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Ahmed M, Majeed K, Ali H, Syed H, Batool A. Off-pump vs. on-pump coronary artery bypass grafting in patients with chronic kidney disease: an updated systematic review and meta-analysis. Int Urol Nephrol 2025; 57:463-477. [PMID: 39249666 DOI: 10.1007/s11255-024-04198-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Accepted: 08/31/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND In patients with chronic kidney disease (CKD), cardiovascular disease is found to be the primary cause of mortality, and after coronary artery bypass grafting (CABG), their prognosis deteriorates. METHODS We conducted a meta-analysis comparing off-pump CABG versus on-pump CABG in CKD patients. We searched electronic databases, including PubMed, Cochrane, and Google Scholar, using relevant keywords. We included studies comparing off-pump CABG with on-pump CABG in patients with chronic kidney disease, which was defined as an estimated glomerular filtration rate (eGFR) < 60 ml/min per 1.73 m2. Effect estimates were synthesized using a random-effects model and expressed as risk ratios (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, with corresponding 95% confidence intervals (CIs). Our primary outcome was short-term mortality. RESULTS A total of 25 studies, of which 23 were observational and 2 were RCTs, were included in this meta-analysis, comprising 234,585 patients (66,591 in the off-pump group and 167,994 in the on-pump group). Our meta-analysis showed that there was a significantly higher mortality rate in the on-pump CABG group as compared to the off-pump CABG group (RR: 0.73, 95% CI [0.61, 0.88]; P = 0.0006, I2 = 60%). CONCLUSION Compared with OPCAB, short-term mortality was significantly higher in ONCAB.
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Affiliation(s)
- Muhammad Ahmed
- Department of Internal Medicine, Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan.
| | - Kanwal Majeed
- Department of Internal Medicine, Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan
| | - Hassam Ali
- Department of Internal Medicine, Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan
| | - Hina Syed
- Department of Internal Medicine, Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan
| | - Atiya Batool
- Department of Internal Medicine, Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan
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Razavi AA, Malas J, Salam A, Emerson DA, Bowdish ME. Off-Pump Coronary Artery Bypass Grafting is Overutilized. Semin Thorac Cardiovasc Surg 2024; 37:43-47. [PMID: 39730082 PMCID: PMC12077573 DOI: 10.1053/j.semtcvs.2024.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2024] [Revised: 12/13/2024] [Accepted: 12/20/2024] [Indexed: 12/29/2024]
Abstract
Off-pump coronary artery bypass grafting (CABG), developed to avoid the potential complications of cardiopulmonary bypass, remains a subject of debate. Studies have demonstrated that off-pump CABG is associated with higher rates of incomplete revascularization, inferior graft patency, and increased reintervention rates compared to on-pump CABG, leading to worse outcomes. The theoretical neuroprotective and renal-protective benefits associated with off-pump CABG have not been definitively proven, with stroke and renal failure rates similar to those of on-pump CABG in both short- and long-term follow-up. Off-pump CABG presents technical challenges, contributing to a steep learning curve, and its effectiveness is dependent on surgeon and center experience. Lower-volume centers and surgeons performing off-pump CABG have shown increased rates of mortality and reintervention. Despite the potential cost savings by avoiding cardiopulmonary bypass, the need for repeat interventions and associated complications can lead to higher long-term healthcare costs. This paper advocates for a more selective use of off-pump CABG while maintaining on-pump CABG as the standard approach for patients with coronary artery disease.
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Affiliation(s)
- Allen A Razavi
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jad Malas
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Aminah Salam
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dominic A Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael E Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Berger T, Fagu A, Czerny M, Hartikainen T, Von Zur Mühlen C, Kueri S, Eschenhagen M, Kreibich M, Beyersdorf F, Rylski B. Intraoperative Invasive Coronary Angiography after Coronary Artery Bypass Grafting. Thorac Cardiovasc Surg 2024. [PMID: 39496296 DOI: 10.1055/s-0044-1791960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2024]
Abstract
OBJECTIVE The aim of this study was to prospectively evaluate the feasibility and safety of intraoperative invasive coronary angiography (ICA) following coronary artery bypass grafting using a mobile angiography C-arm. METHODS Between August 2020 and December 2021, 18 patients were enrolled for intraoperative ICA following coronary artery bypass grafting. After skin closure, ICA was performed including angiography of all established bypass grafts via a mobile angiography system by an interventional cardiologist. Data on graft patency, stenosis, and kinking were assessed. Grafts were rated on an ordinal scale ranging from very poor (1) to excellent (5). Furthermore, the impact of ICA compared with flow measurement was assessed using the ordinal Likert scale ranging from (I) worse to (V) much better. RESULTS The ICA was considered better (V) compared with transient flow measurement in 38 (93%) and comparable (III) in 3 (7%) distal anastomoses. ICA impacted clinical or surgical decision-making in three patients (17%). In one patient, dual antiplatelet therapy for 6 months was initiated and rethoracotomy was needed in two (11%) patients with bypass graft revision and additional bypass grafting for graft occlusion. There were no cerebral and distal embolic events or access vessel complications observed and no postoperative acute kidney injury occurred. CONCLUSION Intraoperative angiography after coronary bypass grafting is safe. Using a mobile angiographic device, graft patency, and function assessment was superior to transit time flow measurement leading to further consequences in a relevant number of patients. Therefore, it has the potential to reduce postoperative myocardial injury and improve survival.
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Affiliation(s)
- Tim Berger
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Freiburg, Freiburg, Germany
- University of Freiburg, Freiburg, Germany
| | - Albi Fagu
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Freiburg, Freiburg, Germany
- University of Freiburg, Freiburg, Germany
- Department of Cardiac Surgery, Spitali Universitar"Shefqet Ndroqi", Tirana, Albania
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Freiburg, Freiburg, Germany
- University of Freiburg, Freiburg, Germany
| | - Tau Hartikainen
- University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology, University Heart Center, University Medical Center Freiburg, Freiburg, Germany
| | - Constantin Von Zur Mühlen
- University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology, University Heart Center, University Medical Center Freiburg, Freiburg, Germany
| | - Sami Kueri
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Freiburg, Freiburg, Germany
- University of Freiburg, Freiburg, Germany
| | - Matthias Eschenhagen
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Freiburg, Freiburg, Germany
- University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Freiburg, Freiburg, Germany
- University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Freiburg, Freiburg, Germany
- University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Freiburg, Freiburg, Germany
- University of Freiburg, Freiburg, Germany
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Fong KY, Yeo S, Luo H, Kofidis T, Teoh KLK, Kang GS. Stroke prevention strategies for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. ANZ J Surg 2024; 94:522-535. [PMID: 38529814 DOI: 10.1111/ans.18947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 01/15/2023] [Accepted: 03/04/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Stroke is a much-feared complication of cardiac surgery, but existing literature on preventive strategies is fragmented. Hence, a systematic review and meta-analysis of stroke prevention strategies for cardiac surgery was conducted. METHODS An electronic literature search was conducted to retrieve randomized controlled trials (RCTs) investigating perioperative interventions for cardiac surgery, with stroke as an outcome. Random-effects meta-analyses were conducted to generate risk ratios (RRs), 95% confidence intervals (95% CI), and forest plots. Descriptive analysis and synthesis of literature was conducted for interventions not amenable to meta-analysis, focusing on risks of stroke, myocardial infarction and study-defined major adverse cardiovascular events (MACE). RESULTS Fifty-six RCTs (61 894 patients) were retrieved. Many included trials were underpowered to detect differences in stroke risk. Among pharmacological therapies, only preoperative amiodarone was shown to reduce stroke risk in one trial. Concomitant left atrial appendage closure (LAAC) significantly reduced stroke risk (RR = 0.55, 95% CI = 0.36-0.84, P = 0.006) in patients with preoperative atrial fibrillation, and there was no difference in on-pump versus off-pump coronary artery bypass grafting (CABG) (RR = 0.94, 95% CI = 0.64-1.37, P = 0.735). Much controversy exists in literature on the timing of carotid endarterectomy relative to CABG in patients with severe carotid stenosis. The use of preoperative remote ischemic preconditioning was not found to reduce rates of stroke or MACE. CONCLUSION This review presents a comprehensive synthesis of existing interventions for stroke prevention in cardiac surgery, and identifies gaps in research which may benefit from future, large-scale RCTs. LAAC should be considered to reduce stroke incidence in patients with preoperative atrial fibrillation.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Selvie Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Haidong Luo
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Theodoros Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Kristine L K Teoh
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Giap Swee Kang
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
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Sakowitz S, Bakhtiyar SS, Sareh S, Ali K, Verma A, Chervu N, Sanaiha Y, Benharash P. Acute clinical and financial outcomes of on- versus off-pump coronary artery bypass grafting in octogenarians. Surgery 2023:S0039-6060(23)00168-X. [PMID: 37202306 DOI: 10.1016/j.surg.2023.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 03/03/2023] [Accepted: 03/29/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Coronary artery bypass surgery in octogenarians is associated with increased postoperative morbidity. Off-pump coronary artery bypass surgery eliminates potential complications of cardiopulmonary bypass, but its use remains controversial. This study aimed to evaluate the clinical and financial impact of off-pump coronary artery bypass surgery compared to conventional coronary artery bypass surgery among this high-risk population. METHODS Patients ≥80 years undergoing first-time, isolated, elective coronary artery bypass surgery were identified using the 2010-2019 Nationwide Readmissions Database. Patients were grouped into off-pump or conventional coronary artery bypass surgery cohorts. Multivariable models were developed to assess the independent associations between off-pump coronary artery bypass surgery and key outcomes. RESULTS Of ∼56,158 patients, 13,940 (24.8%) underwent off-pump coronary artery bypass surgery. On average, the off-pump cohort was more likely to undergo single-vessel bypass (37.3 vs 19.7%, P < .001). After adjustment, undergoing off-pump coronary artery bypass surgery was associated with similar odds of in-hospital mortality (adjusted odds ratio 0.90, 95% confidence interval 0.73-1.12) relative to conventional bypass. Additionally, the off-pump and conventional coronary artery bypass surgery groups were comparable in odds of postoperative stroke (adjusted odds ratio 1.03, 95% confidence interval 0.78-1.35), cardiac arrest (adjusted odds ratio 0.99, 95% confidence interval 0.71-1.37), ventricular fibrillation (adjusted odds ratio 0.89, 95% confidence interval 0.60-1.31), tamponade (adjusted odds ratio 1.21, 95% confidence interval 0.74-1.97), and cardiogenic shock (adjusted odds ratio 0.94, 95% confidence interval 0.75-1.17). However, the off-pump coronary artery bypass surgery cohort was linked with an increased likelihood of ventricular tachycardia (adjusted odds ratio 1.23, 95% confidence interval 1.01-1.49) and myocardial infarction (adjusted odds ratio 1.34, 95% confidence interval 1.16-1.55). Furthermore, those undergoing off-pump coronary artery bypass surgery demonstrated reduced odds of non-home discharge (adjusted odds ratio 0.91, 95% confidence interval 0.83-0.99) and a decrement in hospitalization expenditures ($-1,290, 95% confidence interval -$2,370 to $200). CONCLUSION Off-pump coronary artery bypass surgery was linked with increased odds of ventricular tachycardia and myocardial infarction, but no difference in mortality. Our findings point to the safety of conventional coronary artery bypass surgery in octogenarians. Yet, future work is needed to consider long-term outcomes in this complex surgical cohort.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA. https://twitter.com/sarasakowitz
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA; Department of Surgery, University of Colorado, Aurora, CO. https://twitter.com/Aortologist
| | - Sohail Sareh
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA.
