Abstract
Severely decreased ejection-fraction is an established risk-factor for worse outcome after cardiac surgery. We compare outcomes of off-pump coronary artery bypass grafting (OPCAB) and on-pump CABG (ONCABG) in patients with severely compromised EF. From 2004 to 2009, 478 patients with a decreased EF ≤35% underwent myocardial-revascularization. Patients received either OPCAB (n = 256) or ONCABG (n = 222). Propensity score (PS), including 50 preoperative risk-factors, was used to balance characteristics between groups. PS adjusted logistic regression analysis was performed to assess mortality and major adverse cardiac and cerebrovascular events (MACCE). A composite endpoint for major non-cardiac complications such as respiratory failure, renal failure, rethoracotomy was applied. Complete revascularization (CR) was assumed when the number of distal anastomoses was larger than that of diseased vessels. There was no difference for mortality (2.3 vs. 4.1%; PS-adjusted odds ratio (PS-OR) = 1.05; p = 0.93) and MACCE (13.7 vs. 17.6%; PS-OR = 1.22; p = 0.50) including myocardial-infarction (1.4 vs. 4.9%; PS-OR = 0.39; p = 0.26), low cardiac output (2.3 vs. 4.7%; PS-OR = 0.75; p = 0.72) and stroke (2.3 vs. 2.7%; PS-OR = 0.69; p = 0.66). OPCAB patients presented with a trend to less frequent occurrence of the non-cardiac composite (12.1 vs. 22.1%; PS-OR = 0.54; p = 0.059) including renal dysfunction (PAOR = 0.77; 95% CI 0.31–1.9; p = 0.57), bleeding (PAOR = 0.42; 95% CI 0.14–1.20; p = 0.10) and respiratory failure (PAOR = 0.39; 95% CI 0.05–3.29; p = 0.39). The rate of complete revascularization was similar (92.2 vs. 92.8%; PS-OR = 0.75; p = 0.50). OPCAB in patients with severely decreased EF is safe and feasible. It may even benefit these patients in regard to non-cardiac complications and does not come at cost of less complete revascularization.
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References
Christakis GT, Weisel RD, Fremes SE, Ivanov J, David TE, Goldman BS, Salerno TA (1992) Coronary artery bypass grafting in patients with poor ventricular function. Cardiovascular Surgeons of the University of Toronto. J Thorac Cardiovasc Surg 103:1083–1091; discussion 1091–1092
O’Connor GT, Plume SK, Olmstead EM, Coffin LH, Morton JR, Maloney CT, Nowicki ER, Levy DG, Tryzelaar JF, Hernandez F (1992) Multivariate prediction of in-hospital mortality associated with coronary artery bypass graft surgery. Northern New England Cardiovascular Disease Study Group. Circulation 85:2110–2118
Patel NC, Deodhar AP, Grayson AD, Pullan DM, Keenan DJ, Hasan R, Fabri BM (2002) Neurological outcomes in coronary surgery: independent effect of avoiding cardiopulmonary bypass. Ann Thorac Surg 74:400–405; discussion 405–406
Wan IY, Arifi AA, Wan S, Yip JH, Sihoe AD, Thung KH, Wong EM, Yim AP (2004) Beating heart revascularization with or without cardiopulmonary bypass: evaluation of inflammatory response in a prospective randomized study. J Thorac Cardiovasc Surg 127:1624–1631
Nesher N, Frolkis I, Vardi M, Sheinberg N, Bakir I, Caselman F, Pevni D, Ben-Gal Y, Sharony R, Bolotin G, Loberman D, Uretzky G, Weinbroum AA (2006) Higher levels of serum cytokines and myocardial tissue markers during on-pump versus off-pump coronary artery bypass surgery. J Card Surg 21:395–402
Hannan EL, Wu C, Smith CR, Higgins RS, Carlson RE, Culliford AT, Gold JP, Jones RH (2007) Off-pump versus on-pump coronary artery bypass graft surgery: differences in short-term outcomes and in long-term mortality and need for subsequent revascularization. Circulation 116:1145–1152
Lattouf OM, Thourani VH, Kilgo PD, Halkos ME, Baio KT, Myung R, Cooper WA, Guyton RA, Puskas JD (2008) Influence of on-pump versus off-pump techniques and completeness of revascularization on long-term survival after coronary artery bypass. Ann Thorac Surg 86:797–805
Puskas JD, Williams WH, Duke PG, Staples JR, Glas KE, Marshall JJ, Leimbach M, Huber P, Garas S, Sammons BH, McCall SA, Petersen RJ, Bailey DE, Chu H, Mahoney EM, Weintraub WS, Guyton RA (2003) Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg 125:797–808
