Early and mid-term impacts of cardiopulmonary bypass on coronary artery bypass grafting in patients with poor left ventricular dysfunction: a propensity score analysis.

BACKGROUND: Cardiopulmonary bypass may exacerbate myocardial damage in compromised left ventricles. Early and mid-term outcomes of off-pump coronary artery bypass grafting (OPCAB) vs on-pump coronary artery bypass grafting (On-pump CABG) were compared in patients with poor left ventricular dysfunction, using an analysis of a propensity score matching. METHODS AND RESULTS: Between December 2000 and November 2005, 1,473 patients underwent isolated coronary artery bypass grafting in our institute and 153 patients who had a left ventricular ejection fraction (LVEF) lower than 35% were enrolled. The OPCAB group contained 100 patients and the On-pump CABG group contained 53 patients. Preoperative risk factors were compared and 50 patients in each group were matched. The mean follow-up time was 35.5+/-17.3 months. Three deaths (3.0%) occurred in the matched cohort, with no significant difference between 2 groups. The operation time, ventilation time, intensive care unit admission time and occurrence of respiratory failure were significantly lower in the OPCAB group. The mean LVEF of the 2 groups improved significantly. The overall 6-year actuarial survival rates of the OPCAB and On-pump CABG group were 88.2% and 72.4% (p=0.2), respectively, and there were no significant differences in 6-year rates of freedom from major adverse cardiac and cerebrovascular events (p=0.97). CONCLUSIONS: Coronary artery bypass grafting in patients with poor left ventricular dysfunction improved myocardial function. Postoperative respiratory failure was significantly related to the cardiopulmonary bypass for surgical myocardial revascularization. Off-pump and On-pump surgical revascularization resulted in equivalent mid-term outcomes.     

Pulmonary outcomes of off-pump vs on-pump coronary artery bypass surgery in a randomized trial

STUDY OBJECTIVES: Comparison of pulmonary outcomes after off-pump coronary artery bypass (OPCAB) vs on-pump coronary artery grafting with cardiopulmonary bypass (CABG/CPB).Study design: We examined preoperative and postoperative respiratory compliance, fluid balance, hemodynamics, arterial blood gases, chest radiographs, spirometry, pulmonary complications, and time to extubation in a prospective trial of 200 patients randomized to OPCAB vs CABG/CPB performed by one surgeon. RESULTS: One CABG/CPB patient and two OPCAB patients required mitral valve repair or replacement and were withdrawn. After three crossovers from CABG/CBP to OPCAB and one crossover from OPCAB to CABG, 97 CABG/CPB patients and 100 OPCAB patients remained. There were no significant preoperative demographic differences between groups. Postoperative compliance was reduced more after OPCAB than after CABG/CPB (- 15.4 +/- 10.7 mL/cm H(2)O vs - 11.2 +/- 10.1 mL/cm H(2)O [mean +/- SD]; p = 0.007), associated with rotation of the heart into the right chest to perform posterolateral bypasses (p < 0.001) and the concomitant increased fluid requirements necessary to maintain hemodynamic stability during rotation of the heart. In addition to higher intraoperative fluid intake (4,541 +/- 1,311 mL vs 3,585 +/- 1,033 mL, p < 0.0001), OPCAB patients had higher intraoperative fluid balance (3,903 +/- 1,315 mL vs 1,772 +/- 1,373 mL, p < 0.0001), and higher postoperative pulmonary arterial diastolic pressure (15.0 +/- 5.5 mm Hg vs 11.8 +/- 5.2 mm Hg, p < 0.0001) and central venous pressure (10.4 +/- 4.5 mm Hg vs 8.4 +/- 4.7 mm Hg, p < 0.0001). Despite lower compliance, immediate postoperative Pao(2) on fraction of inspired oxygen of 1.0 (275 +/- 97 torr vs 221 +/- 92 torr, p = 0.001) was higher after OPCAB and extubation was earlier (p = 0.001). Postoperative chest radiographs, spirometry, mortality, reintubation, or readmission for pulmonary complications were not different between groups. CONCLUSIONS: Compared to CABG/CPB, OPCAB was associated with a greater reduction in postoperative respiratory compliance associated with increased fluid administration and rotation of the heart into the right chest to perform posterolateral grafts. OPCAB yielded better gas exchange and earlier extubation but no difference in chest radiographs, spirometry, or rates of death, pneumonia, pleural effusion, or pulmonary edema.     

