RESUMEN
BACKGROUND: This study aimed to explore the effect of a P2Y12 inhibitor regimen on the occurrence of postoperative atrial fibrillation (POAF) after off-pump coronary artery bypass graft surgery in carriers with the cytochrome P450 family 2 subfamily C member19 loss-of-function allele. METHODS AND RESULTS: From May 2019 to November 2023, patients containing the cytochrome P450 family 2 subfamily C member19*2 or *3 allele undergoing elective first-time off-pump coronary artery bypass graft surgery including aspirin 100 mg/d and ticagrelor 180 mg/d (AT group; n=95) versus clopidogrel 75 mg/d (aspirin and clopidogrel group; n=95) were prospectively followed. The primary end point was the cumulative incidence of POAF in a week. The secondary end points were POAF burden, platelet aggregability, systemic immune-inflammation index and heart rate variability. The incidence of POAF was 21.1% in the AT group versus 41.1% in the aspirin and clopidogrel group (hazard ratio, 0.46 [95% CI, 0.27-0.76]; P=0.003). POAF burden, ADP-induced platelet aggregation and systemic immune-inflammation index was notably lower in the AT group than the aspirin and clopidogrel group. Heart rate variability data showed an increase in both high-frequency and SD of normal-to-normal RR intervals in the AT group with a decreased low-frequency/high-frequency ratio, suggesting that the sympathetic/parasympathetic activation was balanced. CONCLUSIONS: In patients carrying the cytochrome P450 family 2 subfamily C member19 loss-of-function allele, an AT regimen after off-pump coronary artery bypass grafting was associated with a lower incidence of POAF, paralleled by lower atrial fibrillation burden, ADP-induced platelet aggregation, lower systemic immune-inflammation index reaction, and a balanced automatic nerve system compared with an aspirin and clopidogrel regimen. Inhibiting the systemic immune-inflammation response and sustaining automatic nerve balance may underlie the therapeutic effect of POAF by a potent antiplatelet combination.
Asunto(s)
Fibrilación Atrial , Clopidogrel , Puente de Arteria Coronaria Off-Pump , Inhibidores de Agregación Plaquetaria , Ticagrelor , Humanos , Clopidogrel/uso terapéutico , Clopidogrel/efectos adversos , Ticagrelor/uso terapéutico , Fibrilación Atrial/etiología , Fibrilación Atrial/epidemiología , Fibrilación Atrial/prevención & control , Fibrilación Atrial/diagnóstico , Masculino , Femenino , Puente de Arteria Coronaria Off-Pump/efectos adversos , Persona de Mediana Edad , Anciano , Inhibidores de Agregación Plaquetaria/uso terapéutico , Inhibidores de Agregación Plaquetaria/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Incidencia , Citocromo P-450 CYP2C19/genética , Citocromo P-450 CYP2C19/metabolismo , Estudios Prospectivos , Agregación Plaquetaria/efectos de los fármacos , Antagonistas del Receptor Purinérgico P2Y/uso terapéutico , Antagonistas del Receptor Purinérgico P2Y/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , Resultado del TratamientoRESUMEN
Background: There is mounting evidence that diabetic-related cardiac metabolism abnormalities with oxidative stress and inflammatory mechanism activation align with the functional impairments that result in atherosclerotic lesion formation. Among the possible non-traditional coronary lesion risk factors, environmental exposure may be significant, especially in diabetic patients. Methods: A total of 140 diabetic patients (115 (82%) males and 25 (18%) females) with a mean age of 65 (60-71) underwent surgical revascularization due to multivessel coronary disease. The possible all-cause mortality risk factors, including demographical and clinical factors followed by chronic air pollution exposure, were identified. Results: All patients were operated on using the off-pump technique and followed for 5.6 (5-6.1) years. The multivariable model for 5-year mortality prediction presented the nitrogen dioxide chronic exposure (HR: 3.99, 95% CI: 1.16-13.71, p = 0.028) and completeness of revascularization (HR: 0.19, 95% CI: 0.04-0.86, p = 0.031) as significant all-cause mortality risk factors. Conclusions: Ambient air pollutants such as an excessive chronic nitrogen dioxide concentration (>15 µg/m3) may increase 5-year all-cause mortality in diabetic patients following surgical revascularization.
