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Thorac Cardiovasc Surg 2010; 58(7): 408-414
DOI: 10.1055/s-0030-1249831
Original Cardiovascular

© Georg Thieme Verlag KG Stuttgart · New York

“Anaortic” Off-Pump Coronary Artery Bypass Grafting Significantly Reduces Neurological Complications Compared to Off-Pump and Conventional On-Pump Surgery with Aortic Manipulation

M. Misfeld1 , K. Potger2 , D. E. Ross2 , D. McMillan2 , P. W. Brady2 , D. Marshman2 , M. N. Mathur2
  • 1Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
  • 2Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, Australia
Further Information

Publication History

received January 20, 2010

Publication Date:
04 October 2010 (online)

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Abstract

Objective: Most studies comparing off-pump coronary artery bypass grafting (OPCAB) with conventional on-pump coronary artery bypass grafting (ONCAB) include patients with aortic manipulation in the OPCAB group. Performing OPCAB without aortic manipulation, i.e., “anaortic” OPCAB (anOPCAB), may improve neurological outcome. Methods: We reviewed the perioperative data of all isolated CABG patients at two metropolitan hospitals for the period from January 2002 to December 2007. Multiple logistic regression analysis was performed to determine whether the type of procedure was an independent predictor of adverse neurological outcome. Results: Out of a total of 3699 consecutive patients, 1346 were anOPCAB, 600 OPCAB and 1753 ONCAB cases. Neurological complications occurred in 0.9 % of all patients. Compared to the anOPCAB group, there was a statistically significant higher odds for neurological complications in the OPCAB group [odds ratio (OR) 7.01, 95 % confidence interval (CI) 1.4–35.0, p = 0.0175] and in the ONCAB group (OR 12.33, 95 % CI 2.9–52.2, p = 0.0007). Conclusions: In this series “anaortic” OPCAB surgery significantly decreases the risk of neurological complications compared to both ONCAB and OPCAB with aortic manipulation. If possible, we advocate avoiding aortic manipulation in OPCAB surgery.