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Forouzannia SM, Forouzannia SK, Yarahmadi P, Alirezaei M, Shafiee A, Anari NY, Masoudkabir F, Dehghani Z, Pashang M. Early and mid-term outcomes of off-pump versus on-pump coronary artery bypass surgery in patients with triple-vessel coronary artery disease: a randomized controlled trial. J Cardiothorac Surg 2023; 18:140. [PMID: 37046338 PMCID: PMC10099835 DOI: 10.1186/s13019-023-02258-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 04/03/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND AND AIM OF THE STUDY Several studies have compared early and late outcomes of on-pump coronary artery bypass grafting (CABG) and off-pump CABG. However, there is still an ongoing debate on this matter, especially in patients with triple-vessel coronary artery disease (3VD). METHODS We randomly assigned 274 consecutive patients with 3VD to two equal groups to undergo on-pump CABG or off-pump CABG. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), including all-cause mortality, acute coronary syndrome, stroke or transient ischemic attack, and the need for repeat revascularization. The secondary outcomes were postoperative infection, ventilation time, ICU admission duration, hospital stay length, and renal failure after surgery. RESULTS The median follow-up duration was 31.2 months (range 24.6-35.2 months). The mean age of patients was 61.4 ± 9.3 years (range: 38-86), and 207 (78.7%) were men. There were 15 (11.2%) and 9 (7.0%) MACCE occurrences in on-pump and off-pump groups, respectively (P value = 0.23). MACCE components including all-cause death, non-fatal MI, CVA, and revascularization did not significantly differ between on-pump and off-pump groups. We observed no difference in the occurrence of MACCE between off-pump and on-pump groups in multivariable regression analysis (HR = 0.57; 95% CI 0.24-1.32; P value = 0.192). There were no statistical differences in postoperative outcomes between the off-pump and on-pump CABG groups. CONCLUSIONS Off-pump CABG is an equal option to on-pump CABG for 3VD patients with similar rates of MACCE and postoperative complications incidence when surgery is performed in the same setting by an expert surgeon in both methods. (IRCT20190120042428N1).
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Affiliation(s)
- Seyed Mohammad Forouzannia
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, North Kargar St, Tehran, 1411713138, Iran
| | - Seyed Khalil Forouzannia
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, North Kargar St, Tehran, 1411713138, Iran.
| | - Pourya Yarahmadi
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, North Kargar St, Tehran, 1411713138, Iran
| | - Mohammad Alirezaei
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, North Kargar St, Tehran, 1411713138, Iran
| | - Akbar Shafiee
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Negin Yazdian Anari
- Faculty of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Farzad Masoudkabir
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Dehghani
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mina Pashang
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Krasivskyi I, Djordjevic I, Ivanov B, Eghbalzadeh K, Großmann C, Reichert S, Radwan M, Sandoval Boburg R, Sabashnikov A, Schlensak C, Wahlers T, Rustenbach CJ. Gender-Related Discrepancies in Short-Term Outcomes in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting Surgery. J Clin Med 2023; 12:jcm12062202. [PMID: 36983204 PMCID: PMC10056417 DOI: 10.3390/jcm12062202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/02/2023] [Accepted: 03/10/2023] [Indexed: 03/18/2023] Open
Abstract
The sex differences in patients undergoing off-pump coronary artery bypass grafting (OPCAB) surgery are still unclear. Our aim was to investigate the impact of gender on short-term outcomes in males and females after off-pump bypass procedures. Our research was designed as a double-center retrospective analysis. Generally, 343 patients (men (n = 255) and women (n = 88)) who underwent an OPCAB procedure were included in our study. To provide a statistical analysis of unequal cohorts, we created a propensity score-based matching (PSM) analysis (men, n = 61; women, n = 61). The primary endpoint was all-cause in-hospital mortality. Dialysis, transient ischemic attack (TIA), low cardiac output syndrome (LCOS), reoperation due to postoperative bleeding, wound infection and duration of hospital stay were secondary outcomes in our analysis. No significant differences were detected within the male and female groups regarding age (p = 0.116), BMI (p = 0.221), diabetes (p = 0.853), cardiogenic shock (0.256), STEMI (p = 0.283), NSTEMI (p = 0.555) and dialysis (p = 0.496). Males underwent significantly more frequently (p = 0.005) total-arterial revascularization with T-graft technique (p = 0.005) than females. In contrast, temporary pacer use was significantly higher (p = 0.022) in females compared to males. The in-hospital mortality rate was not significantly higher (p = 0.496) in the female group compared to the male group. Likewise, secondary outcomes did not differ significantly between the non-adjusted and the adjusted groups. Based on our findings, gender has no impact on short-term outcomes after OPCAB surgery.
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Affiliation(s)
- Ihor Krasivskyi
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
- Correspondence: ; Tel.: +49-176-353-88-719
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, Helios Hospital Siegburg, 53721 Siegburg, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Clara Großmann
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Stefan Reichert
- Department of Cardiothoracic Surgery, University Hospital Tuebingen, 72016 Tuebingen, Germany
| | - Medhat Radwan
- Department of Cardiothoracic Surgery, University Hospital Tuebingen, 72016 Tuebingen, Germany
| | - Rodrigo Sandoval Boburg
- Department of Cardiothoracic Surgery, University Hospital Tuebingen, 72016 Tuebingen, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Christian Schlensak
- Department of Cardiothoracic Surgery, University Hospital Tuebingen, 72016 Tuebingen, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
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Chan J, Dimagli A, Fudulu DP, Dong T, Mikova E, Angelini GD. On- versus off-pump CABG in octogenarians: A propensity-matched analysis from the UK National Database. J Card Surg 2022; 37:4705-4712. [PMID: 36321671 PMCID: PMC10092246 DOI: 10.1111/jocs.17068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/01/2022] [Accepted: 10/12/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Coronary artery bypass grafting (CABG) remains a good revascularization strategy in octogenarians with excellent clinical outcomes and quality of life postoperatively. However, the benefits of off-pump over on-pump CABG in the elderly population are still controversial. We investigated this issue in the UK National Audit database. METHOD We retrospectively analyzed all octogenarians undergoing nonemergency, isolated CABG from 1996 to 2019. Propensity score matching (PSM) was conducted to adjust for imbalance in the baseline characteristics between the off-pump and on-pump groups. Primary outcome was in-hospital mortality and postoperative cerebrovascular accidents. Secondary outcomes were bleeding requiring reoperation, deep sternal wound infection, and postoperative dialysis. RESULT A total of 6436 patients were included for analysis. No differences were observed between off- and on-pump group in-hospital mortality (4% vs. 3.8%, p = .89), return to theater rate (5.4% vs. 6.2%, p = .16) and incidence of deep sternal wound infection (1.1% vs. 1.6%, p = .34). However, octogenarian undergoing off-pump CABG were less likely to experience postoperative transient ischemic attack (TIA)/stroke (1.4% vs. 2.3%, p = .004) but more likely to require renal dialysis (4.8% vs. 3.5%, p = .03). CONCLUSION The data show similar in-hospital mortality in octogenarians regardless of the revascularization technique used. Off-pump when compared with on-pump CABG is associated with a lower incidence in postoperative neurological events but a higher need for renal dialysis.
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Affiliation(s)
- Jeremy Chan
- Bristol Heart InstituteUniversity of BristolBristolUK
| | | | | | - Tim Dong
- Bristol Heart InstituteUniversity of BristolBristolUK
| | - Ester Mikova
- Bristol Heart InstituteUniversity of BristolBristolUK
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9
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Ofoegbu CKP, Manganyi RM. Off-Pump Coronary Artery Bypass Grafting; is it Still Relevant? Curr Cardiol Rev 2022; 18:e271021197431. [PMID: 34711166 PMCID: PMC9413736 DOI: 10.2174/1573403x17666211027141043] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/22/2021] [Accepted: 07/29/2021] [Indexed: 11/22/2022] Open
Abstract
Off-pump Coronary Artery Bypass Grafting (OPCAB) experienced a resurgence in the 1980s -2000s and developed steadily with improvement of the instrumentation and techniques. However questions about graft patency and long-term survival of OPCAB patients still exist. This review attempts to explore the current relevance of OPCAB.
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Affiliation(s)
- Chima K P Ofoegbu
- Chris Barnard Division of Cardiothoracic Surgery, Groote Schuur Hospital Cape Town, Cape Town 7925, South Africa
| | - Rodgers M Manganyi
- Chris Barnard Division of Cardiothoracic Surgery, Groote Schuur Hospital Cape Town, Cape Town 7925, South Africa
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10
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Bassano C, Nardi P, Buioni D, Asta L, Pisano C, Bertoldo F, Altieri C, Ruvolo G. Long-Term Follow-Up of Device-Assisted Clampless Off-Pump Coronary Artery Bypass Grafting Compared with Conventional On-Pump Technique. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:275. [PMID: 35010535 PMCID: PMC8750984 DOI: 10.3390/ijerph19010275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/20/2021] [Accepted: 12/25/2021] [Indexed: 06/14/2023]
Abstract
STUDY OBJECTIVE To evaluate the long-term outcomes of clampless off-pump coronary artery bypass grafting (C-OPCAB) compared with conventional on-pump double clamping coronary artery bypass grafting (C-CABG). METHODS From October 2006 to December 2011, 366 patients underwent isolated coronary artery bypass grafting. After propensity score matching of preoperative variables, 143 pairs were selected who received C-OPCAB with the use of device-assisted PAS-Port proximal venous graft anastomoses or C-CABG, performed by the same surgeon experienced in both techniques. Data of the two groups of patients were retrospectively analyzed up to 14 years of follow-up. RESULTS As compared with C-OPCAB, in the C-CABG patients, the performed number of grafts per patient was higher (2.9 ± 0.5 vs. 2.6 ± 0.6, p-value 0.0001). At 14 years, overall survival, including in-hospital death, was 64 ± 4.7% for the C-OPCAB vs. 55 ± 5.5% for the C-CABG, freedom from overall MACCEs 51 ± 6.2% vs. 41 ± 7.7%, and from late cardiac death 94 ± 2.4% vs. 96 ± 2.2% (p-value not significant, for all comparisons). No significant statistical differences were observed in the actual rates of adverse events during follow-up. Independent predictors of survival were advanced age at operation (p-value 0.001) and a lower mean value of preoperative left ventricular ejection fraction (p-value 0.015). CONCLUSIONS Our single-center study analysis suggests that clampless OPCAB using device-assisted proximal anastomoses proved to be not inferior to double-clamping CABG in the long-term follow-up, provided that involved surgeons are familiar with both techniques. These conclusions are supported by a large and long-term follow-up period, eliminating potential bias, i.e., by means of the propensity score matching and analyzing single-surgeon experience.