Improvement in diastolic left ventricular function after coronary artery bypass grafting as assessed by recordings of mitral annular velocity using Doppler tissue imaging.

AIMS: The aim of the study was to evaluate the changes in diastolic function after coronary artery bypass grafting (CABG), using pulsed-wave Doppler tissue imaging (DTI). METHODS: Fifty-three patients with coronary artery disease were studied before and 3 and 12 months after CABG. Using pulsed-wave DTI, the mitral annular velocities were determined at 4 sites in the left ventricle (LV). Patients were also examined with dobutamine stress echocardiography and myocardial scintigraphy before and 3 months after CABG. RESULTS: The conventional transmitral velocity profiles were unchanged after CABG. DTI showed a marked improvement in diastolic LV function after CABG (early diastolic velocity: 7.5+/-1.9, 8.2+/-1.7 and 9.3+/-2.7 cm/s before and 3 and 12 months after CABG, respectively, P < 0.01). The improvement in early diastolic velocity was more pronounced in patients showing no sign of residual ischemia in comparison to those with residual ischemia determined by myocardial scintigraphy (7.41+/-2.04 vs. 9.25+/-2.61 cm/s, P < 0.01 in the nonischemic group; 7.29+/-2.16 vs. 8.41+/-2.55 cm/s, n.s., in the ischemic group). Before CABG, a significant increase in the systolic velocity (6.4+/-1.3 vs. 8.7+/-2.5 cm/s, P < 0.001), but not the early diastolic velocity (7.6+/-1.9 vs. 8.0+/-2.2 cm/s), was noted during stress echocardiography. Three months after CABG, both the systolic (6.5+/-1.3 vs. 9.3+/-2.8 cm/s, P < 0.001) and the early diastolic velocities (8.1+/-1.8 vs. 10.3+/-2.2 cm/s, P < 0.001) improved during stress echocardiography. CONCLUSION: The results of the present study show that diastolic function improves at rest and under stress in patients after CABG. The improvement was seen only in patients without postoperative signs of reversible ischemia.     

Mortality and Readmissions After On-Pump Versus Off-Pump Redo Coronary Artery Bypass Surgery

IntroductionLarge institutional and administrative datasets that have compared on pump versus off pump first time coronary artery bypass grafting (CABG). However, comparison of off-pump vs on-pump outcomes in patients undergoing redo CABG are limited in current literature.MethodsAll patients who underwent redo CABG for coronary artery disease from 2011 to 2017 at our institution were included in the study. Cox regression analysis was performed to identify variables associated with 5-year mortality and readmission.ResultsThree hundred and fifty patients underwent redo CABG; of which, 309 underwent on-pump CABG and 41 underwent off-pump CABG. Blood product transfusion (31.7% vs 58.9%; p = 0.001) and new onset atrial fibrillation (17.1% vs 35.6%; p = 0.018) were higher in the on-pump cohort. There was no difference in 30-day (2.4% vs 8.1%; p = 0.209), 1-year (4.9% vs 16.5%; p = 0.074), or 5-year mortality (31.7% vs 35.6%; p = 0.213) for off vs on pump redo CABG. There was no difference in 30-day or 1- hospital readmissions between groups. Five-year all cause readmissions (76.9% vs 55.3%; p = 0.037) was significantly higher in the off-pump redo CABG group. On multivariable analysis, on vs. off pump CABG was not significantly associated with mortality or readmission at 5 years.ConclusionThere was no short or long-term survival advantage for on-pump vs off-pump CABG despite risk adjustment. Hospital readmissions at 5-years were higher in the off-pump group.     

Does Totally Endoscopic Access for Off-pump Cardiac Surgery Influence the Incidence of Postoperative Atrial Fibrillation in Coronary Artery Bypass Grafting? A Preliminary Report