Asunto(s)
Dióxido de Nitrógeno , Humanos , Masculino , Femenino , Anciano , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Dióxido de Nitrógeno/análisis , Dióxido de Nitrógeno/efectos adversos , Puente de Arteria Coronaria Off-Pump/efectos adversos , Puente de Arteria Coronaria Off-Pump/mortalidad , Diabetes Mellitus/mortalidad , Exposición a Riesgos Ambientales/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/complicacionesRESUMEN
OBJECTIVES: To determine whether balanced solutions can reduce the incidence of acute kidney injury after off-pump coronary artery bypass surgery compared with saline. DESIGN: Randomized controlled trial. SETTING: Single tertiary care center. PARTICIPANTS: Patients who underwent off-pump coronary artery bypass surgery between June 2014 and July 2020. INTERVENTIONS: Balanced solution-based chloride-restrictive intravenous fluid strategy. MEASUREMENTS AND MAIN RESULTS: The primary outcome was acute kidney injury within 7 postoperative days, as defined by the 2012 Kidney Disease: Improving Global Outcomes Clinical Practice Guideline. The incidence of acute kidney injury was 4.4% (8/180) in the balanced group and 7.3% (13/178) in the saline group. The difference was not statistically significant (risk difference, -2.86%; 95% confidence interval [CI], -7.72% to 2.01%; risk ratio, 0.61, 95% CI, 0.26 to 1.43; p = 0.35). Compared with the balanced group, the saline group had higher levels of intraoperative serum chloride and lower base excess, which resulted in a lower pH. CONCLUSIONS: In patients undergoing off-pump bypass surgery with a normal estimated glomerular filtration rate, the intraoperative balanced solution-based chloride-restrictive intravenous fluid administration strategy did not decrease the rate of postoperative acute kidney injury compared with the saline-based chloride-liberal intravenous fluid administration strategy.
Asunto(s)
Lesión Renal Aguda , Puente de Arteria Coronaria Off-Pump , Complicaciones Posoperatorias , Solución Salina , Humanos , Lesión Renal Aguda/prevención & control , Lesión Renal Aguda/etiología , Lesión Renal Aguda/epidemiología , Puente de Arteria Coronaria Off-Pump/métodos , Puente de Arteria Coronaria Off-Pump/efectos adversos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Solución Salina/administración & dosificación , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Fluidoterapia/métodosRESUMEN
BACKGROUND: Off-pump coronary artery bypass grafting (OPCABG) presents distinct hemodynamic characteristics, yet the relationship between intraoperative hypotension and short-term adverse outcomes remains clear. Our study aims to investigate association between intraoperative hypotension and postoperative acute kidney injury (AKI), mortality and length of stay in OPCABG patients. METHODS: Retrospective data of 494 patients underwent OPCABG from January 2016 to July 2023 were collected. We analyzed the relationship between intraoperative various hypotension absolute values (MAP > 75, 65 < MAP ≤ 75, 55 < MAP ≤ 65, MAP ≤ 55 mmHg) and postoperative AKI, mortality and length of stay. Logistic regression assessed the impacts of exposure variable on AKI and postoperative mortality. Linear regression was used to analyze risk factors on the length of intensive care unit stay (ICU) and hospital stay. RESULTS: The incidence of AKI was 31.8%, with in-hospital and 30-day mortality at 2.8% and 3.5%, respectively. Maintaining a MAP greater than or equal 65 mmHg [odds ratio (OR) 0.408; p = 0.008] and 75 mmHg (OR 0.479; p = 0.024) was significantly associated with a decrease risk of AKI compared to MAP less than 55 mmHg for at least 10 min. Prolonged hospital stays were linked to low MAP, while in-hospital mortality and 30-day mortality were not linked to IOH but exhibited correlation with a history of myocardial infarction. AKI showed correlation with length of ICU stay. CONCLUSIONS: MAP > 65 mmHg emerges as a significant independent protective factor for AKI in OPCABG and IOH is related to length of hospital stay. Proactive intervention targeting intraoperative hypotension may provide a potential opportunity to reduce postoperative renal injury and hospital stay. TRIAL REGISTRATION: ChiCTR2400082518. Registered 31 March 2024. https://www.chictr.org.cn/bin/project/edit?pid=225349 .