Key words

coronary bypass surgery - stroke - cardiopulmonary bypass - off‐pump

References

  • 1 Sellke F W, DiMaio J M, Caplan L R et al. Comparing on-pump and off-pump coronary artery bypass grafting. Numerous studies but few conclusions: a scientific statement from the American Heart Association Council on cardiovascular surgery and anesthesia in collaboration with the interdisciplinary working group on quality of care and outcomes research.  Circulation. 2005;  111 2858-2864
    CrossrefPubMedSearch in Google Scholar
  • 2 Angelini G D, Taylor F C, Reeves B C, Ascione R. Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS1 and 2): a pooled analysis of two randomized controlled trials.  Lancet. 2002;  359 1194-1199
    CrossrefPubMedSearch in Google Scholar
  • 3 Hannan E L, Wu C, Smith C R et al. 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. 2007;  116 1145-1152
    CrossrefPubMedSearch in Google Scholar
  • 4 Puskas J D, Williams W H, Mahoney E M et al. Off-pump vs. conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial.  JAMA. 2004;  291 1841-1849
    CrossrefPubMedSearch in Google Scholar
  • 5 Nathoe H M, van Dijk D, Jansen E W et al. Octopus Study Group. A Comparison of on-pump and off-pump coronary artery bypass surgery in low-risk patients.  N Engl J Med. 2003;  348 394-402
    CrossrefPubMedSearch in Google Scholar
  • 6 Van Dijk D, Spoor M, Hijman R et al. Octopus Study Group. Cognitive and cardiac outcome 5 years after off-pump vs. on pump coronary artery bypass graft surgery.  JAMA. 2007;  297 701-708
    CrossrefPubMedSearch in Google Scholar
  • 7 Lev-Ran O, Braunstein R, Sharony R et al. No-touch aorta off-pump coronary surgery: the effect on stroke.  J Thorac Cardiovasc Surg. 2005;  129 307-313
    CrossrefPubMedSearch in Google Scholar
  • 8 Kim K-B, Kang C H, Chang W-I et al. Off-pump coronary artery bypass with complete avoidance of aortic manipulation.  Ann Thorac Surg. 2002;  74 S1377-S1382
    CrossrefPubMedSearch in Google Scholar
  • 9 Calafiore A M, Di Mauro M, Teodori G M et al. Impact of aortic manipulation on incidence of cerebrovascular accidents after surgical myocardial revascularization.  Ann Thorac Surg. 2002;  73 1387-1393
    CrossrefPubMedSearch in Google Scholar
  • 10 Dawson-Saunders B, Trapp R. Basic & clinical biostatistics, 2nd ed. Connecticut; Appleton & Lange 1994: 894-895
    Search in Google Scholar
  • 11 Gerola L R, Buffolo E, Jasbik W et al. Off-pump versus on-pump myocardial revascularization in low-risk patients with one or two vessel disease: perioperative results in a multicenter randomized controlled trial.  Ann Thorac Surg. 2004;  77 569-573
    CrossrefPubMedSearch in Google Scholar
  • 12 Khan N E, De Souza A, Mister R et al. A randomized comparison of off-pump and on-pump multivessel coronary-artery bypass surgery.  N Engl J Med. 2004;  350 21-28
    CrossrefPubMedSearch in Google Scholar
  • 13 Parolari A, Alamanni F, Polvani G et al. Meta-analysis of randomized trials comparing off-pump with on-pump coronary artery bypass graft patency.  Ann Thorac Surg. 2005;  80 2121-2125
    CrossrefPubMedSearch in Google Scholar
  • 14 Reston J T, Tregear S J, Turkelson C M. Meta-analysis of short-term and mid-term outcomes following off-pump coronary artery bypass grafting.  Ann Thorac Surg. 2003;  76 1510-1515
    CrossrefPubMedSearch in Google Scholar
  • 15 Van der Heijden G J M G, Nathoe H M, Jansen E W L, Grobbee D E. Meta-analysis on the effect of off-pump coronary artery bypass surgery.  Eur J Cardiothorac Surg. 2004;  26 81-84
    CrossrefPubMedSearch in Google Scholar
  • 16 Wijeysundera D N, Beattie S, Djaiani G et al. Off-pump coronary artery surgery for reducing mortality and morbidity: meta-analysis of randomized and observational studies.  J Am Coll Cardiol. 2005;  46 872-882
    CrossrefPubMedSearch in Google Scholar
  • 17 Barbut D, Yao F F, Lo Y W et al. Determination of size of aortic emboli and embolic load during coronary artery bypass.  Ann Thorac Surg. 1997;  63 1262-1267
    PubMedSearch in Google Scholar
  • 18 Roach G W, Kanchuger M, Mangano C M for The Multicenter Study of Perioperative Ischemia Research Group and The Ischemia Research and Education Foundation Investigators et al. Adverse cerebral outcomes after coronary bypass surgery.  N Engl J Med. 1996;  335 1857-1863
    CrossrefPubMedSearch in Google Scholar
  • 19 Mickleborough L L, Walker P M, Takagi Y, Ohashi M, Ivanov J, Tamariz M. Risk factors for stroke in patients undergoing coronary artery bypass surgery.  J Thorac Cardiovasc Surg. 1996;  112 1250-1259
    CrossrefPubMedSearch in Google Scholar
  • 20 Lev-Ran O, Loberman D, Matsa M et al. Reduced strokes in the elderly: the benefit of untouched aorta off-pump coronary surgery.  Ann Thorac Surg. 2004;  77 102-107
    CrossrefPubMedSearch in Google Scholar
  • 21 Vallely M P, Potger K, McMillan D et al. Anaortic techniques reduce neurological morbidity after off-pump coronary artery bypass surgery.  Heart Lung Circ. 2008;  17 299-304
    CrossrefPubMedSearch in Google Scholar
  • 22 Patel N C, Deodhar A P, Grayson A D et al. Neurological outcome in coronary surgery: independent effect of avoiding cardiopulmonary bypass.  Ann Thorac Surg. 2002;  74 400-405
    CrossrefPubMedSearch in Google Scholar
  • 23 Wilson M G, Boyd S Y, Lisagor P G, Rubal B J, Cohen D J. Ascending aortic atheroma assessed intraoperatively by epiaortic and transesophageal echocardiography.  Ann Thorac Surg. 2000;  70 25-30
    CrossrefPubMedSearch in Google Scholar
  • 24 Wareing T H, Davila-Roman V G, Barzilai B, Murphy S F, Kouchoukos N T. Management of severely atherosclerotic ascending aorta during cardiac operations.  J Thorac Cardiovasc Surg. 1992;  103 453-462
    PubMedSearch in Google Scholar
  • 25 Shimokawa T, Minato N, Yamada N, Takeda Y, Hisamatsu Y, Itoh M. Assessment of ascending aorta using epiaortic ultrasonography during off-pump coronary artery bypass grafting.  Ann Thorac Surg. 2002;  74 2097-2100
    CrossrefPubMedSearch in Google Scholar
  • 26 Lattouf O M, Puskas J D, Thourani V H, Noora J, Kilgo P D, Guyton R A. Does the number of grafts influence surgeon choice and patient benefit of off-pump over conventional on-pump coronary artery revascularization in multivessel coronary artery disease?.  Ann Thorac Surg. 2007;  84 1485-1494
    CrossrefPubMedSearch in Google Scholar
  • 27 Calafiore A M, Di Giammarco G, Teodori G et al. Late results of first myocardial revascularization in multiple vessel disease: single versus bilateral internal mammary artery with or without saphenuous vein grafts.  Eur J Cardiothorac Surg. 2004;  26 542-548
    CrossrefPubMedSearch in Google Scholar
  • 28 Bonacchi M, Battaglia F, Priffi E et al. Early and late outcome of skeletonised bilateral internal mammary arteries anastomosed to the left coronary system.  Heart. 2005;  91 195-202
    CrossrefPubMedSearch in Google Scholar
  • 29 Peterson M D, Borger M A, Rao V, Peninston C M, Feindel C M. Skeletonization of bilateral internal thoracic artery grafts lowers the risk of sternal infection in patient with diabetes.  J Thorac Cardiovasc Surg. 2003;  126 1314-1319
    CrossrefPubMedSearch in Google Scholar
  • 30 Lev-Ran O, Mohr R, Pevni D et al. Bilateral internal thoracic artery grafting in diabetic patients: short-term and long-term results of a 515-patient series.  J Thorac Cardiovasc Surg. 2004;  127 1145-1150
    CrossrefPubMedSearch in Google Scholar
  • 31 Jensen B O, Hughes P, Rasmussen L S, Pedersen P U, Steinbrüchel D A. Cognitive outcomes in elderly high-risk patients after off-pump versus conventional coronary artery bypass grafting: a randomized trial.  Circulation. 2006;  113 2790-2795
    CrossrefPubMedSearch in Google Scholar

Dr. Martin Misfeld, MD. PhD

Department of Cardiac Surgery
Heart Centre Leipzig

Struempellstr. 39

04289 Leipzig

Germany

Email: martinmisfeld@yahoo.com