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      Off-Pump Coronary Artery Bypass Grafting for Patients with Left Main Disease

       

      Cardiology

      S. Karger AG

      Follow-up study, Coronary artery disease, Off-pump bypass, Prospective study

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          Abstract

          Background: Multivessel off-pump coronary artery bypass grafting (CABG) has been performed with favorable results in our institute. In this study, we analyzed the outcomes in patients who underwent off-pump CABG for left main disease, since the surgical outcomes for such patients have not been clarified. Methods: Between March 1, 1999 and July 30, 2002, a total of 147 patients with left main disease (112 males and 35 females, mean age 66.9 ± 9.8 years) underwent off-pump CABG. Perioperative and follow-up data were entered into a structured database and the results were analyzed. Results: Urgent or emergent surgery was performed in 25 patients (17.0%), and a preoperative intra-aortic balloon pump was used in 12 patients (8.2%). The mean number of bypass grafts was 3.2 ± 1.0, and complete revascularization was performed in 127 patients (86.4%). There were 4 incidences of intraoperative conversion from off-pump to on-pump surgery. The mean intubation period, intensive care unit stay and postoperative hospital stay were 9.4 ± 13.0 h, 2.3 ± 1.4 days and 13.4 ± 7.3 days, respectively. There was 1 hospital death (0.7%). Postoperative myocardial infarction was observed in 2 patients (1.4%), postoperative stroke in 1 (0.7%), prolonged ventilator support in 5 (3.4%) and mediastinitis in 3 (2.0%). During the follow-up period of 2.1 ± 1.0 years, there were 4 deaths and 7 cardiac events. The actuarial 3-year survival rate was 97.0%, and the event-free rate was 94.3%. Conclusion: Our observations support off-pump CABG as a surgical option with a favorable outcome for patients with left main disease.

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          Most cited references 7

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          Off-pump coronary artery bypass grafting decreases risk-adjusted mortality and morbidity.

          The purpose of this study was to determine whether coronary artery bypass grafting without cardiopulmonary bypass (off-pump CABG) decreases risk-adjusted operative death and major complications after coronary artery bypass grafting in selected patients. Using The Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, procedural outcomes were compared for conventional and off-pump CABG procedures from January 1, 1998, through December 31, 1999. Mortality and major complications were examined, both as unadjusted rates and after adjusting for known base line patient risk factors. A total of 126 experienced centers performed 118,140 total CABG procedures. The number of off-pump CABG cases was 11,717 cases (9.9% of total cases). The use of an off-pump procedure was associated with a decrease in risk-adjusted operative mortality from 2.9% with conventional CABG to 2.3% in the off-pump group (p < 0.001). The use of an off-pump procedure decreased the risk-adjusted major complication rate from 14.15% with conventional CABG to 10.62% in the off-pump group (p < 0.0001). Patients receiving off-pump procedures were less likely to die (adjusted odds ratio 0.81, 95% CI 0.70 to 0.91) and less likely to have major complications (adjusted odds ratio 0.77, 95% CI 0.72 to 0.82). Off-pump CABG is associated with decreased mortality and morbidity after coronary artery bypass grafting. Off-pump CABG may prove superior to conventional CABG in appropriately selected patients.
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            In-hospital outcomes of off-pump versus on-pump coronary artery bypass procedures: a multicenter experience.