Asunto(s)
Lesión Renal Aguda , Puente de Arteria Coronaria Off-Pump , Hipotensión , Complicaciones Intraoperatorias , Tiempo de Internación , Complicaciones Posoperatorias , Humanos , Lesión Renal Aguda/epidemiología , Lesión Renal Aguda/mortalidad , Masculino , Estudios Retrospectivos , Femenino , Hipotensión/epidemiología , Puente de Arteria Coronaria Off-Pump/efectos adversos , Tiempo de Internación/estadística & datos numéricos , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Anciano , Complicaciones Intraoperatorias/epidemiología , Complicaciones Intraoperatorias/mortalidad , Estudios de Cohortes , Mortalidad Hospitalaria , Factores de RiesgoRESUMEN
BACKGROUND: To our knowledge, a possible predictive relationship of the multi-inflammatory index (MII) with new-onset atrial fibrillation (AF) after off-pump coronary artery bypass grafting (CABG) has not yet been studied in the literature. AIMS: We aimed to investigate whether the MII is a novel group of hematological markers for predicting postoperative new-onset AF in patients undergoing off-pump CABG. METHODS: A total of 427 patients undergoing isolated off-pump CABG between October 2021 and December 2023 were enrolled in this retrospective observational cohort study and allocated to two groups: the AF group (n = 108) and the non-AF group (n = 319). The groups were compared in terms of baseline clinical patient characteristics, laboratory parameters, and operative and postoperative data. RESULTS: The median values of age, length of hospital stay, platelet and neutrophil count, C-reactive protein level, systemic immune-inflammation index, MII-1, MII-2, and MII-3 were significantly greater in the AF group compared to the non-AF group in univariate analyses. In multiple explanatory variable logistic regression analysis, MII-1, MII-2, and MII-3 were determined to be significant hematological variables, and thereby these indices were considered the independent predictors of postoperative new-onset AF. Receiver operating characteristic curve analyses showed that to predict postoperative new-onset AF, MII-1 of 22.47 constituted the cut-off value with 62.0% sensitivity and 57.0% specificity, MII-2 of 141.77 constituted the cut-off value with 43.5% sensitivity and 76.8% specificity, and MII-3 of 5669 constituted the cut-off value with 63.8% sensitivity and 58.3% specificity. CONCLUSION: This study demonstrated for the first time that all MIIs predicted new-onset AF after off-pump CABG.
Asunto(s)
Fibrilación Atrial , Puente de Arteria Coronaria Off-Pump , Humanos , Fibrilación Atrial/etiología , Puente de Arteria Coronaria Off-Pump/efectos adversos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Estudios Retrospectivos , Inflamación/sangre , Inflamación/etiología , Complicaciones Posoperatorias/sangre , Complicaciones Posoperatorias/etiología , Biomarcadores/sangre , Proteína C-Reactiva/análisis , Proteína C-Reactiva/metabolismoRESUMEN
This study was intended to evaluate the pathological outcome of cardiopulmonary bypass whilst considering socio-demographic variables and surgical technique on early postoperative results following coronary artery bypass graft (CABG) surgery in patients at a tertiary level hospital in Bangladesh. This observational study evaluated a total of 880 patients with ischemic heart disease in Bangabandhu Sheikh Mujib Medical University, Bangladesh from 2011 to 2019 who were undergoing an isolated CABG surgery. In this current study, the population divided into two groups- Group A: Off-pump CABG (n=440) and Group B: On-pump CABG (n=440). The mean age of the patients was 55.25±5.0 years in off-pump and 50.75±5.2 years in the on-pump group. Risk factors, including smoking, hypertension, and hyperlipidemia, were predominant in both study groups. Total operative time was notably higher in the on-pump CABG group. However, grafting time was more in the off-pump CABG procedures. Postoperative neurological deficits were higher amongst the on-pump CABG population. The mean time of mechanical ventilation, intensive care unit (ICU) stay, total hospital stay, and mortality was notably higher in the on-pump CABG group. Moreover, the number of mortalities in on-pump CABG patients was primarily due to the low output syndrome, failure of weaning from cardiopulmonary bypass (CPB) and sudden cardiac arrest. Off-pump CABG is now more acceptable due to its potentiality to avoid CPB induced complications, aortic cannulation, and cross-clamping. Cardiac arrest in on-pump CABG induces global ischemia and reperfusion injury to the cardiac muscle. Besides, the Off-pump CABG provides a conspicuous survival advantage compared to the on-pump CABG, in association with a notable reduction in postoperative morbidity and mortality.
