping with other studies specifically designed to investigate this outcome [31][32][33].…”

Section: Discussionmentioning

confidence: 55%

A pilot study of cerebral tissue oxygenation and postoperative cognitive dysfunction among patients undergoing coronary artery bypass grafting randomised to surgery with or without cardiopulmonary bypass*

et al. 2014

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SummaryCoronary artery bypass surgery, performed with or without cardiopulmonary bypass, is frequently followed by postoperative cognitive decline. Near-infrared spectroscopy is commonly used to assess cerebral tissue oxygenation, especially during cardiac surgery. Recent studies have suggested an association between cerebral desaturation and postoperative cognitive dysfunction. We therefore studied cerebral oxygen desaturation, defined as area under the cerebral oxygenation curve < 40% of > 10 min.%, with respect to cognitive performance at 4 days (early) and 3 months (late) postoperatively, compared with baseline, using a computerised cognitive test battery. We included 60 patients, of mean (SD) age 62.8 (9.4) years, scheduled for elective coronary artery bypass grafting, who were randomly allocated to surgery with or without cardiopulmonary bypass. Cerebral desaturation occurred in only three patients and there was no difference in cerebral oxygenation between the two groups at any time. Among patients who received cardiopulmonary bypass, 18 (62%) had early cognitive decline, compared with 16 (53%) in the group without cardiopulmonary bypass (p = 0.50). Three months after surgery, 11 patients (39%) in the cardiopulmonary bypass group displayed cognitive dysfunction, compared with four (14%) in the non-cardiopulmonary bypass group (p = 0.03). The use of cardiopulmonary bypass was identified as an independent risk factor for the development of late cognitive dysfunction (OR 6.4 (95% CI 1.2-33.0) p = 0.027. In conclusion, although cerebral oxygen desaturation was rare in our population, postoperative cognitive decline was common in both groups, suggesting that factors other than hypoxic neuronal injury are responsible.

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Section: Discussionmentioning

confidence: 55%

A pilot study of cerebral tissue oxygenation and postoperative cognitive dysfunction among patients undergoing coronary artery bypass grafting randomised to surgery with or without cardiopulmonary bypass*

et al. 2014

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“…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). …”

Section: =0%) (1)mentioning

confidence: 90%

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

et al. 2016

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Coronary artery bypass grafting remains the standard treatment for patients with extensive coronary artery disease. Coronary surgery without use of cardiopulmonary bypass avoids the deleterious systemic inflammatory effects of the extracorporeal circuit. However there is an ongoing debate surrounding the clinical outcomes after on-pump versus off-pump coronary artery bypass (ONCAB versus OPCAB) surgery. The current review is based on evidence from randomized controlled trials (RCTs) and metaanalyses of randomized studies. It focuses on operative mortality, mid-and long-term survival, graft patency, completeness of revascularisation, neurologic and neurophysiologic outcomes, perioperative complications and outcomes in the high risk groups. Early and late survival rates for both OPCAB and ONCAB grafting are similar. Some studies suggest early poorer vein graft patency with off-pump when compared with onpump, comparable midterm arterial conduit patency with no difference in long term venous and arterial graft patency. A recent, pooled analysis of randomised trials shows a reduction in stroke rates with use offpump techniques. Furthermore, OPCAB grafting seems to reduce postoperative renal dysfunction, bleeding, transfusion requirement and respiratory complications while perioperative myocardial infarction rates are similar to ONCAB grafting. The high risk patient groups seem to benefit from off-pump coronary surgery. Developed about 40 decades ago (5-7), OPCAB reached a plateau in Europe, accounting for nearly 15-20% of all coronary operations, while in Asia 60-100% of patients are offered coronary artery bypass grafting (2). A retrospective analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database in USA revealed a decline in off-pump operations, currently being used in fewer than one out of five patients (8). The current review focuses on the main outcomes of on-pump coronary artery bypass (ONCAB) grafting versus OPCAB from randomized controlled trials (RCTs) (i.e., level I evidence). The main criticism of RCTs in this area, is the under powering because of recruitment of low risk patients but also because of the low mortality and morbidity of coronary artery bypass grafting that would require very large sample populations to detect a difference (4). Therefore, we will also be reviewing pooled data from recent, updated meta-analyses of randomized trials only. We selected in our review large sample size RCTs or large meta-analyses of RCTs to discuss the hard end-point outcomes but smaller trials were also included to discuss other outcomes. Operative mortalityThe majority of the large RCTs to date failed to show a difference in early mortality between off-pump and on-pump surgery (1,3,9-13). One small sample size RCT by Fattouch et al. showed a reduced mortality in patients with ST elevation undergoing urgent/emergent off-pump coronary surgery compared to on-pump surgery (14). Deppe et al. in meta-analysis of RCTs on almost 16,900 patients found no difference in 30-day mortality. Kow...