            Concern about the possible adverse effects of the cardiopulmonary bypass (CPB) pump and advances in retractors and operative techniques to access all coronary segments have resulted in increased interest in off-pump coronary artery bypass (OPCAB) procedures. Four of the Northern New England Cardiovascular Disease Study Group centers initiated OPCAB programs in 1998. We compared the preoperative risk profiles and in-hospital outcomes of patients done off-pump with those done by conventional coronary artery bypass (CCAB) with CPB. Between 1998 and 2000, 1,741 OPCAB and 6,126 CCAB procedures were performed at these four medical centers. Minimally invasive direct coronary artery bypass grafting procedures were excluded. Data were available for patient and disease risk factors, extent of coronary disease and adverse in-hospital outcomes. The OPCAB and CCAB groups were somewhat different in their preoperative patient and disease characteristics. The OPCAB patients were more likely to be female and to have peripheral vascular disease. The CCAB patients were more likely to have an ejection fraction less than 0.40 and be urgent or emergent at operation. However, overall predicted risk of in-hospital mortality, based on preoperative factors, was similar in the OPCAB and CCAB groups; the mean predicted risk was 2.6% (p = 0.567). Crude rates of mortality (2.54% OPCAB versus 2.57%, CCAB), intraoperative or postoperative stroke (1.33% versus 1.82%), mediastinitis (1.10% versus 1.37%), and return to the operating room for bleeding (3.46% versus 2.93%) did not differ significantly. The OPCAB patients did have a statistically significant reduction in the need for intraoperative or postoperative intraaortic balloon pump support (2.31% versus 3.41%; p = 0.023) and in the incidence of postoperative atrial fibrillation (21.21% versus 26.31%; p < 0.001). Adjustment for preoperative risk factors and extent of coronary disease did not substantially change the crude results. Median postoperative length of stay was significantly shorter (5 days versus 6 days, p < 0.001) for OPCAB patients than for CCAB patients. This multicenter study showed that patients having OPCAB are not exposed to a greater risk of short-term adverse outcomes. These data also provided evidence that patients having OPCAB have significantly lower need for intraoperative or postoperative intraaortic balloon pump, lower rates of postoperative atrial fibrillation, and a shorter length of stay.
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              Off-pump coronary artery bypass surgery for critical left main stem disease: safety, efficacy and outcome.

              To determine whether patients with critical left main stem (LMS) coronary artery disease can undergo off-pump coronary artery bypass (OPCAB) surgery safely and successfully. From May 1996 to March 2000 data for patients with critical (> or =50%) LMS stenosis who underwent conventional coronary artery bypass surgery with cardiopulmonary bypass (CCAB) or without (OPCAB) were collected prospectively using the Patient Analysis & Tracking System. A reusable pressure stabilizer, intra-coronary shunts and a single posterior pericardial stitch exposure technique were used in all OPCAB cases. Non-randomized, retrospective data analysis included demographic and preoperative risk factors, operative details, clinical outcome and early follow-up. During the study period 387 patients with LMS stenosis underwent surgery (OPCAB n=75, CCAB n=312). Groups were similar in terms of preoperative and intraoperative variables although CCAB patients received significantly more grafts per patient (3.1+/-0.73 vs. 2.6+/-0.76, P< or =0.001). Mortality was similar in both groups (OPCAB 1.3% vs. CCAB 2.6%). OPCAB patients when compared to CCAB patients had a lower requirement for postoperative inotropes (12.0% vs. 38.1%, P=0.0001), temporary postoperative pacing (2.7% vs. 10.1%, P=0.02), and blood product transfusion (6.7% vs. 31.4%, P<0.0001), a lower incidence of postoperative chest infection (0% vs. 6.7%, P=0.02) and a slightly reduced postoperative length of stay (7.9+/-5.46 vs. 8.3+/-5.11 days, P=0.01). At 24 months follow-up, CCAB and OPCAB actuarial survival was 94.1+/-1.7% and 97.7+/-2.3%, respectively. OPCAB surgery is safe and effective in patients with critical LMS disease.
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                Author and article information

                Journal
                CRD
                Cardiology
                10.1159/issn.0008-6312
                Cardiology
                S. Karger AG
                0008-6312
                1421-9751
                2004
                February 2004
                27 February 2004
                : 101
                : 4
                : 194-198
                Affiliations
                Department of Cardiovascular Surgery, Juntendo University Hospital, Tokyo, Japan
                Article
                76696 Cardiology 2004;101:194–198
                10.1159/000076696
                14967962
                © 2004 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Tables: 5, References: 10, Pages: 5
                Categories
                Cardiac Surgery

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