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Bonacchi M, Howe R, Micali LR, Weigel D, Parise O, Parise G, Gelsomino S. Off-Pump Coronary Artery Bypass Reduces Cardiac Death in Patients with Peripheral Arteriopathy. Thorac Cardiovasc Surg 2021; 69:614-620. [PMID: 33626589 DOI: 10.1055/s-0041-1724036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The aim of this study was to investigate whether the use of off-pump coronary artery bypass (OPCAB) may enhance early outcomes in subjects with peripheral artery disease (PAD) undergoing coronary artery bypass grafting (CABG). METHODS We employed a propensity-score (PS) method to compare early postoperative results of OPCAB and on-pump CABG patients with associated PAD. The study population consisted of 1,961 patients: 284 in the OPCAB and 1,677 in the on-pump CABG group. The inverse probability of treatment weighting was used as PS method. RESULTS The incidence of death (1.2% [95% confidence interval, CI: -0.9 to 3.3%], p = 0.262), stroke (2.2% [95% CI: -1.4 to 5.7%], p = 0.235), acute kidney disease (1.5% [95% CI: -3.8 to 6.8%], p = 0.586), limb ischemia (3.2% [95% CI: -0.6 to 7.0%], p = 0.315), and low output syndrome (1.2% [95% CI: -0.9 to 3.3%], p = 0.262) did not differ between the two groups. On the other hand, the rate of cardiac death (1.2% [95% CI: -0.1 to 2.3%], p = 0.038) was significantly higher in on-pump CABG group. CONCLUSIONS The OPCAB procedure considerably reduced the occurrence of cardiac death after coronary revascularization. This finding might suggest that the OPCAB procedure should be considered as the first option in patients with higher cardiovascular risk scores. Further research is warranted.
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Affiliation(s)
- Massimo Bonacchi
- Cardiac Surgery, University Hospital Careggi, Firenze, Toscana, Italy
- Cardiothoracic Surgery Department, Maastricht University Cardiovascular Research Institute (CARIM), Maastricht, The Netherlands
| | - Rosemary Howe
- Cardiothoracic Surgery Department, Maastricht University Cardiovascular Research Institute (CARIM), Maastricht, The Netherlands
| | - Linda Renata Micali
- Cardiothoracic Surgery Department, Maastricht University Cardiovascular Research Institute (CARIM), Maastricht, The Netherlands
| | - Daniel Weigel
- Cardiothoracic Surgery Department, Maastricht University Cardiovascular Research Institute (CARIM), Maastricht, The Netherlands
| | - Orlando Parise
- Cardiothoracic Surgery Department, Maastricht University Cardiovascular Research Institute (CARIM), Maastricht, The Netherlands
| | - Gianmarco Parise
- Cardiothoracic Surgery Department, Maastricht University Cardiovascular Research Institute (CARIM), Maastricht, The Netherlands
| | - Sandro Gelsomino
- Cardiac Surgery, University Hospital Careggi, Firenze, Toscana, Italy
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Sheikhy A, Fallahzadeh A, Sadeghian S, Forouzannia K, Bagheri J, Salehi-Omran A, Tajdini M, Jalali A, Pashang M, Hosseini K. Mid-term outcomes of off-pump versus on-pump coronary artery bypass graft surgery; statistical challenges in comparison. BMC Cardiovasc Disord 2021; 21:412. [PMID: 34454415 PMCID: PMC8403445 DOI: 10.1186/s12872-021-02213-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 08/18/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite several studies comparing off- and on-pump coronary artery bypass grafting (CABG), the effectiveness and outcomes of off-pump CABG still remain uncertain. METHODS In this registry-based study, we assessed 8163 patients who underwent isolated CABG between 2014 and 2016. Propensity score matching (PSM), inverse probability of weighting (IPW) and covariate adjustment were performed to correct for and minimize selection bias. RESULTS The overall mean age of the patients was 62 years, and 25.7% were women. Patients who underwent off-pump CABG had shorter length of hospitalization (p < 0.001), intubation time (p = 0.003) and length of ICU admission (p < 0.001). Off-pump CABG was associated with higher risk of 30-days mortality (OR: 1.7; 95% CI 1.09-2.65; p = 0.019) in unadjusted analysis. After covariate adjustment and matching (PSM and IPW), this difference was not statistically significant. After an average of 36.1 months follow-up, risk of MACCE and all-cause mortality didn't have significant differences in both surgical methods by adjusting with IPW (HR: 1.03; 95% CI 0.87-1.24; p = 0.714; HR: 0.91; 95% CI 0.73-1.14; p = 578, respectively). CONCLUSION Off-pump and on-pump techniques have similar 30-day mortality (adjusted, PSM and IPW). Off-pump surgery is probably more cost-effective in short term; however, mid-term survival and MACCE trends in both surgical methods are comparable.
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Affiliation(s)
- Ali Sheikhy
- Research Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Aida Fallahzadeh
- Research Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeed Sadeghian
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Khalil Forouzannia
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Jamshid Bagheri
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Abbas Salehi-Omran
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Masih Tajdini
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Arash Jalali
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Mina Pashang
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Kaveh Hosseini
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran.
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Sirin G. Surgical strategies for severely atherosclerotic (porcelain) aorta during coronary artery bypass grafting. World J Cardiol 2021; 13:309-324. [PMID: 34589167 PMCID: PMC8436682 DOI: 10.4330/wjc.v13.i8.309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/27/2021] [Accepted: 07/26/2021] [Indexed: 02/06/2023] Open
Abstract
Porcelain aorta (PA) is an asymptomatic atherosclerotic disease, characterized by circumferential calcification throughout the whole perimeter of the aorta. It is seen in 2% to 9.3% of patients undergoing elective coronary artery bypass grafting (CABG) and makes manipulation of the ascending aorta impossible. It has been clearly shown that most emboli seen and detected during the CABG procedure occur during aortic cross-clamping and aortic side-clamping. Manipulation of porcelain or a severely atherosclerotic aorta increases the risk of perioperative stroke. The incidence of stroke after CABG is between 0.48% and 2.9%, and the risk is correlated with the extent and severity of the atherosclerotic disease. A conventional CABG procedure involves successive steps that include cannulation of the ascending aorta, application of a cross-clamp to the aorta, and partial clamping of the aorta to create the proximal anastomosis. Therefore in procedures that involve cannulation, clamping, or proximal anastomosis, and where aortic manipulation is inevitable, preassessment of the atherosclerotic aortic plaques is crucial. Although many surgeons still rely on intraoperative manual aortic palpation, this approach has very low sensitivity and underestimates the severity of the atherosclerotic illness. Imaging methods including preoperative computed tomography or intraoperative epiaortic ultrasonography enable modification of the surgical technique according to the severity of atherosclerosis. Various surgical techniques have been described to reduce the risk of atheroembolism that may lead to cerebrovascular events in patients with severely atherosclerotic ascending aorta. Anaortic or "no-touch" techniques that do not utilize aortic manipulation may significantly decrease the development of neurological complications by avoiding aortic maneuvers known to cause emboli. In cases where severe atherosclerotic disease or other factors preclude safe use of the ascending aorta, modifications in the surgical techniques, such as switching to different cannulation sites including the axillary/subclavian, femoral and innominate arteries, or using hypothermic ventricular fibrillation and in-situ pedicled arterial grafts, or performing proximal anastomoses at alternative anatomical locations will enable CABG operations to be performed safely with low morbidity and mortality rates in patients with porcelain aortas.
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Affiliation(s)
- Gokce Sirin
- Department of Cardiovascular Surgery, Biruni University, Istanbul 34010, Turkey
- Department of Cardiovascular Surgery, Camlica Medicana Hospital, Istanbul 34692, Turkey.
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Surgical strategies for severely atherosclerotic (porcelain) aorta during coronary artery bypass grafting. World J Cardiol 2021. [DOI: 10.4330/wjc.v13.i8.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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15
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Lazar HL. Commentary: Percutaneous coronary intervention for left main lesions: Once again coronary artery bypass grafting gets the shaft. J Thorac Cardiovasc Surg 2021:S0022-5223(21)01235-6. [PMID: 34456054 DOI: 10.1016/j.jtcvs.2021.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 08/15/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Harold L Lazar
- Division of Cardiac Surgery, Boston University School of Medicine, Boston, Mass.
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On-Pump Beating Heart versus Off-Pump Coronary Artery Bypass Graft Surgery: Short-Term Follow-up Outcomes of a Single Center. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2021. [DOI: 10.2478/jce-2021-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract
Background and Aim: Novel surgical approaches are gaining attention in an attempt to overcome possible adverse events following coronary artery bypass graft (CABG) surgery. This single-center study aimed to evaluate and compare the early postoperative outcomes of on-pump beating-heart (OPBH-CABG) versus off-pump CABG surgery in similar risk groups with a total number of 1–2 grafts.
Methods: The records of a total of 229 patients who underwent non-emergency, primary, isolated, either OPBH-CABG (n = 32) or off-pump CABG (n = 197) surgery were retrospectively evaluated. Reported outcome measures included baseline data, the number of coronary artery grafts, prophylactic intra-aortic balloon pump, time of extubation from mechanical ventilation, duration of stay in the coronary ICU and hospital, as well as early postoperative complications, in-hospital and early postoperative mortality.
Results: The groups were identical with regards to age and BMI. The patients in the off-pump group received a higher number of grafts (1.84 ± 0.36 vs. 1.18 ± 0.39, p <0.0001). The OPBH-CABG group had a higher Euroscore II score (2.514 ± 1.68 vs. 1.706 ± 1.93, p = 0.021). The time to extubation after the surgery, postoperative length of ICU stay, and total length of hospital stay were similar between the groups (p = 0.2228; p = 0.098; p = 0.717, respectively). The incidence of arrythmia and atrial fibrillation was higher in the on-pump group (12.5% vs. 2.53%, p <0.05). One patient in the on-pump, and four patients in the off-pump groups deceased due to postoperative complications.
Conclusions: OPBH-CABG surgery is comparable to off-pump CABG in terms of early postoperative outcomes. In patients who underwent OPBH-CABG, the risk of arrythmia and atrial fibrillation should be of concern and solved with optimal strategies.