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“…Hence, advanced age and atherosclerosis may be more important determinants of long-term cognitive dysfunction than the type of CABG procedure performed. Recently, Kennedy and coworkers 54 reported their findings on cognitive outcome after on-and offpump CABG in a meta-analysis of 13 randomized, controlled trials involving 2405 patients using 7 psychometric tests. No significant differences were found between on-and off-pump patients in any of the tests after 1 year.…”

Section: Neurological and Cognitive Changesmentioning

confidence: 99%

Should Off-Pump Coronary Artery Bypass Grafting Be Abandoned?

Lazar

2013

Circulation

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406O ne of the most controversial areas of cardiac surgery has been whether off-pump coronary artery bypass graft (OPCAB) surgery is superior to traditional on-pump coronary artery bypass graft (CABG) surgery. On-pump CABG surgery has been an effective, safe, and time-proven technique and is the gold standard with which all other surgical revascularization methods have been compared. However, performing coronary revascularization on cardiopulmonary bypass (CPB) can result in myocardial ischemic injury, neurocognitive deficits, and strokes and activate inflammatory pathways that contribute to pulmonary, renal, and hematologic complications. OPCAB offered a promising alternative strategy that had the potential to decrease perioperative morbidity, mortality, and cost by eliminating CPB. In fact, throughout Asia and particularly in India, 95% of CABG surgery is performed offpump. In North America, OPCAB procedures peaked at 25% in 2004 and have declined steadily since that time.1 It is a more technically demanding procedure and results in less complete revascularization. There is growing concern that OPCAB is associated with reduced long-term graft patency and increased need for revascularization procedures and results in inferior long-term survival compared with traditional on-pump CABG surgery.In view of these concerns, should OPCAB be abandoned? The purpose of this review is to examine clinical data that most accurately compare the advantages and disadvantages of OPCAB to determine what, if any, role it should have in the practice of surgical coronary artery revascularization. To reach these conclusions, retrospective nonrandomized, prospective randomized, and meta-analyses trials will be reviewed. The effect of incomplete revascularization and conversion to conventional CABG will be examined. The relationship between OPCAB and the inflammatory response, neurological and cognitive changes, and quality of life will be studied, and the impact of OPCAB on sex, renal transplant recipients, and elderly patients will be determined. Retrospective StudiesRetrospective studies were largely single center and lacked randomization. Surgeons who were more skilled in OPCAB were more likely to perform these procedures. Hence, there was a significant selection bias. In most studies, the intentionto-treat principle was not honored. Therefore, if a patient was converted to an on-pump CABG, an adverse outcome associated with this patient would be attributed to the on-pump CABG and not the originally planned OPCAB. Earlier studies may have lacked proper stabilizing equipment and intracoronary perfusion devices. Many trials reported only short-term outcomes. The retrospective studies discussed in this section generally involve >1 surgeon, had larger sample sizes to detect statistically significant differences in clinical outcomes, and contained long-term data.One of the largest databases used to compare outcomes between OPCAB and on-pump CABG techniques involved the New York State Registry for CABG Surgery. Racz and coworkers 2 first...

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Cognitive Outcome After On- and Off-Pump Coronary Artery Bypass Grafting Surgery: A Systematic Review and Meta-Analysis

Cited by 49 publications

References 42 publications

A pilot study of cerebral tissue oxygenation and postoperative cognitive dysfunction among patients undergoing coronary artery bypass grafting randomised to surgery with or without cardiopulmonary bypass*

A pilot study of cerebral tissue oxygenation and postoperative cognitive dysfunction among patients undergoing coronary artery bypass grafting randomised to surgery with or without cardiopulmonary bypass*

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

Should Off-Pump Coronary Artery Bypass Grafting Be Abandoned?

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