Background The occurrence rate of atrial fibrillation (AF) after coronary artery bypass grafting, quoted in the literature, is wide ranging from 5% to over 40%. It is speculated that, off-pump coronary artery bypass grafting (OPCAB) and also minimally invasive cardiac surgery reduces the incidence of postoperative AF due to reduced trauma, ischemia, and inflammation. Current data, however, do not clearly answer the question, whether the incidence of postoperative AF is reduced in using minimally invasive techniques, ideally resulting in the combination of both small access and off-pump surgery. The aim of this study was to evaluate the incidence of postoperative AF in patients undergoing totally endoscopic off-pump coronary artery bypass grafting (TECAB).Methods A retrospective analysis of 72 patients undergoing myocardial revascularization was performed. Early postoperative incidence of AF was compared between three groups of patients: 24 after conventional coronary artery bypass grafting (CABG), 24 after OPCAB, and 24 after totally endoscopic off-pump CABG. Clinical profile of the patients, including factors having potential influence on postoperative AF was matched for groups.Results Postoperative AF occurred in 25% of the patients in the CABG group, in 16% of the patients in the OPCAB group, and in 16% of the patients in the TECAB group. This difference has no statistical significance. Risk factors and incidence of postoperative complications were comparable in all groups excepting the number of distal anastomoses. There was a statistical significance between CABG group and TECAB group.Conclusion Avoiding cardiopulmonary bypass and minimizing surgical trauma did not reduce the incidence of postoperative AF in this patient collective. It remains an attractive hypothesis that postoperative AF is reduced by off-pump myocardial revascularisation and minimizing surgical trauma but more robust data are required.     

Coronary artery bypass performed without the use of cardiopulmonary bypass is associated with reduced cerebral microemboli and improved clinical results

STUDY OBJECTIVES: Strokes and neurocognitive dysfunction have been correlated with cerebral microemboli produced during cardiopulmonary bypass (CPB). The purpose of this study was to determine whether, and to what extent, off-pump coronary artery bypass (OPCAB) reduces the occurrence of cerebral microemboli compared with traditional coronary artery bypass grafting (CABG) with CPB and to compare clinical results. DESIGN AND PATIENTS: A retrospective review of 137 patients undergoing elective CABG was performed, 70 of whom underwent traditional CABG and 67 of whom underwent OPCAB. Using transcranial Doppler ultrasonography, 40 patients (20 CABG, 20 OPCAB) were continuously monitored intraoperatively for the occurrence and pattern of cerebral microemboli. SETTING: Private, university-affiliated tertiary care hospitals. RESULTS: There was no statistical difference in the age, sex, or underlying comorbidities between those patients undergoing CABG and OPCAB. CABG patients did have a slightly lower preoperative ejection fraction (50.9% vs 55.5%, p = 0.03). Despite these similar preoperative characteristics, the OPCAB group experienced significant reductions in cerebral microemboli (27 vs 1,766, p = 0.003), transfusion requirements (29.9% vs 47.1%, p = 0.04), intubation time (3.3 vs 9.5 h, p < 0.001), ICU length of stay (1.5 vs 2.8 days, p = 0.02), and overall hospitalization (4.9 vs 6.6 days, p = 0.01) without an increase in mortality. Fewer strokes and deaths were observed in the OPCAB group, but these trends failed to reach statistical significance. CONCLUSIONS: In similar patient populations, OPCAB was associated with significantly fewer cerebral microemboli and improved clinical results without an increase in mortality. We believe that these early results support OPCAB as a viable and potentially safer alternative to traditional CABG.     

Performance of EuroSCORE in CABG and off-pump coronary artery bypass grafting: single institution experience and meta-analysis

Aims: To assess EuroSCORE performance in predicting in-hospital mortalityin on-pump coronary artery bypass grafting (CABG) and off-pumpcoronary artery bypass grafting (OPCAB). Methods and results: Additive and logistic EuroSCORE were computed for consecutivepatients undergoing CABG (n = 3440, 75%) or OPCAB (n = 1140,25%) at our hospital from 1999 to September 2007. The areasunder the receiver operating characteristic (ROC) curves (AUCs)were used to describe performance and accuracy. No differencein performance between CABG and OPCAB and between additive andlogistic EuroSCORE (additive EuroSCORE AUCs of 0.808 and 0.779for CABG and OPCAB, respectively; logistic EuroSCORE AUCs of0.813 and of 0.773 for CABG and OPCAB, respectively) was found,although a marked tendency to overpredict mortality by bothmodels was evident. A meta-analysis of previously publisheddata was done, and a total of eight studies representing 19212 and 5461 patients undergoing CABG and OPCAB, respectively,met inclusion criteria. Meta-analysis confirmed similar performanceof EuroSCORE in CABG and OPCAB: estimated AUCs were 0.767 and0.766 for CABG and OPCAB, respectively, with an estimated differenceof 0.001 (95% CI –0.061 to 0.063). Conclusion: Additive and logistic EuroSCORE algorithms performed similarly,and cumulative evidence suggests comparable performance in CABGand OPCAB procedures; both risk models, however, significantlyoverestimated mortality.     