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17
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Borgomoni GB, Mejia OAV, Orlandi BMM, Goncharov M, Lisboa LAF, Conte PH, Oliveira MAP, Fiorelli AI, Petrucci O, Tiveron MG, Dallan LADO, Jatene FB. Current Impact of Cardiopulmonary Bypass in Coronary Artery Bypass Grafting in São Paulo State. Arq Bras Cardiol 2020; 115:595-601. [PMID: 33111853 PMCID: PMC8386981 DOI: 10.36660/abc.20190145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 08/12/2019] [Accepted: 08/18/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Previous results on the use of cardiopulmonary bypass (CPB) have generated difficulties in choosing the best treatment for each patient undergoing myocardial revascularization surgery (CABG) in the current context. OBJECTIVE Evaluate the current impact of CPB in CABG in São Paulo State. METHODS A total of 2905 patients who underwent CABG were consecutively analyzed in 11 São Paulo State centers belonging to the São Paulo Registry of Cardiovascular Surgery (REPLICCAR) I. Perioperative and follow-up data were included online by trained specialists in each hospital. Associations of the perioperative variables with the type of procedure and with the outcomes were analyzed. The study outcomes were morbidity and operative mortality. The expected mortality was calculated using EuroSCORE II (ESII). The values of p <5% were considered significant. RESULTS There were no significant differences concerning the patients' age between the groups (p=0.081). 72.9% of the patients were males. Of the patients, 542 underwent surgery without CPB (18.7%). Of the preoperative characteristics, patients with previous myocardial infarction (p=0.005) and ventricular dysfunction (p=0.031) underwent surgery with CPB. However, emergency or New York Heart Association (NYHA) class IV patients underwent surgery without CPB (p<0.001). The ESII value was similar in both groups (p=0.427). In CABG without CPB, the radial graft was preferred (p<0.001), and in CABG with CPB the right mammary artery was the preferred one (p<0.001). In the postoperative period, CPB use was associated with reoperation for bleeding (p=0.012). CONCLUSION Currently in the REPLICCAR, reoperation for bleeding was the only outcome associated with the use of CPB in CABG. (Arq Bras Cardiol. 2020; 115(4):595-601).
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Affiliation(s)
- Gabrielle Barbosa Borgomoni
- Universidade de São PauloUniversidade de São PauloFaculdade de Medicina Hospital das ClínicasSão PauloSPBrasil Universidade de São Paulo - Faculdade de Medicina Hospital das Clínicas - Instituto do Coração, São Paulo, SP - Brasil
| | - Omar Asdrúbal Vilca Mejia
- Universidade de São PauloUniversidade de São PauloFaculdade de Medicina Hospital das ClínicasSão PauloSPBrasil Universidade de São Paulo - Faculdade de Medicina Hospital das Clínicas - Instituto do Coração, São Paulo, SP - Brasil
- Hospital Samaritano PaulistaSão PauloHospital Samaritano PaulistaSão PauloSPBrasil Hospital Samaritano Paulista, São Paulo, SP - Brasil
| | - Bianca Maria Maglia Orlandi
- Universidade de São PauloUniversidade de São PauloFaculdade de Medicina Hospital das ClínicasSão PauloSPBrasil Universidade de São Paulo - Faculdade de Medicina Hospital das Clínicas - Instituto do Coração, São Paulo, SP - Brasil
| | - Maxim Goncharov
- Universidade de São PauloUniversidade de São PauloFaculdade de Medicina Hospital das ClínicasSão PauloSPBrasil Universidade de São Paulo - Faculdade de Medicina Hospital das Clínicas - Instituto do Coração, São Paulo, SP - Brasil
| | - Luiz Augusto Ferreira Lisboa
- Universidade de São PauloUniversidade de São PauloFaculdade de Medicina Hospital das ClínicasSão PauloSPBrasil Universidade de São Paulo - Faculdade de Medicina Hospital das Clínicas - Instituto do Coração, São Paulo, SP - Brasil
| | - Pedro Henrique Conte
- Beneficência Portuguesa de São PauloSão PauloBeneficência Portuguesa de São PauloSão PauloSPBrasil Beneficência Portuguesa de São Paulo, São Paulo, SP - Brasil
| | - Marco Antonio Praca Oliveira
- Beneficência Portuguesa de São PauloSão PauloBeneficência Portuguesa de São PauloSão PauloSPBrasil Beneficência Portuguesa de São Paulo, São Paulo, SP - Brasil
| | - Alfredo Inácio Fiorelli
- Universidade de São PauloUniversidade de São PauloFaculdade de Medicina Hospital das ClínicasSão PauloSPBrasil Universidade de São Paulo - Faculdade de Medicina Hospital das Clínicas - Instituto do Coração, São Paulo, SP - Brasil
| | - Orlando Petrucci
- Universidade Estadual CampinasUniversidade Estadual CampinasFaculdade de Ciências MédicasCampinasSPBrasil Universidade Estadual Campinas FCM Unicamp - Faculdade de Ciências Médicas, Campinas, SP - Brasil
| | - Marcos Grandim Tiveron
- Hospital Santa Casa de Misericórdia MaríliaHospital Santa Casa de Misericórdia MaríliaMaríliaSPBrasil Hospital Santa Casa de Misericórdia Marília, Marília, SP - Brasil
| | - Luís Alberto de Oliveira Dallan
- Universidade de São PauloUniversidade de São PauloFaculdade de Medicina Hospital das ClínicasSão PauloSPBrasil Universidade de São Paulo - Faculdade de Medicina Hospital das Clínicas - Instituto do Coração, São Paulo, SP - Brasil
| | - Fabio Biscegli Jatene
- Universidade de São PauloUniversidade de São PauloFaculdade de Medicina Hospital das ClínicasSão PauloSPBrasil Universidade de São Paulo - Faculdade de Medicina Hospital das Clínicas - Instituto do Coração, São Paulo, SP - Brasil
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Moreno PR, Stone GW, Gonzalez-Lengua CA, Puskas JD. The Hybrid Coronary Approach for Optimal Revascularization. J Am Coll Cardiol 2020; 76:321-333. [DOI: 10.1016/j.jacc.2020.04.078] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/17/2020] [Accepted: 04/20/2020] [Indexed: 11/25/2022]
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Narayan P, Shales S. Commentary on "Ten-year improved survival in patients with multi-vessel coronary disease and poor left ventricular function following surgery: A retrospective cohort study". Int J Surg 2020; 77:136-137. [PMID: 32247082 DOI: 10.1016/j.ijsu.2020.03.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 03/23/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Pradeep Narayan
- Department of Cardiac Surgery, NH Rabindranath Tagore International Institute of Cardiac Sciences; Kolkata, India.
| | - Sufina Shales
- Department of Cardiac Surgery, NH Rabindranath Tagore International Institute of Cardiac Sciences; Kolkata, India
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Nadeem R, Agarwal S, Jawed S, Yasser A, Altahmody K. Impact of Cardiopulmonary Bypass Time on Postoperative Duration of Mechanical Ventilation in Patients Undergoing Cardiovascular Surgeries: A Systemic Review and Regression of Metadata. Cureus 2019; 11:e6088. [PMID: 31857920 PMCID: PMC6897343 DOI: 10.7759/cureus.6088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The objective of this study was to detect if cardiopulmonary bypass time duration has any impact on the duration of postoperative mechanical ventilation (MV). The study design was a systematic review and regression analysis of pooled data from previously published studies. All available data are from prospective, retrospective, cross-sectional, and observational studies. Participants included only patient/human studies. There were no interventions. PubMed and Cochrane libraries were searched by utilizing different combinations of keywords: cardiopulmonary bypass and mechanical ventilation. Inclusion criteria were: (1) English articles, (2) studies with an adult population that underwent cardiac surgeries using cardiopulmonary bypass (CPB), (3) studies where the duration of CPB is provided as well as the duration of mechanical ventilation. A regression analysis was performed on the metadata. For the hours of MV, eight studies with 13 data sets (as some studies provide data in subgroups) were included for a total number of 989 subjects. The duration of CPB ranged from 55 to 173.5 minutes for these operations. Postoperative MV hours ranged from nine to 408 hours. Stepwise multiple regression analysis found that cardiopulmonary bypass time (CPBT), age, diabetes, male gender, and ejection fraction correlated with prolonged mechanical ventilation; CPBT was the most strongly correlated variable. Cardiopulmonary bypass time appears to affect clinical outcomes adversely and is associated with prolonged MV. Avoiding CPB or limiting it to a minimum may decrease the days of MV required.
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Affiliation(s)
| | | | - Shafaq Jawed
- Surgery, Jinnah Sindh Medical University, Karachi, PAK
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Abstract
Objectives Outcomes after coronary artery bypass grafting (CABG) are worse in women than in men. This study aims to investigate whether off-pump coronary artery bypass (OPCAB) surgery improves the outcomes in women by comparing different outcome measures in both genders. Methods Patients who underwent isolated CABG, either on-pump (ONCAB) or OPCAB, between January 1998 and June 2017 were included. Primary endpoints were 30-day and 120-day mortality. Logistic regression models were constructed to evaluate the effect of the CABG technique on important outcomes such as mortality and the need for blood transfusion. Results The data of 17,052 patients were analysed, 3,684 of whom were women (414 OPCAB) and 13,368 men (1,483 OPCAB). The mean number of grafts was lower in the OPCAB group of both genders (p < 0.001). Postoperatively, both men and women undergoing OPCAB surgery received fewer red blood cell transfusions (p < 0.001) and had higher postoperative haemoglobin levels (p < 0.001) than those undergoing ONCAB. Early mortality occurred less frequently after OPCAB surgery in both genders, although the difference was not significant. However, 120-day mortality was significantly lower after OPCAB surgery in women, even after correction for preoperative risk factors [odds ratio (OR) = 0.356, 95% confidence interval (CI) 0.144–0.882, p = 0.026]. The difference in 120-day mortality was not significant in men (OR = 0.787, 95% CI 0.498–1.246, p = 0.307). Conclusions Women undergoing CABG benefit more from OPCAB surgery than from ONCAB surgery in terms of 120-day mortality. This difference was not found in men in our patient population.
