Effect of avoiding cardiopulmonary bypass in non-elective coronary artery bypass surgery: a propensity score analysis

Karthik, Shishir; Musleh, Ghassan; Grayson, Antony D.; Keenan, Daniel; Hasan, Ragheb; Pullan, D. Mark; Dihmis, Walid C.; Fabri, Brian M.

doi:10.1016/s1010-7940(03)00255-0

Cited by 29 publications

(27 citation statements)

References 19 publications

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“…Exclusion of these five studies from the analysis resulted in a calculated OR for incidence of AF of 0.81 (95% CI 0.63 -1.03), with heterogeneity of 9.67 ðP ¼ 0:29Þ: Similarly, cold blood cardioplegia was not used in four studies [21,22,29,30] and not reported in one study [33]. When we excluded these five studies from the analysis the calculated OR for incidence of AF changed to 0.59 (95% CI 0.41-0.83), with heterogeneity of 29.06 ðP ¼ 0:0003Þ: Retrograde cardioplegia was used in four studies [23,24,26,32,33] and was not reported in one [33]. On exclusion of these five studies from the analysis the calculated OR for incidence of AF changed to 0.61 (95% CI 0.45-0.84), with heterogeneity of 17.79 ðP ¼ 0:02Þ: Inclusion criteria: 1, informed consent; 2, elective CABG; 3, severe obstructive pulmonary disease; 4, normal ejection fraction; 5, multi-vessel disease; 6, no diffuse coronary disease; 7, no ventricular hypertrophy; 8, no cardiac enlargement; 9, low risk patients; 10, no significant renal dysfunction; 11, LAD lesion equal or more than 70%; 12, associated lesion in the RCA; 13, vessel size .1.2 mm; 14, absence of diffuse coronary disease; 15, stable angina pectoris; 16, moderate ventricular function; 17, non-elective cases.…”

Section: Sensitivity Analysis Resultsmentioning

confidence: 99%

“…It is important to recognise that two studies selected for our analysis caused significant heterogeneity in our results [25,32]. The first of these reported a significantly higher incidence of post-operative AF in the CPB group (49%) as compared to OPCAB (14%) [25].…”

Section: Discussionmentioning

confidence: 97%

“…When considering the other risk factors for post-operative AF, the incidence of pre-operative hypertension was not comparable between the two groups in two studies [25,32], ejection fraction in one study [32] and extent of coronary disease in one study [32]. Re-do operations were included in only three studies [30,32,34]. One study defined the outcome of interest as atrial arrhythmia [32], whereas in the remainder atrial fibrillation was clearly stated.…”

Section: Selected Studiesmentioning

confidence: 99%

“…Re-do operations were included in only three studies [30,32,34]. One study defined the outcome of interest as atrial arrhythmia [32], whereas in the remainder atrial fibrillation was clearly stated.…”

Section: Selected Studiesmentioning

confidence: 99%

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Does off-pump coronary artery bypass reduce the incidence of post-operative atrial fibrillation? A question revisited

Athanasiou¹

2004

European Journal of Cardio-Thoracic Surgery

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Atrial fibrillation (AF) is the most common post-operative complication in patients undergoing coronary artery bypass grafting, with an increased incidence associated with advancing age. This study aims to determine whether off-pump coronary artery bypass (OPCAB) reduces the incidence of AF in a generalized population (mean age <70 years). A meta-analysis was performed including all randomised and propensity score matched non-randomised studies published between 2001 and 2003 reporting a comparison between the two techniques in a generalised patient group (average age <70 years). The primary outcome of interest was post-operative AF. Sensitivity analysis was performed to evaluate consistency of the calculated treatment effect. Fourteen studies fulfilled our inclusion criteria, including a total of 16,505 subjects. The incidence of AF was 19% (1612/8265) in the off-pump group versus 24% (1976/8240) in the on-pump group. When considering only the 11 randomised studies (2207 subjects), we found a significant reduction in the incidence of post-operative AF in the off-pump group using a random-effect model (odds ratio (OR)=0.60, 95% confidence interval (CI)=0.45-0.82, and chi-square of heterogeneity=18.02, P=0.05). Sensitivity analysis highlighted one randomised study causing funnel plot asymmetry, exclusion of which resulted in a significant reduction in the incidence of post-operative AF in the off-pump group (OR=0.71, 95% CI=0.57-0.90), with a non-significant heterogeneity of 3.91 (P=0.92). When only studies of high quality were considered (898 patients), no significant difference was seen between on and off-pump groups (OR=0.78, 95% CI=0.57-1.07, and heterogeneity=0.53, P=0.91). This may be due to small number of patients in this group. Our results suggest that although OPCAB surgery may reduce the incidence of post-operative AF in a generalised population (age <70 years) this finding is not clearly supported by high quality randomised trials. Although previous evidence suggests that the incidence of post-operative AF is reduced in an elderly population (>70 years) with off-pump surgery, our results show that the evidence is less clear in a younger population group. The question of whether off-pump surgery in this patient group results in a lower rate of post-operative AF remains to be answered by further high quality randomised research.