Puskas JD, Thourani VH, Kilgo P, Cooper W, Vassiliades T, Vega JD, Morris C, Chen E, Schmotzer BJ, Guyton RA, Lattouf OM (2009) Off-pump coronary artery bypass disproportionately benefits high-risk patients. Ann Thorac Surg 88:1142–1147
Moshkovitz Y, Sternik L, Paz Y, Gurevitch J, Feinberg MS, Smolinsky AK, Mohr R (1997) Primary coronary artery bypass grafting without cardiopulmonary bypass in impaired left ventricular function. Ann Thorac Surg 63:S44–S47
Chamberlain MH, Ascione R, Reeves BC, Angelini GD (2002) Evaluation of the effectiveness of off-pump coronary artery bypass grafting in high-risk patients: an observational study. Ann Thorac Surg 73:1866–1873
Shennib H, Endo M, Benhamed O, Morin JF (2002) Surgical revascularization in patients with poor left ventricular function: on- or off-pump? Ann Thorac Surg 74:S1344–S1347
Arom KV, Flavin TF, Emery RW, Kshettry VR, Petersen RJ, Janey PA (2000) Is low ejection fraction safe for off-pump coronary bypass operation? Ann Thorac Surg 70:1021–1025
Emmert MY, Salzberg SP, Seifert B, Schurr UP, Hoerstrup SP, Reuthebuch O, Genoni M (2010) Routine off-pump coronary artery bypass grafting is safe and feasible in high-risk patients with left main disease. Ann Thorac Surg 89:1125–1130
Kumazaki S, Koyama J, Aizawa K, Kasai H, Koshikawa M, Izawa A, Tomita T, Takahashi M, Ikeda U (2010) Effect of graft adaptation of the internal mammary artery on longitudinal phasic blood flow velocity characteristics after surgery. Heart Vessels 25:515–521
Shroyer AL, Grover FL, Hattler B, Collins JF, McDonald GO, Kozora E, Lucke JC, Baltz JH, Novitzky D (2009) On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med 361:1827–1837
Stamou SC, Jablonski KA, Hill PC, Bafi AS, Boyce SW, Corso PJ (2005) Coronary revascularization without cardiopulmonary bypass versus the conventional approach in high-risk patients. Ann Thorac Surg 79:552–557
Al-Ruzzeh S, Nakamura K, Athanasiou T, Modine T, George S, Yacoub M, Ilsley C, Amrani M (2003) Does off-pump coronary artery bypass (OPCAB) surgery improve the outcome in high-risk patients?: a comparative study of 1398 high-risk patients. Eur J Cardiothorac Surg 23:50–55
Sharoni E, Song HK, Peterson RJ, Guyton RA, Puskas JD (2006) Off pump coronary artery bypass surgery for significant left ventricular dysfunction: safety, feasibility, and trends in methodology over time—an early experience. Heart 92:499–502
Koh TW, Carr-White GS, DeSouza AC, Ferdinand FD, Hooper J, Kemp M, Gibson DG, Pepper JR (1999) Intraoperative cardiac troponin T release and lactate metabolism during coronary artery surgery: comparison of beating heart with conventional coronary artery surgery with cardiopulmonary bypass. Heart 81:495–500
Krejca M, Skiba J, Szmagala P, Gburek T, Bochenek A (1999) Cardiac troponin T release during coronary surgery using intermittent cross-clamp with fibrillation, on-pump and off-pump beating heart. Eur J Cardiothorac Surg 16:337–341
Rastan AJ, Eckenstein JI, Hentschel B, Funkat AK, Gummert JF, Doll N, Walther T, Falk V, Mohr FW (2006) Emergency coronary artery bypass graft surgery for acute coronary syndrome: beating heart versus conventional cardioplegic cardiac arrest strategies. Circulation 114:I477–I485
Stamou SC, Corso PJ (2001) Coronary revascularization without cardiopulmonary bypass in high-risk patients: a route to the future. Ann Thorac Surg 71:1056–1061
Thomas GN, Martinez EC, Woitek F, Emmert MY, Sakaguchi H, Muecke S, Lee CN, Kofidis T (2009) Off-pump coronary bypass grafting is safe and efficient in patients with left main disease and higher EuroScore. Eur J Cardiothorac Surg 36:616–620
Yeatman M, Caputo M, Ascione R, Ciulli F, Angelini GD (2001) Off-pump coronary artery bypass surgery for critical left main stem disease: safety, efficacy and outcome. Eur J Cardiothorac Surg 19:239–244
Blackstone EH (2002) Comparing apples and oranges. J Thorac Cardiovasc Surg 123:8–15
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Emmert, M.Y., Salzberg, S.P., Theusinger, O.M. et al. Off-pump surgery for the poor ventricle?. Heart Vessels 27, 258–264 (2012). https://doi.org/10.1007/s00380-011-0146-0
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DOI: https://doi.org/10.1007/s00380-011-0146-0