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Farina P, Gaudino M, Angelini GD. Off-pump coronary artery bypass surgery: The long and winding road. Int J Cardiol 2019; 279:51-55. [DOI: 10.1016/j.ijcard.2018.09.101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/23/2018] [Accepted: 09/25/2018] [Indexed: 11/27/2022]
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Tena MÁ, Urso S, Martínez-Comendador JM, Bellot R, Gutiérrez EM, González JM, Sadaba R, Meca J, Ríos L, Abad C, Portela F. Cirugía coronaria sin bomba: revisión sistemática contemporánea y metaanálisis de sus resultados respecto a la cirugía con circulación extracorpórea. CIRUGIA CARDIOVASCULAR 2019. [DOI: 10.1016/j.circv.2018.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Paez RP, Hossne Junior NA, Santo JADE, Berwanger O, Santos RHN, Kalil RAK, Jatene FB, Cavalcanti AB, Zilli AC, Bettiati Jr LC, Figueira FAMDS, D'Azevedo SSP, Soares MJF, Fernandes MP, Ardito RV, Bogdan RAB, Campagnucci VP, Nakasako D, Rodrigues CG, Rodrigues Junior AB, Cascudo MM, Atik FA, Lima EB, Nina VJDS, Heluy RA, Azeredo LG, Henrique Junior OS, de Mendonça JT, Silva KKDOG, Pandolfo M, de Lima Júnior JD, Faria RM, dos Santos JG, Coelho GHB, Pereira SN, Senger R, Buffolo E, Caputi GM, de Oliveira JAB, Gomes WJ, BYPASS Registry Study Group. Coronary Artery Bypass Surgery in Brazil: Analysis of the National Reality Through the BYPASS Registry. Braz J Cardiovasc Surg 2019; 34:142-148. [PMID: 30916123 PMCID: PMC6436784 DOI: 10.21470/1678-9741-2018-0313] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/27/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Coronary artery bypass grafting (CABG) is the most frequently performed heart surgery in Brazil. Recent international guidelines recommend that national societies establish a database on the practice and results of CABG. In anticipation of the recommendation, the BYPASS Registry was introduced in 2015. OBJECTIVE To analyze the profile, risk factors and outcomes of patients undergoing CABG in Brazil, as well as to examine the predominant surgical strategy, based on the data included in the BYPASS Registry. METHODS A cross-sectional study of 2292 patients undergoing CABG surgery and cataloged in the BYPASS Registry up to November 2018. Demographic data, clinical presentation, operative variables, and postoperative hospital outcomes were analyzed. RESULTS Patients referred to CABG in Brazil are predominantly male (71%), with prior myocardial infarction in 41.1% of cases, diabetes in 42.5%, and ejection fraction lower than 40% in 9.7%. The Heart Team indicated surgery in 32.9% of the cases. Most of the patients underwent cardiopulmonary bypass (87%), and cardioplegia was the strategy of myocardial protection chosen in 95.2% of the cases. The left internal thoracic artery was used as a graft in 91% of the cases; the right internal thoracic artery, in 5.6%; and the radial artery in 1.1%. The saphenous vein graft was used in 84.1% of the patients, being the only graft employed in 7.7% of the patients. The median number of coronary vessels treated was 3. Operative mortality was 2.8%, and the incidence of cerebrovascular accident was 1.2%. CONCLUSION CABG data in Brazil provided by the BYPASS Registry analysis are representative of our national reality and practice. This database constitutes an important reference for indications and comparisons of therapeutic procedures, as well as to propose subsequent models to improve patient safety and the quality of surgical practice in the country.
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Affiliation(s)
- Rodrigo Pereira Paez
- Hospital São Paulo, Escola Paulista de Medicina da
Universidade Federal de São Paulo, (EPM - UNIFESP), São Paulo, SP,
Brazil
| | - Nelson Américo Hossne Junior
- Hospital São Paulo, Escola Paulista de Medicina da
Universidade Federal de São Paulo, (EPM - UNIFESP), São Paulo, SP,
Brazil
| | | | - Otavio Berwanger
- Instituto de Pesquisa do Hospital do Coração (IP -
HCor), São Paulo, SP, Brazil
| | | | - Renato Abdala Karam Kalil
- Instituto de Cardiologia do Rio Grande do Sul -
Fundação Universitária de Cardiologia, Porto Alegre, RS,
Brazil
| | - Fabio B. Jatene
- Cardiovascular Surgery Division, Instituto do Coração
do Hospital das Clínicas da Faculdade de Medicina da Universidade de
São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | | | | | | | | | | | | | | | - Roberto Vito Ardito
- Instituto de Moléstias Cardiovasculares (IMC), São
José do Rio Preto, SP, Brazil
| | | | - Valquíria Pelisser Campagnucci
- Irmandade da Santa Casa de São Paulo (INCT-HPV/Faculdade de
Ciências Médicas da Santa Casa de São Paulo), São Paulo,
SP, Brazil
| | - Diana Nakasako
- Irmandade da Santa Casa de São Paulo (INCT-HPV/Faculdade de
Ciências Médicas da Santa Casa de São Paulo), São Paulo,
SP, Brazil
| | - Clarissa Garcia Rodrigues
- Instituto de Cardiologia do Rio Grande do Sul -
Fundação Universitária de Cardiologia, Porto Alegre, RS,
Brazil
| | | | | | | | | | | | | | | | | | | | | | - Marcelo Pandolfo
- Instituto de Cirurgia Cardiovascular (ICCV)/Hospital Nossa Senhora
da Salete, Cascavel, PR, Brazil
| | | | | | | | | | | | - Roberta Senger
- Hospital Universitário de Santa Maria, Santa Maria, RS,
Brazil
| | - Enio Buffolo
- Hospital do Coração (HCor), São Paulo, SP,
Brazil
| | | | | | - Walter J. Gomes
- Hospital São Paulo, Escola Paulista de Medicina da
Universidade Federal de São Paulo, (EPM - UNIFESP), São Paulo, SP,
Brazil
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Butt JH, Olsen PS, Torp-Pedersen C, Gislason GH, Køber L, Fosbøl EL. Burden and causes for hospitalizations following coronary artery bypass grafting: a nationwide cohort study†. Eur J Cardiothorac Surg 2019; 55:893-902. [DOI: 10.1093/ejcts/ezy418] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 09/21/2018] [Accepted: 10/29/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Skov Olsen
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Gunnar H Gislason
- Department of Cardiology, Herlev-Gentofte University Hospital, Hellerup, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
- The National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Abstract
See Article by Gaudino et al .
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Affiliation(s)
- Harold L Lazar
- 1 Division of Cardiac Surgery Boston University School of Medicine Boston MA
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Hueb W, Rezende PC, Gersh BJ, Soares PR, Favarato D, Lima EG, Garzillo CL, Jatene FB, Ramires JAF, Filho RK. Ten-Year Follow-Up of Off-Pump and On-Pump Multivessel Coronary Artery Bypass Grafting: MASS III. Angiology 2018; 70:337-344. [PMID: 30286625 DOI: 10.1177/0003319718804402] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
It was a randomized trial, and 308 patients undergoing revascularization were randomly assigned: 155 to off-pump coronary artery bypass (OPCAB) and 153 to on-pump coronary artery bypass (ONCAB). End points were freedom from death, myocardial infarction, revascularization, and cerebrovascular accidents. The rates for 10-year, event-free survival for ONCAB versus OPCAB were 69.6% and 64%, (hazard ratio [HR]: 0.88; 95% confidence interval [CI] 0.86-1.02; P = .41), respectively. Adjusted Cox proportional hazard ratio was similar (HR: 0.92; 95% CI 0.61-1.38, P = .68). A difference occurred between the duration of OPCAB and ONCAB, respectively (4.9 ± 1.5 vs 6.6 ± 1.1 h, P < .001). Statistical differences occurred between OPCAB and ONCAB in the length of intensive care unit (ICU) stay (20 ± 2.5 vs 48 ± 10 hours, P < .001), time to extubation (5.5 ± 4.2 vs 10.2 ± 3.5 hours, P < .001), hospital stay (6.7 ± 1.4 vs 9.2 ± 1.3 days, P < .001), higher incidence of atrial fibrillation (AF; 33 vs 5 patients, P < .001), and blood requirements (46 vs 64 patients, P < .001). Grafts per patient was higher in ONCAB (3.15 vs 2.55 grafts, P < .001). No difference existed between the groups in primary composite end points at 10-year follow-up. Although OPCAB surgery was related to a lower number of grafts and higher incidence of AF, it had no effects related to long-term outcomes.
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Affiliation(s)
- Whady Hueb
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Paulo Cury Rezende
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Paulo Rogério Soares
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Desidério Favarato
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo Gomes Lima
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Cibele Larrosa Garzillo
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Fabio B Jatene
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - José Antonio Franchini Ramires
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Roberto Kalil Filho
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Go on-pump or off-pump in diabetic patients? J Thorac Cardiovasc Surg 2018; 157:972-973. [PMID: 30266393 DOI: 10.1016/j.jtcvs.2018.08.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 08/20/2018] [Indexed: 11/23/2022]
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Wagner TH, Hattler B, Bakaeen FG, Collins JF, Almassi GH, Quin JA, Grover FL, Bishawi M, Shroyer ALW. Costs Five Years After Off-Pump or On-Pump Coronary Artery Bypass Surgery. Ann Thorac Surg 2018; 107:99-105. [PMID: 30273569 DOI: 10.1016/j.athoracsur.2018.07.075] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/28/2018] [Accepted: 07/23/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is a common surgical treatment for ischemic heart disease. Little is known about the long-term costs of conducting the surgery on-pump or off-pump. METHODS As part of the Randomized On/Off Bypass follow-up study, we followed 2,203 participants randomized to on-pump (n = 1,099) and off-pump (n = 1,104) CABG for 5 years using Department of Veterans Affairs and Medicare administrative data. We examined annual costs through 5 years, standardized to 2016 dollars, using multivariate regression models, controlling for site and baseline patient factors. RESULTS In the first year, including the CABG surgery, annual average costs were $66,599 (SE, $1,946) for the on-pump group and $70,552 (SE, $1,954) for the off-pump group. In years 2 to 5, average costs ranged from $15,000 to $20,000 per year. There was no significant difference between on-pump and off-pump across the 5 years. We explored differences among high-risk subgroups (diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, cerebrovascular disease, renal dysfunction, ejection fraction < 35%, over age 70 years), and found no treatment assignment by time interactions, except for a nonsignificant trend in patients with diabetes. CONCLUSIONS At 5 years, the average costs of off-pump and on-pump CABG patients did not statistically differ. Costs do not favor one approach and the decision should be based on clinical risks, especially in subgroups. Future research is warranted to examine post-CABG costs and outcomes for diabetic patients over time.