Asunto(s)
Puente de Arteria Coronaria , Humanos , Persona de Mediana Edad , Masculino , Femenino , Bangladesh/epidemiología , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/estadística & datos numéricos , Factores de Riesgo , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Puente de Arteria Coronaria Off-Pump/efectos adversos , Puente de Arteria Coronaria Off-Pump/métodos , Tiempo de Internación/estadística & datos numéricos , Isquemia Miocárdica/cirugía , Isquemia Miocárdica/epidemiología , Tempo Operativo , Resultado del TratamientoRESUMEN
There are some discrepancies about the superiority of the off-pump coronary artery bypass grafting (CABG) surgery over the conventional cardiopulmonary bypass (on-pump). The aim of this study was estimating risk ratio of mortality in the off-pump coronary bypass compared with the on-pump using a causal model known as collaborative targeted maximum likelihood estimation (C-TMLE). The data of the Tehran Heart Cohort study from 2007 to 2020 was used. A collaborative targeted maximum likelihood estimation and targeted maximum likelihood estimation, and propensity score (PS) adjustment methods were used to estimate causal risk ratio adjusting for the minimum sufficient set of confounders, and the results were compared. Among 24,883 participants (73.6% male), 5566 patients died during an average of 8.2 years of follow-up. The risk ratio estimates (95% confidence intervals) by unadjusted log-binomial regression model, PS adjustment, TMLE, and C-TMLE methods were 0.86 (0.78-0.95), 0.88 (0.80-0.97), 0.88 (0.80-0.97), and 0.87(0.85-0.89), respectively. This study provides evidence for a protective effect of off-pump surgery on mortality risk for up to 8 years in diabetic and non-diabetic patients.
Asunto(s)
Puente de Arteria Coronaria Off-Pump , Humanos , Masculino , Puente de Arteria Coronaria Off-Pump/efectos adversos , Puente de Arteria Coronaria Off-Pump/mortalidad , Femenino , Persona de Mediana Edad , Anciano , Funciones de Verosimilitud , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Irán/epidemiología , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Resultado del Tratamiento , Puntaje de Propensión , Puente Cardiopulmonar/efectos adversosRESUMEN
Background/aim: In this prospective observational study, our goal was to investigate the relationship between serum levels of oxidative stress (OS) parameters and regional cerebral oxygen saturation (rSO2) in addition to evaluating postoperative clinical outcomes among patients undergoing coronary artery bypass graft surgery (CABG). Materials and methods: This study comprised 64 adult patients undergoing elective CABG (on-pump [n = 48] and off-pump [n = 16]) procedures. Serum OS levels and rSO2 values were measured intraoperatively at three specific time points: T1 (after induction), T2 (15 min before aortic cross-clamp removal or the final distal anastomosis), and T3 (15 min after aortic cross-clamp removal or the last distal anastomosis). Results: Serum OS and lactate values demonstrated higher levels at T2 and T3 (p < 0.001), while rSO2 values were lower at T2 (p = 0.024) in the on-pump CABG group compared to the off-pump CABG group. The rSO2 values at T2 exhibited a negative correlation with OS parameters, lactate levels at T2 and T3, aortic clamp time, postoperative mechanical ventilation time, and intensive care unit stay length. In the multivariate linear regression analysis (R2 = 0.181, p = 0.001), lactate values at T2 emerged as the sole factor affecting the OS index at T2 (t = 2.843, p = 0.006). Conclusion: In our study, we observed elevated OS values and relatively low rSO2 values during on-pump CABG procedures, with rSO2 showing an association with increased OS parameters. Close monitoring of the OS response level and rSO2 during CABG could potentially enhance postoperative clinical outcomes.
