Chest
Clinical Investigations: SurgeryPulmonary Outcomes of Off-Pump vs On-Pump Coronary Artery Bypass Surgery in a Randomized Trial
Section snippets
Patient Selection, Randomization, Care, and Data Collection
The SMART trial3233 was designed to compare completeness of revascularization, graft patency, clinical outcomes, and resource utilization in unselected patients referred for elective, primary coronary bypass surgery randomized to undergo OPCAB with a stabilization device (Octopus; Medtronic; Minneapolis, MN) or CABG/CPB at a single hospital by a single surgeon. Patients were not excluded on the basis of any preoperative comorbidities or any pattern of coronary artery disease.32, 33
Patients were
Patients
Two hundred patients agreed to participate. Three patients were determined by transesophageal echocardiography after randomization and induction of anesthesia to require mitral valve repair or replacement and were withdrawn from the study. The study groups were 99 patients who were to undergo CABG/CPB and 98 patients who were to undergo OPCAB. Three patients had severe aortic calcification or atherosclerosis by epiaortic ultrasound and/or transesophageal echocardiography after randomization in
Discussion
This is the largest prospective randomized trial to date to provide comprehensive analysis of the pulmonary aspects of OPCAB vs CABG/CPB. We have demonstrated that a greater decrease in postoperative respiratory static compliance seen in the OPCAB patients appears to be due to the need to rotate the heart into the right chest to allow bypass to posterolateral vessels and the larger amounts of IVF required to maintain systemic BP during the operation. Paradoxically, CABG/CPB patients actually
Acknowledgments
We are indebted to Roland H. Ingram, MD, for his helpful discussions of the respiratory static compliance data and review of the manuscript, and we also thank Kenneth V. Leeper, MD, and Bruce Krieger, MD, for their helpful comments. We could not have performed this study without the help of our nurse coordinators, Susan A. McCall, RN, Bonnie Sammons, RN, and Rebecca J. Peterson, RN.
References (44)
- et al.
Lung injury and acute respiratory distress syndrome after cardiopulmonary bypass
Ann Thorac Surg
(1999) - et al.
Incidence and predictors of ARDS after cardiac surgery
Chest
(2001) - et al.
Pre- and postoperative pulmonary function abnormalities in coronary artery revascularization surgery
Chest
(1978) - et al.
Postoperative pulmonary function abnormalities after coronary artery bypass surgery
Respir Med
(1992) - et al.
Postoperative pulmonary function in coronary artery bypass graft surgery patients undergoing early tracheal extubation: a comparison between short-term mechanical ventilation and early extubation
J Cardiothorac Vasc Anesth
(2002) - et al.
Pulmonary function after coronary artery bypass surgery
Respir Med
(1997) - et al.
Pre- and postoperative inspiratory mechanics in ischemic and valvular heart disease
Chest
(1987) - et al.
Antioxidant and antiprotease status in peripheral blood and BAL fluid after cardiopulmonary bypass
Chest
(2001) - et al.
III Off-pump coronary revascularization: current state of the art
Semin Thorac Cardiovasc Surg
(2002) - et al.
Inflammatory response after myocardial revascularization with or without cardiopulmonary bypass
Ann Thorac Surg
(1998)
Inflammatory response after coronary revascularization with or without cardiopulmonary bypass
Ann Thorac Surg
Systemic inflammation present in patients undergoing CABG without extracorporeal circulation
Chest
On-pump versus off-pump coronary revascularization: evaluation of renal function
Ann Thorac Surg
Effect of off-pump coronary artery bypass grafting on morbidity
Am J Cardiol
Off-pump versus on-pump coronary bypass in high-risk subgroups
Ann Thorac Surg
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
Off-pump (OPCAB) vs on-pump coronary artery bypass surgery (CABG/CPB): spirometry, respiratory compliance, (Cs), gas exchange, and pulmonary complications in a randomized trial [abstract]
Chest
Effect of cardiopulmonary bypass on pulmonary gas exchange: a prospective randomized study
Ann Thorac Surg
Different CABG methods in patients with chronic obstructive pulmonary disease
Ann Thorac Surg
Intrapulmonary shunt after cardiopulmonary bypass: the use of vital capacity maneuvers versus off-pump coronary artery bypass grafting
J Thorac Cardiovasc Surg
Pulmonary vascular permeability after cardiopulmonary bypass and its relationship to oxidative stress
Crit Care Med
Adult respiratory distress syndrome following cardiopulmonary bypass: incidence, prophylaxis and management
J Cardiovasc Surg
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Comparison of Changes in Thoracic Fluid Content Between On-Pump and Off-Pump CABG by Use of Electrical Cardiometry
2022, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :The higher TFC in the ONCAB group probably caused pulmonary congestion, which led to alveolar collapse, a decrease in functional residual capacity, and atelactasis, particularly in the basal segments, all of which resulted in decreased pulmonary function and delayed extubation. Staton et al.25 also discovered that the average duration of postoperative ventilation was shorter in patients who underwent OPCAB than in the patients who underwent ONCAB, as in the present study. The patients who underwent ONCAB had poorer gas exchange immediately after surgery, possibly due to the release of inflammatory mediators induced by CPB or a failure of surfactant replenishment due to a lack of ventilatory cycling of the lungs.
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Dr. Duke has received consultant fees from Medtronic, Inc., and Dr. Puskas has received consultant fees and speaker honoraria from Medtronic, Inc
This study was supported by grants from Medtronic, Inc, Minneapolis, MN; and The Carlyle Fraser Heart Center Foundation, Atlanta, GA