Comparison of long-term outcome of off-pump coronary artery bypass grafting versus drug-eluting stents in triple-vessel coronary artery disease

After the introduction of drug-eluting stents (DESs), percutaneous coronary intervention with DESs has challenged coronary artery bypass grafting as the gold standard for the treatment of 3-vessel coronary artery disease. The purpose of this study was to compare the long-term clinical results between percutaneous coronary intervention with DESs and off-pump coronary artery bypass grafting (OPCAB) in 3-vessel coronary artery disease. Two hundred ninety propensity-score matched patients with 3-vessel coronary artery disease treated by DESs or OPCAB were included. Mean follow-up duration was 58.8 ± 11.5 months (2 to 73) and follow-up rate was 97.9%. Five-year survival rates were 94.8 ± 2.1% in the DES group and 96.5 ± 1.5% in the OPCAB group (p = 0.658). Five-year rates of freedom from major adverse cardiac and cerebrovascular event were 71.6 ± 4.1% in the DES group and 89.6 ± 2.5% in the OPCAB group (p < 0.001). Freedom from nonfatal myocardial infarction and target vessel revascularization rates were the determining factors between the 2 groups (p = 0.018 and p < 0.001, respectively). The OPCAB group showed better clinical outcomes compared to the DES group in 3-vessel coronary artery disease after 5-year follow-up. Freedom from major adverse cardiac and cerebrovascular event rate was significantly higher in the OPCAB group mainly because of the lower incidence of target vessel revascularization and nonfatal myocardial infarction. Longer follow-up with randomization will clarify our present conclusions.     

Beating heart coronary artery bypass grafting: technical aspects and results in 200 patients.

OBJECTIVE: To describe the initial experience of the first 200 patients who underwent coronary artery bypass grafting (CABG) on beating hearts at the Montreal Heart Institute, Montreal. DESIGN: A prospective cohort of 200 patients was analyzed to study immediate and short term (two-year follow-up) results. SETTING: Patients underwent CABG at the Montreal Heart Institute from February 1996 to June 1998. The first 30 patients underwent CABG without the use of a myocardial wall stabilizer (group 1), and a myocardial wall stabilizer was used in the following 170 patients (group 2). PATIENTS: Group 1 patients averaged 60+/-10 years of age compared with 66+/-10 years in group 2 (P=0.002). Twelve patients (40%) in group 1 had unstable angina compared with 107 patients (63%) in group 2 (P=0.03). INTERVENTIONS: Group 1 patients underwent 1.7+/-0.7 CABG per patient compared with 2.4+/-0.8 grafts per patient in group 2 (P=0.001). Sixty-seven patients (39%) in group 2 had an obtuse marginal coronary artery grafted, and 145 patients (73%) of both groups had a complete myocardial revascularization. RESULTS: Ten patients (5%) in both groups were converted to cardiopulmonary bypass during surgery. Seven patients (3.5%) died postoperatively: five from myocardial infarction, one from aortic dissection and rupture, and one from arrhythmia. Seventeen patients (8.5%) suffered a perioperative myocardial infarction. In groups 1 and 2, respectively, actuarial survival was 100% and 95+/-2%, and freedom rate from reoperation, percutaneous balloon dilation and recurrent myocardial infarction averaged 93+/-4% and 97+/-2% 18 months following CABG. CONCLUSION: CABG on beating hearts appears to be an alternative approach to the use of cardiopulmonary bypass in selected patients.     

Coronary artery bypass surgery versus percutaneous coronary intervention with drug-eluting stent implantation in patients with multivessel coronary disease