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Section: Sensitivity Analysis Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 97%

Section: Selected Studiesmentioning

confidence: 99%

Section: Selected Studiesmentioning

confidence: 99%

See 2 more Smart Citations

Does off-pump coronary artery bypass reduce the incidence of post-operative atrial fibrillation? A question revisited

Athanasiou¹

2004

European Journal of Cardio-Thoracic Surgery

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“…Another case-controlled trial found that serum Cr levels were significantly lower and CrCl was significantly higher in the off-pump group compared to the on-pump group [16]. Karthik et al [17] constructed a propensity score for risk-adjusted comparison of patients undergoing nonelective on- and off-pump CABG. The incidence of renal impairment, as assessed by an increase in Cr level >1.5 mg/ml, was significantly higher in the on-pump group.…”

Section: Discussionmentioning

confidence: 99%

On- versus Off-Pump Coronary Artery Bypass Grafting: No Difference in Early Postoperative Kidney Function Based on TNF-α or C-Reactive Protein

Nezami

Djavadzadegan²,

Tabatabaie-Adl³

et al. 2012

Cardiorenal Med

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Background/Aims: There are controversial data about renal function following off-pump coronary artery bypass grafting (CABG). The present study aimed to evaluate renal function changes 24 h after on- and off-pump CABG, as well as renal function correlated with high-sensitivity C-reactive protein (hs-CRP) and tumor necrosis factor-α (TNF-α). Methods: Ninety patients with coronary artery disease referred to our center for CABG from July 2006 to November 2007 were enrolled in the study. Patients were equally and randomly divided in two groups, on- and off-pump. Serum levels of creatinine (Cr), blood urea nitrogen, creatinine clearance (CrCl), hs-CRP, and TNF-α were determined immediately before and 24 h after surgery. Results: Cr and CrCl changes after surgery were not significantly different between the two groups; however, blood urea nitrogen levels after surgery were significantly higher in the on-pump group (p = 0.035). No statistically significant difference was noted between the two groups in terms of changes in levels of hs-CRP and TNF-α (p = 0.350 and 0.805, respectively). The changes in CrCl levels had no significant correlation with hs-CRP and TNF-α. Conclusions: The early Cr and CrCl levels after surgery are not significantly different in on- and off-pump groups. The early renal function after on- or off-pump CABG is not correlated with the levels of inflammatory markers including hs-CRP and TNF-α.

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Chirurgische Koronarrevaskularisation am schlagenden Herzen

Rastan

Walther

Falk³

et al. 2007

Herz

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Since the introduction of off-pump coronary artery bypass grafting (OPCAB) for coronary multivessel disease there was growing interest to evaluate the impact of OPCAB surgery compared to conventional coronary artery bypass grafting (CCAB) with cardiopulmonary bypass and cardioplegic arrest. However, subsequent prospective randomized studies and meta-analyses comparing OPCAB and CCAB surgery were performed on low-risk patients or mixed-risk populations. They usually failed to demonstrate a significant benefit of OPCAB surgery on early mortality or perioperative major cardiac and cerebrovascular events. In recent years, efforts were made to analyze the meaning of beating-heart concepts for patients with specific cardiac and extracardiac risks like ischemic cardiomyopathy, older age, renal failure, acute coronary syndrome, left main stenosis and others. For these subsets of patients several mono- and multicenter studies are available today. Even if most of them were nonrandomized and thus failed to reach evidence level A according to the AHA/ACC (American Heart Association/American College of Cardiology) definition, they still allow analyzing interim results for each specific perioperative risk factor. Particularly multi-risk patients and patients with severely reduced left ventricular function seem to benefit in terms of perioperative mortality and major morbidity by avoiding cardiopulmonary bypass and cardioplegic arrest. Analyzing early results and long-term follow-up of 364 patients with severely reduced ejection fraction<20%, the authors found a long-term benefit for patients when using OPCAB strategies particularly due to reduced perioperative mortality. Moreover, for most subsets of patients with significant extracardiac risk factors the incidence or perioperative stroke was reduced. In patients with preoperative renal and pulmonary dysfunction a decrease of corresponding organ failure was found for OPCAB strategy. For most risk populations transfusion requirements were significantly lower in OPCAB compared to CCAB surgery. In none of the patients an unfavorable outcome of beating-heart surgery compared to CCAB was shown. For emergency patients with an acute coronary syndrome presenting stable and unstable hemodynamics the authors found a clinical benefit by using beating-heart strategies. Particularly in patients with cardiogenic shock, cardiopulmonary bypass was often required to guarantee adequate perioperative organ perfusion. However, these patients seemed to benefit from avoiding global cardiac ischemia and maintaining native coronary blood flow. Follow-up results were comparable for these patients. In conclusion, beating-heart coronary artery bypass grafting seems to be advantageous in various risk populations and should be considered for patients with more than average risks for cardiopulmonary bypass and cardioplegic arrest.

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Effect of avoiding cardiopulmonary bypass in non-elective coronary artery bypass surgery: a propensity score analysis

Abstract: In this experience, off-pump coronary surgery in non-elective patients is safe with acceptable results. Non-elective off-pump patients have a significantly reduced incidence of renal failure, and shorter post-operative stays compared to on-pump coronary artery bypass surgery.

Cited by 29 publications

References 19 publications

Does off-pump coronary artery bypass reduce the incidence of post-operative atrial fibrillation? A question revisited

Does off-pump coronary artery bypass reduce the incidence of post-operative atrial fibrillation? A question revisited

On- versus Off-Pump Coronary Artery Bypass Grafting: No Difference in Early Postoperative Kidney Function Based on TNF-α or C-Reactive Protein

Chirurgische Koronarrevaskularisation am schlagenden Herzen

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