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Affiliation(s)
- Todd H Wagner
- VA Palo Alto Health Economics Resource Center, Menlo Park, California; Department of Surgery, Stanford University, Palo Alto, California.
| | - Brack Hattler
- Eastern Colorado Health Care System, Department of Veterans Affairs, Denver, Colorado; University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Joseph F Collins
- Cooperative Studies Program Coordinating Center, Veterans Affairs Medical Center, Perry Point, Maryland
| | - G Hossein Almassi
- Veterans Affairs Medical Center, Milwaukee, Wisconsin; Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Frederick L Grover
- Eastern Colorado Health Care System, Department of Veterans Affairs, Denver, Colorado; University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
| | - Muath Bishawi
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - A Laurie W Shroyer
- Eastern Colorado Health Care System, Department of Veterans Affairs, Denver, Colorado; Northport VA Medical Center, Northport, New York
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Chikwe J, Lee T, Itagaki S, Adams DH, Egorova NN. Long-Term Outcomes After Off-Pump Versus On-Pump Coronary Artery Bypass Grafting by Experienced Surgeons. J Am Coll Cardiol 2018; 72:1478-1486. [DOI: 10.1016/j.jacc.2018.07.029] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 07/02/2018] [Indexed: 10/28/2022]
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Lin CH, Hsu RB. Which Procedure, or Which Patient? ACTA CARDIOLOGICA SINICA 2017; 33:551-552. [PMID: 28959110 DOI: 10.6515/acs20170626a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Cheng-Hsin Lin
- Department of Surgery, Shuang Ho Hospital, and College of Medicine, Taipei Medical University
| | - Ron-Bin Hsu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Filardo G, Hamman BL, da Graca B, Sass DM, Machala NJ, Ismail S, Pollock BD, Collinsworth AW, Grayburn PA. Efficacy and effectiveness of on- versus off-pump coronary artery bypass grafting: A meta-analysis of mortality and survival. J Thorac Cardiovasc Surg 2017; 155:172-179.e5. [PMID: 28958597 DOI: 10.1016/j.jtcvs.2017.08.026] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 07/24/2017] [Accepted: 08/09/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Despite many studies comparing on- versus off-pump coronary artery bypass graft (CABG), there is no consensus as to whether one of these techniques offers patients better outcomes. METHODS We searched PubMed from inception to June 30, 2015, and identified additional studies from bibliographies of meta-analyses and reviews. We identified 42 randomized controlled trials (RCTs) and 31 rigorously adjusted observational studies (controlling for the Society of Thoracic Surgeons-recognized risk factors for mortality) reporting mortality for off-pump versus on-pump CABG at specified time points. Trial data were extracted independently by 2 researchers using a standardized form. Differences in probability of mortality (DPM) were estimated for the RCTs and observational studies separately and combined, for time points ranging from 30 days to 10 years. RESULTS RCT-only data showed no significant differences at any time point, whereas observational-only data and the combined analysis showed short-term mortality favored off-pump CABG (n = 1.2 million patients; 36 RCTs, 26 observational studies; DPM [95% confidence interval (CI)], -44.8% [-45.4%, -43.8%]) but that at 5 years it was associated with significantly greater mortality (n = 60,405 patients; 3 RCTs, 5 observational studies; DPM [95% CI], 10.0% [5.0%, 15.0%]). At 10 years, only observational data were available, and off-pump CABG showed significantly greater mortality (DPM [95% CI], 14.0% [11.0%, 17.0%]). CONCLUSIONS Evidence from RCTs showed no differences between the techniques, whereas rigorously adjusted observational studies (with >1.1 million patients) and the combined analysis indicated that off-pump CABG offers lower short-term mortality but poorer long-term survival. These results suggest that, in real-world settings, greater operative safety with off-pump CABG comes at the expense of lasting survival gains.
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Affiliation(s)
- Giovanni Filardo
- Department of Epidemiology, Baylor Scott & White Health, Dallas, Tex; Robbins Institute for Health Policy and Research, Baylor University, Waco, Tex; Department of Statistics, Southern Methodist University, Dallas, Tex.
| | - Baron L Hamman
- Department of Cardiothoracic Surgery, Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Tex
| | - Briget da Graca
- Center for Clinical Effectiveness, Baylor Scott & White Health, Dallas, Tex; Robbins Institute for Health Policy and Research, Baylor University, Waco, Tex
| | - Danielle M Sass
- Department of Epidemiology, Baylor Scott & White Health, Dallas, Tex
| | - Natalie J Machala
- Department of Epidemiology, Baylor Scott & White Health, Dallas, Tex
| | - Safiyah Ismail
- Department of Epidemiology, Baylor Scott & White Health, Dallas, Tex
| | - Benjamin D Pollock
- Department of Epidemiology, Baylor Scott & White Health, Dallas, Tex; Robbins Institute for Health Policy and Research, Baylor University, Waco, Tex
| | - Ashley W Collinsworth
- Center for Clinical Effectiveness, Baylor Scott & White Health, Dallas, Tex; Robbins Institute for Health Policy and Research, Baylor University, Waco, Tex
| | - Paul A Grayburn
- Department of Cardiology, Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Tex
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Abstract
PURPOSE OF REVIEW The techniques of coronary artery bypass grafting (CABG) have evolved remarkably over the last two decades since the introduction of off-pump coronary artery bypass (OPCAB). This article focuses on the clinical outcomes of 'clampless' CABG strategies, that include OPCAB with a partial clamp, OPCAB with a proximal suture device, and aorta no-touch OPCAB. RECENT FINDINGS Observational studies have shown the superiority of OPCAB for preventing strokes and pulmonary complications. Conversely, recent large-scale randomized controlled trials (RCTs) have been unable to demonstrate the benefits of OPCAB. Because of these differing results across numerous studies, the debate about the overall superiority of OPCAB versus on-pump CABG remains controversial. However, the literature regarding the OPCAB technique with minimized manipulation of the aorta suggests this has likely benefits, especially for high-risk patients. SUMMARY Previous large RCTs did not focus on specific approaches of OPCAB or the importance of the experience of surgeons and institutions, and so further studies are needed. Observational studies and meta-analyses have indicated that improved outcomes can be achieved by applying specific OPCAB approaches according to each patient's characteristics.
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Wang Y, Zhu S, Gao P, Zhou J, Zhang Q. Off-pump versus on-pump coronary surgery in patients with chronic kidney disease: a meta-analysis. Clin Exp Nephrol 2017. [DOI: 10.1007/s10157-017-1432-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Miao N, Yang F, Du Z, Jiang C, Hao X, Wang J, Jiang Y, Yang X, Xie H, Hou X. Mortality risk factors from converting off-pump coronary artery bypass to on-pump coronary artery bypass. Perfusion 2017; 32:554-560. [PMID: 28425317 DOI: 10.1177/0267659117705193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: A number of large-scale retrospective studies revealed that off-pump coronary artery bypass (OPCAB) was superior to on-pump coronary artery bypass (ONCAB). The aim of the study was to investigate risk factors for mortality when OPCAB is converted to ONCAB. Methods: Patients who underwent OPCAB conversion to ONCAB at the Beijing Anzhen Hospital between January 2003 and January 2013 were assigned to the non-survivor and survivor groups. Background demographics, illness history and preoperative, intraoperative and postoperative variables were compared. Results: Of the 247 cases, 15.4% of the patients died. Patients in the non-survivor group were older and more frequently had diabetes mellitus (DM), arrhythmia, myocardial infarction (MI) in the past 30 days (all p<0.05) and MI combined with mitral regurgitation (p<0.0001); they more frequently had bigger left ventricular end-diastolic dimension (p=0.0019), greater fall in blood pressure, ventricular fibrillation for longer periods, longer conversion time and bypass graft occlusion. All patients in the non-survivor group received intra-aortic balloon pump compared to 89.5% in the survivor group and extracorporeal membrane oxygenation was more common. Left main coronary artery disease (OR=4.431, 95%CI: 2.440-8.048, p<0.0001), blood pressure decline ⩽40 mmHg (OR=0.509, 95%CI: 0.447-0.580, p<0.0001) and time for conversion to ONCAB ⩾20 min were independently associated with mortality. Rates of postoperative complications, such as renal failure, cerebral infarction or hemorrhage, MI and redo sternotomy, were higher in the non-survivor group. Conclusions: Conversion from OPCAB to ONCAB is associated with high mortality. Risk factors include left main artery disease and duration of blood pressure decline >40 min.
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Affiliation(s)
- Na Miao
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Feng Yang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Zhongtao Du
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Chunjing Jiang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Xing Hao
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Jinhong Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Yu Jiang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Xiaofang Yang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Haixiu Xie
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anding Road, Chaoyang District, Beijing 100029, China
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Apostolakis E, Papakonstantinou NA, Koniari I. Myocardial revascularization without extracorporeal circulation; Why hasn't it convinced yet? Ann Card Anaesth 2017; 20:219-225. [PMID: 28393784 PMCID: PMC5408529 DOI: 10.4103/aca.aca_39_16] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Extracorporeal circulation has led to a great development in cardiovascular surgery during the last five decades. Its time-proven efficacy and safety have made on-pump coronary artery bypass grafting (CABG) the gold standard method of surgical revascularization. However, coronary revascularization on cardiopulmonary bypass and the accompanying aortic manipulation are related to plenty of deleterious complications. Therefore, off-pump CABG surgery was established to avoid complications. Nevertheless, despite the initial enthusiasm on this technique, only 20% of myocardial revascularization procedures worldwide are performed off-pump. Not only are off-pump cardiac procedures more technically difficult but also they do not provide better results in terms of graft patency, completeness of revascularization, repeat revascularization requirement, cost, and quality of life. Completeness of revascularization and anastomotic quality should not be compromised to avoid cardiopulmonary bypass.
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Affiliation(s)
- Efstratios Apostolakis
- Department of Cardiothoracic Surgery, University Hospital of Ioannina, School of Medicine, 45500 Ioannina, Greece
| | | | - Ioanna Koniari
- Department of Cardiothoracic Surgery, University Hospital of Patras, School of Medicine, Rion 26500, Patras, Greece
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Moreyra AE, Maniatis GA, Gu H, Swerdel JN, McKinney JS, Cosgrove NM, Kostis WJ, Kostis JB. Frequency of Stroke After Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting (from an Eleven-Year Statewide Analysis). Am J Cardiol 2017; 119:197-202. [PMID: 27817795 DOI: 10.1016/j.amjcard.2016.09.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/21/2016] [Accepted: 09/21/2016] [Indexed: 10/20/2022]
Abstract
We compared stroke rates associated with coronary artery bypass grafting (CABG), both on-pump and off-pump, and percutaneous coronary intervention (PCI) with both drug-eluting stent (DES) and bare-metal stent (BMS) and the impact on 30-day and 1-year all-cause mortality. The Myocardial Infarction Data Acquisition System database was used to study patients who had on-pump CABG (n = 47,254), off-pump CABG (n = 19,118), and PCI with BMS (n = 46,641), and DES (n = 115,942) in New Jersey from 2002 to 2012. Multiple logistic and Cox proportional hazard models were used to compare the risk of stroke and mortality. Adjustments were made for demographics, year of hospitalization, and co-morbidities. The rate of postprocedural stroke was lowest with DES (0.5%), followed by BMS (0.6%), off-pump CABG (1.3%), and on-pump CABG (1.8%). After adjustment, on-pump CABG had a higher risk of stroke compared with off-pump (odds ratio 1.36, 95% CI 1.18 to 1.56, p <0.0001). DES had lower risk of stroke compared with off-pump CABG (odds ratio 0.64, 95% CI 0.55 to 0.74, p <0.0001). There was a significant excess risk of 1-year mortality due to the interaction between stroke and procedure type (on-pump vs off-pump CABG and PCI with DES vs BMS; p value for interaction = 0.02). In conclusion, in this retrospective analysis of nonrandomized data from a statewide database, PCI with DES was associated with the lowest rate of postprocedural stroke, and off-pump CABG had a lower rate of postprocedural stroke than on-pump CABG; there was an excess 1-year mortality risk with on-pump versus off-pump CABG and with DES versus BMS in patients with stroke.