BACKGROUND: Drug-eluting stents (DES) constitute a major breakthrough in restenosis prevention after percutaneous coronary intervention (PCI). This study compared the clinical outcomes of PCI using DES versus coronary artery bypass graft (CABG) in patients with multivessel coronary artery disease (MVD) in real-world. METHODS: From January 2003 to December 2004, 466 consecutive patients with MVD underwent revascularization, 235 by PCI with DES and 231 by CABG. The study end-point was the incidence of major adverse cardiovascular events (MACEs) at the first 30 days after procedure and during follow-up. RESULTS: Most preoperative characteristics were similar in the two groups, but left main disease (24.7% vs 2.6%, P<0.001) and three-vessel disease (65% vs 54%, P = 0.02) were more prevalent in CABG group. The number of coronary lesions was also greater in CABG group (3.7 +/- 1.1 vs 3.3 +/- 1.1, P<0.001). Despite higher early morbidity (3.9% vs 0.8%, P = 0.03) associated with CABG, there were no significant differences in composite MACEs at the first 30 days between the two groups. During follow-up (mean 25+/-8 months), the incidence of death, myocardial infarction, or cerebrovascular event was similar in both groups (PCI 6.3% vs CABG 5.6%, P = 0.84). However, bypass surgery still afforded a lower need for repeat revascularization (2.8% vs 10.4%, p = 0.001). Consequently, overall MACE rate (14.5% vs 7.9%, P = 0.03) remained higher after PCI. CONCLUSION: PCI with DES is a safe and feasible alternative to CABG for selected patients with MVD. The reintervention gap was further narrowed in the era of DES. Aside from restenosis, progression of disease needs to receive substantial emphasis.     

Beating heart versus conventional reoperative coronary artery bypass surgery

BACKGROUND: The incidence of reoperative coronary artery bypass grafting is increasing with an increase in the number of patients undergoing coronary artery bypass surgery. The clinical outcome of redo coronary artery bypass grafting without cardiopulmonary bypass and conventional coronary artery bypass grafting using cardiopulmonary bypass are different. METHODS AND RESULTS: We compared clinical parameters in patients who underwent off-pump (n=156) versus on-pump (n=194) redo coronary artery bypass grafting performed between January 1995 and December 2001 in our institute, to determine if off-pump surgery has improved the surgical outcome of redo coronary artery bypass grafting and emerged as an ideal technique. Patients who underwent on-pump redo surgery required more postoperative blood transfusion (86.53% on-pump v. 12.82% off-pump. p=0.001), prolonged ventilatory support (>24 hours) (16.49% on-pump v. 7.7% off-pump, p=0.021) and higher inotropic support (23.71% on-pump v. 10.89% off-pump, p=0.003). On-pump redo coronary artery bypass grafting was also associated with a prolonged stay in the intensive care unit (40+/-6.2 hours on-pump v. 20+/-4.1 hours off-pump, p=0.001) and longer hospital stay (9+/-4.2 days on-pump v. 5+/-3.4 days off-pump, p=0.001). In-hospital mortality was higher in on-pump patients than in off-pump ones (7.7% v. 3.2%); however, this was not statistically significant (p=0.114). CONCLUSIONS: Off-pump redo coronary artery bypass grafting is a safe method of myocardial revascularization with lower operative morbidity and mortality, less requirement of blood products and early hospital discharge, compared with conventional on-pump redo coronary artery bypass grafting.     

The early outcome in patients undergoing off-pump coronary artery bypass grafting: our experience.

BACKGROUND: Many studies confirm that beating heart surgery is an alternative to on-pump myocardial revascularization. However, the clinical conditions of patients are currently considered as a major landmark in the indication for beating heart surgery. This retrospective non-randomized study was carried out to evaluate the efficacy and the advantages of this surgical technique when anatomical criteria are used to choose the surgical strategy. METHODS: From February to December 2003, 222 consecutive patients underwent isolated myocardial revascularization: 76 (34%) with an off-pump coronary artery bypass (OPCAB) and 146 (66%) with an on-pump coronary artery bypass (ONCAB) procedure. Selection for surgical treatment was based on coronary anatomy. All patients were stratified for mortality risk class according to the EuroSCORE system. Operative and postoperative data were analyzed. RESULTS: Morbidity and mortality did not differ significantly between the two groups but the release of creatine kinase-MB fraction was significantly higher in the ONCAB group (48.7 +/- 55.3 vs 20.8 +/- 16.6 U/ml, p < 0.001). Patients at high surgical risk were dealt with a more complicated clinical outcome; logistic regression analysis showed that this class was an independent risk factor for postoperative complications in both groups. CONCLUSIONS: We did not find any statistical difference in hospital mortality and morbidity either using ONCAB or OPCAB; however a lower release of creatine kinase-MB in beating heart revascularization group suggests that OPCAB reduces myocardial injury and preserves cardiac function when anatomical criteria are considered for patient selection.     

