Off-Pump Coronary Artery Bypass May Increase Late Mortality: A Meta-Analysis of Randomized Trials

Takagi, Hisato; Matsui, Masafumi; Umemoto, Takuya

doi:10.1016/j.athoracsur.2010.03.010

Cited by 61 publications

(42 citation statements)

References 38 publications

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“…[17][18][19][20][21][22][23][24][25][26][27] The findings of these studies are summarized in the following paragraphs.…”

Section: Meta-analysesmentioning

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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“…[17][18][19][20][21][22][23][24][25][26][27] The findings of these studies are summarized in the following paragraphs.…”

Section: Meta-analysesmentioning

confidence: 99%

Should Off-Pump Coronary Artery Bypass Grafting Be Abandoned?

Lazar

2013

Circulation

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“…This attitude is limiting the adoption of off-pump CABG worldwide. Off-pump CABG surgery may be associated with a higher incidence of incomplete revascularization, recurrent angina, and graft occlusion, suggesting poorer graft quality and anastomotic accuracy in some series (6). Whether this is related to the technical expertise of the surgeon for off-pump CABG surgery in these trials is a matter of debate (3)(4)(5).…”

Section: Introductionmentioning

confidence: 99%

Intra-operative Graft Blood Flow Measurements for Composite and Sequential Coronary Artery Bypass Grafting

et al. 2014

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Objectives Intraoperative assessment of coronary artery bypass grafts (CABG) anastomotic quality can be performed using transit-time flowmetry (TTF). The aim of this study was to compare on- versus off-pump coronary graft TTF and early postoperative outcomes. Materials and methods Between January 2009 and January 2010, 521 distal graft flows were assessed using TTF measurements in 253 consecutive patients undergoing primary isolated CABG surgery. Data were analyzed using multilevel models accounting for clustering among surgeons and grafts performed in the same patient. Results Mean age was 66 ± 10 years and 22% were female (n = 55) with 34% diabetics (n = 86) and 40% pre-operative myocardial infarction (MI) (n = 101). The surgeries were performed off-pump in 67% (n = 170) with sequential vein grafts in 57% (n = 144) of patients. Off-pump patients had higher pre-operative left ventricular ejection fractions (LVEF), fewer urgent surgeries, fewer distal anastomoses, and fewer sequential vein grafts (all p<0.001). Intra-operative coronary graft TTF measurements were lower in sequential vein grafts performed off-pump versus on-pump. More patients in the on-pump group needed milrinone or dobutamine 24-48 h postoperatively (p = 0.005). Independent predictors of lower TTF included female gender and off-pump surgery, whereas predictors of better TTF were pre-operative MI, larger coronary diameter at the site of the distal anastomosis, and sequential vein grafting. Conclusions Lower intra-operative TTF measurements were found in sequential vein grafts in offpump CABG. However, off-pump patients experienced similar short-term outcomes compared to on-pump patients.

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“…2,3 Because prolonged cardiopulmonary bypass (CPB) time has been associated with postoperative AKI, some have advocated the use of off-pump coronary artery bypass (OPCAB) techniques for high-risk patients. Although randomized trials of OPCAB have not demonstrated benefits in a general population, 4,5 patients with CKD have composed ,10% of those studied, including ,8% of those in the recent Veterans Affairs Randomized On/Off Bypass (ROOBY) trial. 4 In this analysis, we examined a nationally representative patient cohort who underwent elective, isolated CABG at 1000 centers in the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) to test the following hypotheses: (1) off-pump procedures are associated with a lower incidence of cardiac surgery-associated AKI compared with on-pump CABG, and (2) the degree of renal protection associated with off-pump CABG is directly related to the extent of preoperative renal dysfunction.…”

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confidence: 99%

Off-Pump versus On-Pump Coronary Artery Bypass Grafting Outcomes Stratified by Preoperative Renal Function

Chawla

Zhao

Lough

et al. 2012

Journal of the American Society of Nephrology

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Clinical trials of off-pump coronary artery bypass grafting (CABG) have largely excluded patients with CKD. Here, we sought to determine whether pump status affects outcomes in patients with CKD. Using a nonrandomized cohort of 742,909 non-emergent, isolated CABG cases, which included 158,561 off-pump cases, in the Society of Thoracic Surgery Database from 2004 through 2009, we evaluated the association between pump status (off-pump versus on-pump) and in-hospital death or incident renal replacement therapy (RRT) across strata of preoperative renal function. We used propensity methods to adjust patientand center-level analyses for imbalances in baseline patient risk. Patients who received on-pump and off-pump CABG had similar mean age and distribution of preoperative estimated GFR (eGFR). In a propensity-weighted analysis, off-pump CABG was associated with a reduction in the composite in-hospital death or RRT, with patients having lower preoperative renal function exhibiting greater benefit, on average. The risk difference (on-pump minus off-pump) ranged from 0.05 (95% confidence interval, 20.06 to 0.16) per 100 patients for eGFR $90 ml/min per 1.73 m 2 to 3.66 (95% confidence interval, 2.14-5.18) per 100 patients for eGFR 15-29 ml/min per 1.73 m 2 . Both component endpoints suggested the same trend. In summary, these data suggest that patients with CKD experience less death or incident RRT when treated with off-pump compared with on-pump CABG. The reduction in incident RRT, not death, drove this effect on the composite among patients with low eGFR. Prospective trials comparing these procedures in patients with impaired preoperative renal function are warranted.

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Off-Pump Coronary Artery Bypass May Increase Late Mortality: A Meta-Analysis of Randomized Trials

Cited by 61 publications

References 38 publications

Should Off-Pump Coronary Artery Bypass Grafting Be Abandoned?

Should Off-Pump Coronary Artery Bypass Grafting Be Abandoned?

Intra-operative Graft Blood Flow Measurements for Composite and Sequential Coronary Artery Bypass Grafting

Off-Pump versus On-Pump Coronary Artery Bypass Grafting Outcomes Stratified by Preoperative Renal Function

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