Off-pump versus on-pump coronary artery bypass grafting surgery in high-risk patients: PRAGUE-6 trial at 30 days and 1 year

Abstract

Aims. Off-pump coronary artery bypass graft surgery (OPCAB) is an established alternative to on-pump surgical revascularization. Previous studies in patients with low or intermediate risk showed no significant differences between off-pump and on-pump surgical revascularization. The aim of this study was to compare the two techniques in patients with high operative risk. Methods. PRAGUE-6 is a prospective randomized single-center study of 206 patients, with an additive EuroSCORE ≥ 6, scheduled for isolated coronary surgery: Group A -on-pump (n = 108) versus Group B -off-pump (n = 98). The primary outcome was a combined endpoint of all-cause deaths, stroke, myocardial infarction, or renal failure requiring new hemodialysis, within 30 days and 1 year after randomization. All data were analyzed using the "intention-to-treat" principle. Results. Early postoperative myocardial infarction was detected in 12.1% (A) vs. 4.1% (B) of patients (P = 0.048, hazard ratio 0.32, 95% CI 0.11-0.99). There was a significantly higher incidence of primary combined end-point in group A (20.6% vs. 9.2%, P = 0.028, HR 0.41, 95% CI 0.19-0.91) in the first 30 days, but not after 1 year (30.8% vs. 21.4%, P = 0.117, HR 0.65, CI 0.37-1.12). Conclusion. Off-pump surgical revascularization in patients with high operative risks can significantly reduce the incidence of major postoperative complications during the first 30 days. There was no statistically significant difference in the incidence of these complications after 1 year.

Outcomes of off-pump versus on-pump coronary artery bypass graft surgery in patients with severely dilated left ventricle

“…To large extent, the surgery reduces the recurrence of myocardial ischemia and the demand of revascularization (2). For elderly patients and patients with diabetes mellitus, renal insufficiency, poor left ventricular ejection fraction (LVEF) (≤35%), peripheral vascular disease, left main CAD and chronic obstructive pulmonary disease (COPD), off-pump coronary artery bypass (OPCAB) grafting is associated with lower operative combination and mortality than on-pump coronary artery bypass (ONCAB) (3)(4)(5)(6). For patients with giant left ventricle, few reports are available (7).…”

Use of OPCAB in Czechia 2010-2015: Have we learned any lessons?

“…Despite a signifi cantly lower incidence of severe post-operative complications after 30 days, the trend was not present after one year. We were not able to demonstrate a clear benefi t for the method even for this narrow group of patients, despite a reduction in some signs of postoperative morbidity [22]. The last two extensive meta-analyses of randomized trials led to somewhat different conclusions.…”

Cirurgia de revascularização do miocárdio com e sem circulação extracorpórea. O que os novos estudos evidenciam?

“…Treze dos trinta e três artigos abordaram o número médio de enxertos que os pacientes receberam durante os procedimentos cirúrgicos e, em todos treze estudos, o número de enxertos foi maior no grupo que realizou o procedimento com circulação extracorpórea, devido a complexidade dos casos, necessidades específicas de cada paciente e maior acessibilidade aos vasos coronarianos (11,12,13,18,21,22,24,27,29,33,38,39,41). Da mesma forma, com relação à necessidade de transfusão sanguínea, o grupo com CEC demandou maior quantidade de transfusões sanguíneas em relação ao grupo sem CEC, um dos motivos seria a hemodiluição que ocorre com o uso da CEC.…”

“…Porém, dos artigos que fizeram esta análise de mortalidade, três estudos verificaram a mortalidade em longo prazo (ao menos 5 anos após a realização da cirurgia) e, nestes estudos, foi constatada uma mortalidade superior no grupo de pacientes que realizaram o procedimento sem CEC (11,28,32). Esta tendência de menor mortalidade a longo prazo observada nos pacientes que realizaram cirurgias com CEC pode estar intimamente relacionada com a quantidade de enxertos realizados nestes pacientes, uma vez que, todos os estudos que analisaram este ponto demonstraram que a quantidade de enxertos foi maior neste grupo de pacientes, ou seja, tiveram uma tendência maior à uma revascularização completa (11,12,13,18,21,22,24,27,29,33,38,39,41). É possível inferir que os pacientes que foram submetidos a CRM sem circulação extracorpórea tiveram uma recuperação pós-operatória mais rápida se for analisado o tempo médio até a extubação, bem como o tempo de estadia na unidade de tratamento intensivo.…”