Complete arterial coronary artery bypass grafting versus conventional revascularization--early results

BACKGROUND: Complete arterial coronary artery bypass grafting (CABG) offers the potential to improve long-term results. However, an increased perioperative risk has been controversially discussed. New operative techniques (skeletonization of the ITA/ T-grafts/utilization of the radial artery (RA)) may decrease perioperative risk. We compared the outcome after conventional with that after complete arterial CABG. MATERIAL AND METHODS: Three consecutive groups of patients were analyzed. In group I (n = 50), CABG was performed using left ITA and vein grafts. The other two groups received complete arterial CABG with either both ITA's (group II; n = 52) or left ITA and RA (group III; n = 52). RESULTS: A mean of 3.9+/-0.8 (I) versus 4.2+/-0.8 (II) and 3.9+/-0.9 (III) anastomoses were performed per patient (ns). Mean operating time was significantly prolonged in group II (II: 252+/-54; p<0.0001; vs. I: 191+/-36; III: 203+/-33). Mean ischemic time was significantly prolonged in group II and III (II:65+/-20; p<0.0001; III: 68+/-16; p<0.0001; vs. I: 51+/-15). Mean bypass time (I: 83+/-23; II: 95+/-41; III: 91+/-21), the rate of postoperative complications and in-hospital mortality (I: n = 0; II: n = 2; III: n = 0; ns) showed no significant differences. Conclusions: Complete arterial CABG using modern surgical techniques is as safe as the conventional surgical approach using left ITA and vein graft.     

Myocardial injury in coronary artery bypass grafting: On-pump versus off-pump comparison by measuring heart-type fatty-acid-binding protein release

This prospective study uses heart-type fatty-acid-binding protein (hFABP) and creatine kinase-MB (CK-MB) release to compare myocardial injury in on-pump versus off-pump coronary artery bypass grafting (CABG). Fifty patients were randomly assigned to on-pump or off-pump CABG. The hFABP and CK-MB concentrations were measured in serial venous blood samples drawn before heparinization in both groups and after aortic unclamping at 1, 2, 4, 8, 24, 48, and 72 hours in the on-pump group. In the off-pump group, samples were taken after the last distal anastomosis at the same time intervals as in the on-pump group. The total amount of hFABP and CK-MB released was significantly higher in the on-pump than in the off-pump group (hFABP = 100.43 +/- 77.63 vs 3.94 +/- 0.36 ng/mL, P < 0.0001; CK-MB = 33.33 +/- 3.81 vs 28.65 +/- 3.91 log units, P < 0.001). In all patients, hFABP levels peaked as early as 1 hour after declamping (on-pump group) or 2 hours after the last distal anastomosis (off-pump group), whereas CK-MB peaked only at 4 hours after declamping (on-pump group) or 24 hours after the last distal anastomosis (off-pump group). The lower release of hFABP and CK-MB in the off-pump CABG group indicates that on-pump CABG with cardioplegic arrest causes more myocardial damage than does off-pump CABG. Heart-type fatty-acid-binding protein is a more rapid marker of perioperative myocardial damage, peaks earlier than CK-MB, and may predict the requirement for intensive monitoring for postoperative myocardial infarction.     

Hospital and mid-term outcomes in elderly patients under-going off-pump coronary artery bypass grafting--comparison with younger patients--.

BACKGROUND: Clinical outcomes and problems following off-pump coronary artery bypass grafting (OPCAB) in elderly patients have not been clarified. METHODS AND RESULTS: The surgical results of elderly patients aged 75 years or older (n=50; 38 males, mean age, 78.8 years) were reviewed and compared with those of younger patients (n=95; 79 males, mean age, 63.0 years). The EuroSCORE score was 6.9+/-3.5 in the elderly group and 3.0+/-2.4 in the younger group (p<0.0001). There were no hospital deaths in either group. There was no significant difference in the postoperative complication rate except for atrial fibrillation (40.0% elderly vs 24.2% younger, p=0.0479). Postoperative intensive care unit and hospital stays did not differ. The frequency of blood transfusion was significantly higher in the elderly group (78.0% elderly vs 37.2% younger, p<0.0001). During the mean follow-up of 18.6+/-8.8 months, there was 1 sudden death in the elderly group, but no cardiac deaths in either group. The 32-month cardiac event-free and survival rates were similar for the 2 groups. CONCLUSION: OPCAB provides satisfactory clinical outcomes for elderly as well as younger patients.     