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Affiliation(s)
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- Cardiovascular Institute and the Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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38
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Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Straka Z, Piegas LS, Avezum A, Akar AR, Lanas Zanetti F, Jain AR, Noiseux N, Padmanabhan C, Bahamondes JC, Novick RJ, Tao L, Olavegogeascoechea PA, Airan B, Sulling TA, Whitlock RP, Ou Y, Gao P, Pettit S, Yusuf S. Five-Year Outcomes after Off-Pump or On-Pump Coronary-Artery Bypass Grafting. N Engl J Med 2016; 375:2359-2368. [PMID: 27771985 DOI: 10.1056/nejmoa1601564] [Citation(s) in RCA: 285] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND We previously reported that there was no significant difference at 30 days or at 1 year in the rate of the composite outcome of death, stroke, myocardial infarction, or renal failure between patients who underwent coronary-artery bypass grafting (CABG) performed with a beating-heart technique (off-pump) and those who underwent CABG performed with cardiopulmonary bypass (on-pump). We now report the results at 5 years (the end of the trial). METHODS A total of 4752 patients (from 19 countries) who had coronary artery disease were randomly assigned to undergo off-pump or on-pump CABG. For this report, we analyzed a composite outcome of death, stroke, myocardial infarction, renal failure, or repeat coronary revascularization (either CABG or percutaneous coronary intervention). The mean follow-up period was 4.8 years. RESULTS There were no significant differences between the off-pump group and the on-pump group in the rate of the composite outcome (23.1% and 23.6%, respectively; hazard ratio with off-pump CABG, 0.98; 95% confidence interval [CI], 0.87 to 1.10; P=0.72) or in the rates of the components of the outcome, including repeat coronary revascularization, which was performed in 2.8% of the patients in the off-pump group and in 2.3% of the patients in the on-pump group (hazard ratio, 1.21; 95% CI, 0.85 to 1.73; P=0.29). The secondary outcome for the overall period of the trial - the mean cost in U.S. dollars per patient - also did not differ significantly between the off-pump group and the on-pump group ($15,107 and $14,992, respectively; between-group difference, $115; 95% CI, -$697 to $927). There were no significant between-group differences in quality-of-life measures. CONCLUSIONS In our trial, the rate of the composite outcome of death, stroke, myocardial infarction, renal failure, or repeat revascularization at 5 years of follow-up was similar among patients who underwent off-pump CABG and those who underwent on-pump CABG. (Funded by the Canadian Institutes of Health Research; CORONARY ClinicalTrials.gov number, NCT00463294 .).
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Affiliation(s)
- André Lamy
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - P J Devereaux
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Dorairaj Prabhakaran
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - David P Taggart
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Shengshou Hu
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Zbynek Straka
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Leopoldo S Piegas
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Alvaro Avezum
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Ahmet R Akar
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Fernando Lanas Zanetti
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Anil R Jain
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Nicolas Noiseux
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Chandrasekar Padmanabhan
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Juan-Carlos Bahamondes
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Richard J Novick
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Liang Tao
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Pablo A Olavegogeascoechea
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Balram Airan
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Toomas-Andres Sulling
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Richard P Whitlock
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Yongning Ou
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Peggy Gao
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Shirley Pettit
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
| | - Salim Yusuf
- From the Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON (A.L., P.J.D., R.P.W., Y.O., P.G., S.P., S.Y.), Centre Hospitalier de l'Université de Montréal, Montreal (N.N.), and the University of Calgary, Calgary, AB (R.J.N.) - all in Canada; the Center for Chronic Disease Control, Gurgaon (D.P.), SAL Hospital, Ahmedabad (A.R.J.), G. Kuppuswamy Naidu Memorial Hospital, Coimbatore (C.P.), and All India Institute of Medical Sciences, New Delhi (B.A.) - all in India; the University of Oxford, Oxford, United Kingdom (D.P.T.); Fu Wai Cardiovascular Hospital, Xicheng District, Beijing (S.H.), and Wuhan Asia Heart Hospital, Wuhan (L.T.) - both in China; Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic (Z.S.); Instituto Dante Pazzanese de Cardiologia, São Paulo (L.S.P., A.A.); Ankara University School of Medicine, Ankara, Turkey (A.R.A.); Hospital Regional de Temuco and Universidad de la Frontera, Temuco, Chile (F.L.Z., J.-C.B.); Fundación Médica de Río Negro y Neuquén, Rio Negro, Argentina (P.A.O.); and North Estonia Medical Center, Tallinn, Estonia (T.-A.S.)
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Yanagawa B, Nedadur R, Puskas JD. The future of off-pump coronary artery bypass grafting: a North American perspective. J Thorac Dis 2016; 8:S832-S838. [PMID: 27942403 DOI: 10.21037/jtd.2016.10.07] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Off-pump coronary artery bypass graft (OPCAB) is currently performed routinely in a minority of specialized centers and in many more centers, utilized only when a porcelain aorta mandates a no-touch aortic technique. The OPCAB literature can be summarized as follows: (I) large-scale randomized trials in relatively low risk patients that include surgeons with a range of experience demonstrating no consistent beneficial differences in major cardiovascular and cerebrovascular outcomes but lower transfusion rates and shorter length of stay, tempered by some reports of higher rates of incomplete revascularization and lower rates of long term graft patency; (II) smaller randomized controlled trials (RCTs) from highly specialized programs demonstrating equivalent or superior outcomes with OPCAB and similar completeness of revascularization and graft patency; and (III) observational data from large databases demonstrating a consistent benefit of OPCAB, especially in higher-risk patient subsets. Our rationale for OPCAB remains that if complete and precise revascularization can be safely and routinely accomplished, then the patient should benefit by avoiding the morbidities that can be attributed to aortic cannulation/clamping, cardiopulmonary bypass (CPB), hemodilution, hypothermia and global myocardial ischemia/cardioplegia. We further believe that OPCAB procedures should emphasize the use of arterial grafts to optimize long term patency and minimize aortic manipulation to limit the risk of stroke. Moving forward, the off-pump surgical community and specialty societies must address the challenge of training surgeons and their teams to master this technically demanding procedure. Furthermore, OPCAB opens the door to minimally-invasive surgical revascularization via hybrid coronary revascularization (HCR). A large NIH-funded RCT is currently underway to determine whether hybrid revascularization can offer a superior alternative to multi-vessel percutaneous coronary intervention for patients with low SYNTAX score and proximal LAD disease.
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Affiliation(s)
- Bobby Yanagawa
- Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Canada
| | - Rashmi Nedadur
- Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Canada
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Saint Luke's Hospital, New York, NY, USA
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Davierwala PM. Current outcomes of off-pump coronary artery bypass grafting: evidence from real world practice. J Thorac Dis 2016; 8:S772-S786. [PMID: 27942395 DOI: 10.21037/jtd.2016.10.102] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Coronary artery bypass grafting (CABG) can be performed conventionally using cardiopulmonary bypass (CPB) and aortic clamping or on a beating heart (BH) without the use of CPB, the so-called off-pump CABG. Some surgeons, who are proponents of off-pump CABG, preferentially use this technique for the majority of operations, whereas others use it only in certain situations which warrant avoidance of CPB. Ever since the conception of off-pump CABG, the never-ending debate about which technique of CABG is safe and efficacious continues to date. Several randomized controlled trials (RCTs) have been conducted that have either favored on-pump CABG or have failed to show a significant difference in outcomes between the two techniques. However, these RCTs have been fraught with claims that they do not represent the majority of patients undergoing CABG in real world practice. Therefore, assessment of the benefits and drawbacks of each technique through observational and registry studies would be more representative of patients encountered in daily practice. The present review examines various retrospective studies and meta-analyses of observational studies that compare the early and long-term outcomes of off- and on-pump CABG, which assesses their safety and efficacy. Additionally, their outcomes in older patients, females, and those with diabetes mellitus, renal dysfunction, presence of ascending aortic disease, and/or acute coronary syndrome (ACS) have also been discussed separately. The general consensus is that early results of off-pump CABG are comparable to or in some cases better than on-pump CABG. However, on-pump CABG provides a survival benefit in the long term according to a majority of publications in literature.
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Affiliation(s)
- Piroze M Davierwala
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
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Mizuno T, Egi K, Sakai K, Oi K, Hachimaru T, Makita T, Oishi K, Arai H. Minimally Circulatory-Assisted On-Pump Beating Coronary Artery Bypass Grafting for Patients With Complex Conditions for Off-Pump Surgery. Artif Organs 2016; 41:233-241. [PMID: 27782315 DOI: 10.1111/aor.12761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 02/16/2016] [Accepted: 03/23/2016] [Indexed: 01/16/2023]
Abstract
Off-pump coronary artery bypass grafting (OPCAB) in patients with acute myocardial infarction (AMI) is difficult because of circulatory deterioration during displacement of the heart. At our institution, we performed minimally circulatory-assisted on-pump beating coronary artery bypass grafting (MICAB) in these patients. During MICAB, support flow was controlled at a minimal level to maintain a systemic blood pressure of approximately 100 mm Hg and a pulmonary arterial systolic pressure of <30 mm Hg, providing optimal pulsatile circulation for end-organ perfusion and prevention of heart congestion. From September 2006 to March 2012, MICAB was performed in 37 patients. Either emergent or urgent MICAB was performed in 27 patients following AMI because of hemodynamic instability during reconstruction. Elective MICAB was performed in the remaining 10 patients because of dilated left ventricle (LV) or small target coronary arteries. The details of bypass grafts, perioperative renal function, and early and mid-term morbidity and mortality were compared between the patients who received MICAB and the 37 consecutive patients who underwent OPCAB during the study period at our hospital. The assist flow indices (actual support flow/body surface area) during anastomosis to the left anterior descending artery, left circumflex artery, and right coronary artery were 0.95 ± 0.48 L/min/m2 , 1.32 ± 0.53 L/min/m2 , and 1.15 ± 0.47 L/min/m2 , respectively, in the emergent and urgent patients following AMI, and 0.44 ± 0.39 L/min/m2 , 1.25 ± 0.39 L/min/m2 , and 1.14 ± 0.43 L/min/m2 , respectively, in the elective patients with either dilated LVs or small target vessels. The lowest mixed venous oxygen saturation during pump support in the MICAB group was significantly higher than that in the OPCAB group (83.8 ± 10.8%, 71.6 ± 7.5%, P < 0.001). Comparing MICAB and OPCAB, the median number of distal bypass grafts for both groups was 4 (25th, 75th percentile: 3, 4) (P = 0.558); the complete revascularization rates were 94.6 and 97.3%, respectively (not significant [NS]); the acute patency rates were 98.9 and 99.2%, respectively (NS); and the 30-day mortality rates were 2.7 and 0%, respectively (NS). No instances of either cerebrovascular complications or newly occurring postoperative renal failure were noted in either group. There were no statistically significant differences between the groups with respect to early and mid-term results (freedom from all-cause death: 82.9 vs. 86.5%, respectively, and freedom from cardiac events at 3 years: 96.4 vs. 96.4%, respectively). MICAB is a safe alternative to OPCAB, particularly in patients with AMI and dilated LV. MICAB is associated with high rates of complete revascularization and acute graft patency, adequate preservation of end-organ function, and early and mid-term results comparable with those observed following OPCAB.
