Benefits of Off-pump Coronary Artery Bypass Grafting in High-risk Patients with High EuroSCORE_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

SHENRu-hua ,  YANZhong-ya , WUYi-jun , LUZhong , LEIHong , ZHUZheng-yan , SUNYun , ZHENGLi

Department of Cardiovascular Surgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei 230001, P. R. China;

Corresponding author：

YANZhong-ya, Email: shenruhua119@sina.com

Keywords：

Coronary artery bypass grafting; High risk; Off-pump

DOI：

10.7507/1007-4848.20140173

Video：

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Objective To compare clinical outcomes between coronary artery bypass grafting (CABG)and off-pump coronary artery bypass grafting (OPCAB)for high-risk coronary artery disease (CAD)patients with high European System for Cardiac Operative Risk Evaluation (EuroSCORE). Methods A total of 211 CAD patients undergoing surgical treatment in the Department of Cardiovascular Surgery, Anhui Provincial Hospital Affiliated to Anhui Medical University from June 2007 to July 2013 were enrolled into this study, including 52 patients receiving CABG and 159 patients receiving OPCAB. Predicted risk of operative mortality (PROM)of each patient was calculated by EuroSCORE. Patients with PROM≥6 were stratified into high-risk subgroups. Clinical outcomes were compared between CABG and OPCAB patients, as well as incidence of cardiovascular events, angina and stroke within 30 postoperative days in high-risk subgroup patients. Results OPCAB and CABG group patients had similar left main disease. There was no statistical difference in the number of distal anastomosis between OPCAB (2.75±0.82)and CABG group patients (2.83±0.58) (P > 0.05). Operation time[ (3.92±0.79)hour vs. (6.83±1.53)hour], thoracic drainage[ (983.14±802.39)ml vs. (1 620.40±879.32)ml], blood transfusion[ (1 289.30±668.08)ml vs. (2 325.30±491.98)ml], length of ICU stay[ (3.90±1.33)days vs. (5.08±1.78)days], and mechanical ventilation time[ (9.63±3.32)h vs. (13.76±3.79)h] of OPCAB group patients were significantly shorter or lower than those of CABG group patients (P < 0.05). There was no statistical difference in 30-day mortality between OPCAB and CABG group patients (1.26% vs. 3.85%, P > 0.05). Among high-risk subgroup patients, the odds ratio of stroke within 30 postoperative days in CABG was 5.7 (95%CI 1.28-25.09, P < 0.05)compared with OPCAB group patients, and the incidence of cardiovascular events and angina within 30 postoperative days were similar between the 2 subgroups. Conclusions Postoperative mortality and number of distal anastomosis are not significantly different between CABG and OPCAB patients, but OPCAB can significantly reduce operation time, thoracic drainage, blood transfusion, length of ICU stay and mechanical ventilation time compared with CABG. For high-risk patients with high EuroSCORE, OPCAB can better reduce the incidence of postoperative stroke compared with CABG.

Citation： SHENRu-hua, YANZhong-ya, WUYi-jun, LUZhong, LEIHong, ZHUZheng-yan, SUNYun, ZHENGLi. Benefits of Off-pump Coronary Artery Bypass Grafting in High-risk Patients with High EuroSCORE. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2014, 21(5): 604-608. doi: 10.7507/1007-4848.20140173 Copy