The impact of coronary revascularization on long-term outcomes after surgical repair of abdominal aortic aneurysm]

BACKGROUND: Complications due to undetectable coronary artery disease are the major causes of morbidity and mortality in the surgical treatment of abdominal aortic aneurysm (AAA). The aim of our study was to evaluate the importance of significant coronary artery disease identification and the impact of coronary revascularization on early and late outcomes after surgical repair of AAA. METHODS: Between January 1994 and July 2004, 210 patients (204 males and 6 females, mean age 68 +/- 12 years) were candidates to elective surgical repair of AAA. Coronary angiography was performed in 122 patients (58%) in presence of angina symptoms, previous myocardial infarction, echocardiographic or scinti-scan evidence of myocardial ischemia. Coronary revascularization was performed in 83 patients (39.5%). The population was divided into two groups: coronary artery bypass graft/coronary angioplasty (CABG/PTCA) + AAA group (83 patients submitted to CABG surgery [n = 61], or PTCA [n = 22], for significant coronary artery disease before surgical repair of AAA), AAA group (127 patients without significant coronary artery disease, operated for AAA). Follow-up (90% complete) had a mean duration of 42 +/- 23 months. RESULTS: CABG/PTCA + AAA group compared to AAA group presented major symptoms of angina (p = 0.001), higher incidence of previous myocardial infarction (67 vs 10%, p < 0.0001), lower mean value of left ventricular ejection fraction (50 vs 54%, p = 0.01). Operative mortality was 0.95%, and was not related to any cardiac morbidity: operative mortality was observed in the AAA group (2 patients died of anossic cerebral damage and respiratory failure) and was absent in the CABG/PTCA + AAA group (p = 0.8). The overall 8-year survival in the AAA group and in the CABG/PTCA + AAA group was 80 +/- 11 vs 95 +/- 2.8%, respectively (p = 0.7). Freedom from cardiac late death and freedom from cardiac events (recurrence of angina, myocardial infarction, congestive heart failure) were high in both groups (93 +/- 6.4 vs 97 +/- 2.3%, p = 0.6; and 91 +/- 6.6 vs 89 +/- 6.7%, p = 0.5, respectively). In the CABG/PTCA + AAA group symptoms for angina (p = 0.0002) and dyspnea (p < 0.0001) significantly improved during the follow-up. CONCLUSIONS: Significant coronary artery disease was not negligible (39.5%) in patients candidates to surgical repair of AAA. Identification and correction of coronary artery disease prior to AAA surgery is the most important strategy to reduce the risk of vascular procedure. The beneficial impact of coronary revascularization on early and late outcomes is evident, in terms of satisfactory survival and freedom from cardiac adverse events. Therefore, coronary angiography is strongly suggested to optimize early and long-term results.     

Long-term prognosis after coronary revascularization in patients with end-stage renal disease on dialysis: comparison of percutaneous coronary intervention and coronary artery bypass grafting

OBJECTIVES: To investigate the optimal method of coronary revascularization in patients on dialysis. METHODS: We retrospectively analyzed 145 patients on dialysis who underwent percutaneous coronary intervention (PCI) (81 patients) or coronary artery bypass grafting (CABG) (64 patients). Survival and non-fatal cardiac event-free rates were compared between the two groups by the Kaplan-Meier method. The impact of independent predictors on survival and non-fatal cardiac event-free rates were examined by the Cox regression model. RESULTS: The number of diseased vessels was smaller and ejection fraction was greater in the PCI group compared with the CABG group (1.74 +/- 0.67 vs 2.56 +/- 0.61, p < 0.0001 and 61.1 +/- 14.3% vs 50.6 +/- 17.4%, p = 0.001). The 1-year and 5-year survival rates of the PCI group were significantly higher than those of the CABG group (93.8 +/- 2.7% and 66.6 +/- 5.7% vs 76.0 +/- 5.4% and 44.8 +/- 6.5%, p = 0.0065). However, CABG was not an independent predictor of death by multivariate analysis (p = 0.06). The 1-year and 5-year non-fatal cardiac event-free rates of the PCI group were significantly lower than those of the CABG group (63.7 +/- 5.4% and 34.7 +/- 5.8% vs 83.2 +/- 4.9% and 66.8 +/- 7.4%, p = 0.0003). PCI was an independent predictor of non-fatal cardiac event by multivariate analysis (p = 0.007). CONCLUSIONS: PCI was associated with a higher incidence of non-fatal cardiac events, but survival rate was better after PCI than after CABG. PCI is very important and acceptable as a method of coronary revascularization in patients on dialysis.     