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Affiliation(s)
- Tomohiro Mizuno
- Department of Cardiovascular Surgery, Machida Municipal Hospital, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University
| | - Koso Egi
- Department of Cardiovascular Surgery, Tokyo Yamate Medical Center
| | - Kenji Sakai
- Department of Cardiovascular Surgery, Machida Municipal Hospital
| | - Keiji Oi
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University
| | - Tsuyoshi Hachimaru
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University
| | - Tohru Makita
- Department of Cardiovascular Surgery, Yokosuka Kyosai Hospital
| | - Kiyotoshi Oishi
- Department of Cardiovascular Surgery, Musashino Red Cross Hospital, Tokyo, Japan
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University
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Hussain G, Azam H, Baig MAR, Ahmad N. Early outcomes of on-pump versus off-pump coronary artery bypass grafting. Pak J Med Sci 2016; 32:917-21. [PMID: 27648039 PMCID: PMC5017102 DOI: 10.12669/pjms.324.9680] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objectives: To see the early post-operative outcomes of off-pump versus on-pump coronary artery bypass graft surgery. Methods: This retrospective analytical study was conducted at Ch. Pervaiz Elahi Institute of Cardiology Multan, Pakistan. Our Primary outcome variables were; necessity of inotropic support, nonfatal myocardial infarction, ICU stay, nonfatal stroke, new renal failure requiring dialysis and death within 30 days after operation. There were two groups of patients; Group-I (On-pump group) and Group-II (Off-pump Group). SPSS V17 was used for data analysis. Independent sample t-test and Mann Whitney U test were used to compare quantitative Variables. Chi-square test and Fisher’s exact test were used to analyze qualitative variables. P-value ≤ 0.05 was considered significant. Results: Three hundred patients were included in this study. There were no significant difference regarding risk factors except hyper-cholestrolemia which was high in off pump group (p-value 0.05). Angiographic and Echocardiographic characteristics e.g. preoperative ejection fraction, LV function grade and severity of CAD was same between the groups. Mortality risk scores and Priority status for surgery were also same. Regarding post-operative outcomes; Post-op CKMB Levels, need and duration of inotropic support, mechanical ventilation time and ICU stay was significantly less in Off-Pump group (p-value 0.001, <0.0001, 0.006, 0.025 and 0.001 resp.). Peri-operative chest drainage was significantly high in On-pump CABG group (p-value 0.027). Incidence of post-op complications was not statistically different between the groups. Conclusions: At 30 days follow-up, Incidence of myocardial infarction, necessity and duration of inotropic support, ICU stay period and peri-operative bleeding were significantly less in off-pump group. The incidence of neurologic, pulmonary and renal complications was same between the off-pump and on-pump groups.
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Affiliation(s)
- Ghulam Hussain
- Ghulam Hussain. FCPS Cardiac Surgery. Assistant Professor of Cardiac Surgery, Ch. Pervaiz Elahi Institute of Cardiology (CPEIC), Multan, Pakistan
| | - Hammad Azam
- Hammad Azam. FCPS (Surgery). Assistant Professor of Cardiac Surgery, Sheikh Zayed Medical College and Hospital, Rahim Yaar Khan, Pakistan
| | - Mirza Ahmad Raza Baig
- Mirza Ahmad Raza Baig. BS in Cardiac Perfusion. Clinical Perfusionist, Ch. Pervaiz Elahi Institute of Cardiology (CPEIC), Multan, Pakistan
| | - Naseem Ahmad
- Naseem Ahmad. FCPS Cardiac Surgery. Assistant Professor of Cardiac Surgery, Ch. Pervaiz Elahi Institute of Cardiology (CPEIC), Multan, Pakistan
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Ito H, Mizumoto T, Tempaku H, Fujinaga K, Sawada Y, Teranishi S, Shimpo H. Emergency Off-Pump Coronary Artery Bypass Graft Surgery for Patients on Preoperative Intraaortic Balloon Pump. Ann Thorac Surg 2016; 102:821-828. [DOI: 10.1016/j.athoracsur.2016.02.088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 02/23/2016] [Accepted: 02/25/2016] [Indexed: 11/28/2022]
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Kolh P, Kurlansky P, Cremer J, Lawton J, Siepe M, Fremes S. Transatlantic editorial: A comparison between European and North American guidelines on myocardial revascularization. J Thorac Cardiovasc Surg 2016; 152:304-16. [PMID: 27158134 DOI: 10.1016/j.jtcvs.2016.04.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Philippe Kolh
- Cardiovascular Surgery Department, University Hospital (CHU, ULg) of Liège, Liège, Belgium.
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, Columbia University, New York, NY
| | - Jochen Cremer
- Cardiovascular Surgery Department, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jennifer Lawton
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Centre Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Stephen Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Kolh P, Kurlansky P, Cremer J, Lawton J, Siepe M, Fremes S. Transatlantic Editorial: A Comparison Between European and North American Guidelines on Myocardial Revascularization. Ann Thorac Surg 2016; 101:2031-44. [PMID: 27139371 DOI: 10.1016/j.athoracsur.2016.02.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 02/18/2016] [Accepted: 02/18/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Philippe Kolh
- Cardiovascular Surgery Department, University Hospital (CHU, ULg) of Liège, Liège, Belgium.
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, Columbia University, New York, New York
| | - Jochen Cremer
- Cardiovascular Surgery Department, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jennifer Lawton
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Centre Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Stephen Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Kolh P, Kurlansky P, Cremer J, Lawton J, Siepe M, Fremes S. Transatlantic Editorial: a comparison between European and North American guidelines on myocardial revascularization. Eur J Cardiothorac Surg 2016; 49:1307-17. [DOI: 10.1093/ejcts/ezw086] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Short-term clinical outcomes after hybrid coronary revascularization versus off-pump coronary artery bypass for the treatment of multivessel or left main coronary artery disease: a meta-analysis. Coron Artery Dis 2016; 26:526-34. [PMID: 26018329 PMCID: PMC4520736 DOI: 10.1097/mca.0000000000000265] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Hybrid coronary revascularization (HCR) and off-pump coronary artery bypass grafting (OPCABG) are both feasible, less invasive techniques for coronary revascularization. Although both techniques utilize the left internal mammary artery to left anterior descending artery graft, HCR uses drug-eluting stents instead of saphenous vein bypass. It remains unclear whether HCR is equal to, better or worse than OPCABG. Methods and results A meta-analysis was carried out using a random-effects model. Seven observational studies were included. There was no significant difference either in in-hospital mortality [relative risk (RR) 0.57, 95% confidence interval (CI) 0.13–2.59, P=0.47] or in the MACCE rate (RR 0.63, 95% CI 0.24–1.64, P=0.34) between the HCR group and the OPCABG group. A significant difference was observed between the two groups in the length of hospitalization (RR 0.55, 95% CI 0.13–0.97, P=0.01), length of ICU stay (RR 0.45, 95% CI 0.10–0.80, P<0.05), intubation time (RR 0.48, 95% CI 0.13–0.84, P<0.01), need for red blood transfusion (RR 0.67, 95% CI 0.56–0.82, P<0.001), and total in-hospital costs (RR 0.90, 95% CI 0.39–1.42, P<0.01). Conclusion Compared with OPCABG, HCR did not improve early survival but decreased the length of hospitalization, length of ICU stay, intubation time, and need for red blood transfusion, and increased total in-hospitalcosts.
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Pawliszak W, Kowalewski M, Anisimowicz L. Off-pump versus on-pump coronary artery bypass grafting: Who benefits? J Thorac Cardiovasc Surg 2016; 150:1666-8. [PMID: 26573362 DOI: 10.1016/j.jtcvs.2015.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 09/03/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Wojciech Pawliszak
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Mariusz Kowalewski
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland; Division of Ergonomics and Physical Effort, Department of Hygiene, Epidemiology and Ergonomics, Collegium Medicum UMK, Bydgoszcz, Poland
| | - Lech Anisimowicz
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
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Yu XP, Wu CY, Ren XJ, Yuan F, Song XT, Luo YW, He JQ, Gao YC, Huang FJ, Gu CX, Sun LZ, Lyu SZ, Chen F. Very Long-term Outcomes and Predictors of Percutaneous Coronary Intervention with Drug-eluting Stents Versus Coronary Artery Bypass Grafting for Patients with Unprotected Left Main Coronary Artery Disease. Chin Med J (Engl) 2016; 129:763-70. [PMID: 26996469 PMCID: PMC4819294 DOI: 10.4103/0366-6999.178968] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND There are limited data on longer-term outcomes (>5 years) for patients with unprotected left main coronary artery (ULMCA) disease who underwent percutaneous coronary intervention (PCI) in the drug-eluting stents (DES) era. This study aimed at comparing the long-term (>5 years) outcomes of patients with ULMCA disease underwent PCI with DES and coronary artery bypass grafting (CABG) and the predictors of adverse events. METHODS All consecutive patients with ULMCA disease treated with DES implantation versus CABG in our center, between January 2003 and July 2009, were screened for analyzing. A propensity score analysis was carried out to adjust for potential confounding between the two groups. RESULTS Nine hundred and twenty-two patients with ULMCA disease were enrolled for the analyses (DES = 465 vs. CABG = 457). During the median follow-up of 7.1 years (interquartile range 5.3-8.2 years), no difference was found between PCI and CABG in the occurrence of death (P = 0.282) and the composite endpoint of cardiac death, myocardial infarction (MI) and stroke (P = 0.294). Rates of major adverse cardiac and cerebrovascular events were significantly higher in the PCI group (P = 0.014) in large part because of the significantly higher rate of repeat revascularization (P < 0.001). PCI was correlated with the lower occurrence of stroke (P = 0.004). Multivariate analysis showed ejection fraction (EF) (P = 0.012), creatinine (P = 0.016), and prior stroke (P = 0.031) were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age (P = 0.026) and EF (P = 0.002) were independent predictors in the CABG group. CONCLUSIONS During a median follow-up of 7.1 years, there was no difference in the rate of death between PCI with DES implantation and CABG in ULMCA lesions in the patient cohort. CABG group was observed to have significantly lower rates of repeat revascularization but higher stroke rates compared with PCI. EF, creatinine, and prior stroke were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age and EF were independent predictors in the CABG group.
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Affiliation(s)
- Xian-Peng Yu
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Chang-Yan Wu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Xue-Jun Ren
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Fei Yuan
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Xian-Tao Song
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Ya-Wei Luo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Ji-Qiang He
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Yue-Chun Gao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Fang-Jiong Huang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Cheng-Xiong Gu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Li-Zhong Sun
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Shu-Zheng Lyu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Fang Chen
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
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Off-pump versus on-pump coronary artery bypass grafting in patients with left ventricular dysfunction. J Thorac Cardiovasc Surg 2016; 151:1092-8. [DOI: 10.1016/j.jtcvs.2015.11.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 10/23/2015] [Accepted: 11/15/2015] [Indexed: 01/05/2023]
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