1.	Sá MP, Ferraz PE, Escobar RR, et al. Off-pump versus on-pump coronary artery bypass surgery:meta-analysis and meta-regression of 13524 patients from randomized trials. Rev Bras Cir Cardiovasc, 2012, 27(4):631-641.
2.	Nilsson J, Algotsson L, Höglund P, et al. EuroSCORE predicts intensive care unit stay and costs of open heart surgery. Ann Thorac Surg, 2004, 78(5):1528-1534.
3.	Hirose H, Noguchi C, Inaba H, et al. The role of EuroSCORE in patients undergoing off-pump coronary artery bypass. Interact Cardiovasc Thorac Surg, 2010, 10(5):771-776.
4.	Wan S, Izzat MB, Lee TW, et al. Avoiding cardiopulmonary bypass in multivessel CABG reduces cytokine response and myocardial injury. Ann Thorac Surg, 1999, 68(1):52-56.
5.	Ascione R, Lloyd CT, Underwood MJ, et al. Inflammatory response after coronary revascularization with or without cardiopulmonary bypass. Ann Thorac Surg, 2000, 69(4):1198-1204.
6.	Jarral OA, Saso S, Harling L, et al. Atrial fibrillation, blood Loss, and transfusion in patients with left ventricular dysfunction:what is the effect of cardiopulmonary bypass? ASAIO J, 2012, 58(4):311-319.
7.	Ascione R, Williams S, Lloyd CT, et al. Reduced postoperative blood loss and transfusion requirement after beating-heart coronary operations:a prospective randomized study. J Thorac Cardiovasc Surg, 2001, 121(4):689-696.
8.	Hueb W, Lopes NH, Pereira AC, et al. Five-year follow-up of a randomized comparison between off-pump and on-pump stable multivessel coronary artery bypass grafting. The MASS Ⅲ Trial. Circulation, 2010, 122(11 Suppl):S48-S52.
9.	Møller CH, Perko MJ, Lund JT, et al. No major differences in 30-day outcomes in high-risk patients randomized to off-pump versus on-pump coronary bypass surgery:the best bypass surgery trial. Circulation, 2010, 121(4):498-504.
10.	Shroyer AL, Grover FL, Hattler B, et al. On-pump versus off-pump coronary artery bypass surgery. N Engl J Med, 2009, 361(19):1827-1837.
11.	Pawlaczyk R, Swietlik D, Lango R, et al. Off-Pump coronary surgery may reduce stroke, respiratory failure, and mortality in octogenarians. Ann Thorac Surg, 2012, 94(1):29-37.
12.	高华炜, 郑哲, 胡盛寿, 等.影响冠状动脉旁路移植术手术死亡的危险因素分析.中国胸心血管外科临床杂志, 2007, 14(5):321-325.
13.	Grasso S, Fanelli V, Cafarelli A, et al. Effects of high versus low positive end-expiratory pressures in acute respiratory distress syndrome.Am J Respir Crit Care Med, 2005, 171(9):1002-1008.
14.	Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med, 2000, 342(18):1301-1308.
15.	Kowalik MM, Lango R, Klajbor K, et al. Incidence-and mortality-related risk factors of acute kidney injury requiring hemofiltration treatment in patients undergoing cardiac surgery:a single-center 6-year experience. J Cardiothorac Vasc Anesth, 2011, 25(4):619-624.
16.	Chalmers J, Mediratta N, McShane J, et al. The long-term effects of developing renal failure post-coronary artery bypass surgery in patients with normal preoperative renal function. Eur J Cardiothorac Surg, 2013, 43(3):555-559.
17.	Ascione R, Lloyd CT, Underwood MJ, et al. On-pump versus off-pump coronary revascularization:evaluation of renal function. Ann Thorac Surg, 1999, 68(2):493-498.
18.	Boulton BJ, Kilgo P, Guyton RA, et al. Impact of preoperative renal dysfunction in patients undergoing off-pump versus on-pump coronary artery bypass. Ann Thorac Surg, 2011, 92(2):595-602.
19.	Chowdhury R, White D, Kilgo P, et al. Risk factors for conversion to cardiopulmonary bypass during off-pump coronary artery bypass surgery. Ann Thorac Surg, 2012, 93(6):1936-1942.
20.	Muniraju G, Pandey S, Chakravarthy M, et al. Intra-aortic balloon pump use does not affect the renal function in patients undergoing off pump coronary artery bypass surgery. Ann Card Anaesth, 2011, 14(3):188-191.
21.	丁文军, 魏强, 孙勇新, 等.主动脉内球囊反搏在高危患者非体外循环冠状动脉旁路移植术中的应用.中国胸心血管外科临床杂志, 2013, 20(1):10-14.
22.	刘培生, 陈鑫, 石开虎, 等.冠状动脉旁路移植术中主动脉近端吻合装置的临床应用.中国胸心血管外科临床杂志, 2008, 15(4):255-259.
23.	Kapetanakis El, Stamou SC, Dullum MK, et al. The impact of aortic manipulation on neurologic outcomes after coronary artery bypass surgery:a risk-adjusted study. Ann Thorac Surg, 2004, 78(5):1564-1571.