Does off-pump coronary artery bypass grafting really preserve renal function?

It is well known that the use of cardiopulmonary bypass (CPB) influences renal function and occasionally results in renal failure following cardiac surgery. Coronary artery bypass grafting (CABG) without CPB may avoid this and preserve the perioperative renal function. The present study enrolled 52 patients undergoing CABG without CPB (OPCAB group) and matched them for renal function and prognostic variables with 53 patients undergoing conventional CABG (CABG group). Perioperative renal function and early clinical results were assessed. The OPCAB group had significantly less increase in creatinine levels (0.16 +/- 0.05 vs 0.45 +/- 0.06 mg/dl; p = 0.01) and greater creatinine clearance (81.6 +/- 7.3 vs 56.3 +/- 4.8ml/min; p = 0.01) postoperatively. Postoperative recovery of free water clearance was more prompt in the OPCAB group. The duration of intubation and intensive care unit stay was significantly shorter, and the creatine kinase-MB release and blood transfusion requirements were significantly less in the OPCAB group. The OPCAB technique preserved glomerular filtration rate and prevented the increase in creatinine levels. The results suggest that the technique enables earlier patient recovery and gives superior renal protection compared with conventional CABG.     

Coronary artery bypass grafting is associated with a significant worsening of QT dynamicity and heart rate variability

BACKGROUND: Imbalance in autonomic nervous system and impaired myocardial repolarization has been shown to increase the risk for arrhythmias in patients with coronary artery disease. This study evaluated the effects of coronary artery bypass grafting (CABG) on heart rate variability and QT interval dynamicity in subjects with coronary artery disease undergoing elective CABG surgery. METHODS: The study group consisted of 68 consecutive patients (mean age +/-SD: 61 +/- 9 years) with coronary artery disease who underwent elective CABG. Twenty-four-hour Holter monitoring was performed 2-5 days before cardiac surgery and was repeated 10 days after CABG. ELATEC holter software was used to calculate heart rate variability and QT dynamicity parameters. All subjects had a complete history, laboratory examination and transthoracic echocardiography. RESULTS: All patients had beta-blocking agent medication pre- and postoperatively. Standard deviation of all NN intervals for a selected time period, square root of the mean of the sum of the squares of differences between adjacent RR intervals, the proportion of differences in successive NN intervals greater than 50 ms, normalized low-frequency power, and normalized high-frequency power were significantly decreased after CABG surgery, whereas low-frequency/high-frequency ratio was significantly increased after CABG. QT/RR slopes over 24 h were significantly increased after CABG surgery for QT end and QT apex (QTapex/RR: 0.16 +/- 0.13 vs. 0.28 +/- 0.19, p < 0.001; QTend/RR: 0.18 +/- 0.13 vs. 0.36 +/- 0.23, p < 0.001). CONCLUSION: This prospective study showed for the first time that CABG was associated with a significant worsening of heart rate variability and QT dynamicity parameters in the postoperative period.     

Clinical outcome of percutaneous transluminal coronary rotational atherectomy in patients with end-stage renal disease.

The clinical results of percutaneous transluminal coronary rotational atherectomy (PTCRA) in dialysis patients were retrospectively evaluated in comparison with coronary artery bypass grafting (CABG). From 1997 to 2001, 44 consecutive dialysis patients with 61 lesions underwent PTCRA and 55 consecutive dialysis patients underwent CABG. The initial success rate of PTCRA was 98%. The PTCRA group had a shorter hospital stay (13+/-17 vs 60+/-35 days, p=0.0001) and a lower rate of complications (11% vs 42%, p=0.001) than the CABG group. Although neither event-free survival without death nor myocardial infarction (MI) was significantly different between the CABG and PTCRA groups during the mean follow-up period of 21+/-14 months, 20 patients (45%) in the PTCRA group needed repeat revascularization of the target lesion. In conclusion, PTCRA may be a safe alternative modality for revascularization of high-risk CABG candidates, with excellent short-term results although the long-term outcome is inferior to that of CABG because of the higher restenosis rate.