1. Sá MP, Ferraz PE, Escobar RR, et al. Off-pump versus on-pump coronary artery bypass surgery:meta-analysis and meta-regression of 13524 patients from randomized trials. Rev Bras Cir Cardiovasc, 2012, 27(4):631-641.
2. Nilsson J, Algotsson L, Höglund P, et al. EuroSCORE predicts intensive care unit stay and costs of open heart surgery. Ann Thorac Surg, 2004, 78(5):1528-1534.
3. Hirose H, Noguchi C, Inaba H, et al. The role of EuroSCORE in patients undergoing off-pump coronary artery bypass. Interact Cardiovasc Thorac Surg, 2010, 10(5):771-776.
4. Wan S, Izzat MB, Lee TW, et al. Avoiding cardiopulmonary bypass in multivessel CABG reduces cytokine response and myocardial injury. Ann Thorac Surg, 1999, 68(1):52-56.
5. Ascione R, Lloyd CT, Underwood MJ, et al. Inflammatory response after coronary revascularization with or without cardiopulmonary bypass. Ann Thorac Surg, 2000, 69(4):1198-1204.
6. Jarral OA, Saso S, Harling L, et al. Atrial fibrillation, blood Loss, and transfusion in patients with left ventricular dysfunction:what is the effect of cardiopulmonary bypass? ASAIO J, 2012, 58(4):311-319.
7. Ascione R, Williams S, Lloyd CT, et al. Reduced postoperative blood loss and transfusion requirement after beating-heart coronary operations:a prospective randomized study. J Thorac Cardiovasc Surg, 2001, 121(4):689-696.
8. Hueb W, Lopes NH, Pereira AC, et al. Five-year follow-up of a randomized comparison between off-pump and on-pump stable multivessel coronary artery bypass grafting. The MASS Ⅲ Trial. Circulation, 2010, 122(11 Suppl):S48-S52.
9. Møller CH, Perko MJ, Lund JT, et al. No major differences in 30-day outcomes in high-risk patients randomized to off-pump versus on-pump coronary bypass surgery:the best bypass surgery trial. Circulation, 2010, 121(4):498-504.
10. Shroyer AL, Grover FL, Hattler B, et al. On-pump versus off-pump coronary artery bypass surgery. N Engl J Med, 2009, 361(19):1827-1837.
11. Pawlaczyk R, Swietlik D, Lango R, et al. Off-Pump coronary surgery may reduce stroke, respiratory failure, and mortality in octogenarians. Ann Thorac Surg, 2012, 94(1):29-37.
12. 高华炜, 郑哲, 胡盛寿, 等.影响冠状动脉旁路移植术手术死亡的危险因素分析.中国胸心血管外科临床杂志, 2007, 14(5):321-325.
13. Grasso S, Fanelli V, Cafarelli A, et al. Effects of high versus low positive end-expiratory pressures in acute respiratory distress syndrome.Am J Respir Crit Care Med, 2005, 171(9):1002-1008.
14. Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med, 2000, 342(18):1301-1308.
15. Kowalik MM, Lango R, Klajbor K, et al. Incidence-and mortality-related risk factors of acute kidney injury requiring hemofiltration treatment in patients undergoing cardiac surgery:a single-center 6-year experience. J Cardiothorac Vasc Anesth, 2011, 25(4):619-624.
16. Chalmers J, Mediratta N, McShane J, et al. The long-term effects of developing renal failure post-coronary artery bypass surgery in patients with normal preoperative renal function. Eur J Cardiothorac Surg, 2013, 43(3):555-559.
17. Ascione R, Lloyd CT, Underwood MJ, et al. On-pump versus off-pump coronary revascularization:evaluation of renal function. Ann Thorac Surg, 1999, 68(2):493-498.
18. Boulton BJ, Kilgo P, Guyton RA, et al. Impact of preoperative renal dysfunction in patients undergoing off-pump versus on-pump coronary artery bypass. Ann Thorac Surg, 2011, 92(2):595-602.
19. Chowdhury R, White D, Kilgo P, et al. Risk factors for conversion to cardiopulmonary bypass during off-pump coronary artery bypass surgery. Ann Thorac Surg, 2012, 93(6):1936-1942.
20. Muniraju G, Pandey S, Chakravarthy M, et al. Intra-aortic balloon pump use does not affect the renal function in patients undergoing off pump coronary artery bypass surgery. Ann Card Anaesth, 2011, 14(3):188-191.
21. 丁文军, 魏强, 孙勇新, 等.主动脉内球囊反搏在高危患者非体外循环冠状动脉旁路移植术中的应用.中国胸心血管外科临床杂志, 2013, 20(1):10-14.
22. 刘培生, 陈鑫, 石开虎, 等.冠状动脉旁路移植术中主动脉近端吻合装置的临床应用.中国胸心血管外科临床杂志, 2008, 15(4):255-259.
23. Kapetanakis El, Stamou SC, Dullum MK, et al. The impact of aortic manipulation on neurologic outcomes after coronary artery bypass surgery:a risk-adjusted study. Ann Thorac Surg, 2004, 78(5):1564-1571.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Benefits of Off-pump Coronary Artery Bypass Grafting in High-risk Patients with High EuroSCORE

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