Asunto(s)
Puente de Arteria Coronaria Off-Pump , Puente de Arteria Coronaria , Estrés Oxidativo , Humanos , Masculino , Femenino , Estudios Prospectivos , Persona de Mediana Edad , Puente de Arteria Coronaria Off-Pump/efectos adversos , Estrés Oxidativo/fisiología , Anciano , Encéfalo/metabolismo , Oxígeno/sangre , Oxígeno/metabolismo , Saturación de Oxígeno/fisiologíaRESUMEN
BACKGROUND: The ongoing debate regarding off-pump coronary artery bypass grafting (CABG) and on-pump CABG has endured for over three decades. Although numerous randomized controlled trials (RCTs) and meta-analyses have been reported, new evidence has emerged. Therefore, an updated and comprehensive meta-analysis to guide clinical practice is essential. MATERIALS AND METHODS: A comprehensive search for eligible articles published after 2000, reporting RCTs involving at least 100 patients and comparing off-pump CABG with on-pump CABG, was performed throughout the databases including Embase, Ovid Medline, and Web of Science. The primary interested outcomes included the short-term incidence of stroke and long-term mortality. The primary analysis utilized fixed-effect model with the inverse variance method. The Grade of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the certainty of evidence. RESULTS: After thorough screening, 39 articles were included, consisting of 28 RCTs and involving a total of 16 090 patients. Off-pump CABG significantly reduced the incidence of short-term stroke (1.27 vs. 1.78%, OR: 0.74, P =0.03, high certainty). However, it was observed to be associated with increased mid-term coronary reintervention (2.77 vs. 1.85%, RR: 1.49, P <0.01, high certainty) and long-term mortality (21.8 vs. 21.0%, RR: 1.09, P =0.02, moderate certainty). CONCLUSIONS: Off-pump CABG significantly reduces the short-term incidence of stroke, but it also increases the incidence of mid-term coronary reintervention. Moreover, it may increase long-term mortality.
Asunto(s)
Puente de Arteria Coronaria Off-Pump , Puente de Arteria Coronaria , Humanos , Puente de Arteria Coronaria Off-Pump/efectos adversos , Puente de Arteria Coronaria Off-Pump/mortalidad , Puente de Arteria Coronaria Off-Pump/métodos , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Resultado del Tratamiento , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/etiología , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/prevención & control , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: Patients requiring coronary artery bypass grafting (CABG) are often loaded with antithrombotic drugs (AT) and are at an increased risk for perioperative bleeding complications. Active AT removal by a hemoadsorption cartridge integrated in the cardiopulmonary bypass circuit is increasingly used in this setting to reduce bleeding, and herein we describe the extension of this application in patients on AT undergoing off-pump coronary artery bypass (OPCAB). METHODS: Ten patients (80% male; mean age: 67.4 ± 9.2years) were treated with ticagrelor (eight patients), rivaroxaban and ticagrelor (one patient), and rivaroxaban (one patient) prior to OPCAB surgery. AT's were discontinued one day before surgery in nine patients and on the day of surgery in one patient, and all patients were also on aspirin. The cohort mean EuroSCORE-II was 2.9 ± 1.5%. A hemoadsorption cartridge was integrated into a dialysis device (n=4) or a stand-alone apheresis pump (n=6) periprocedural, for a treatment time of 145 ± 33 min. Outcome measures included bleeding according to Bleeding Academic Research Consortium (BARC)-4 and 24-hour chest-tube-drainage (CTD). RESULTS: Mean operation time was 184 ± 35 min. All patients received a left internal thoracic artery with a mean of 2.3 ± 0.9 total grafts. One patient had a BARC-4 bleeding event and there were no surgical re-explorations for bleeding. Mean 24-hours CTD was 680 ± 307mL. During follow-up of 19.5 ± 17.0 months, none of the patients died or required further reinterventions. No device-related adverse events were reported. CONCLUSIONS: Hemoadsorption via a stand-alone apheresis pump during OPCAB surgery was feasible and safe. This innovative and new approach showed favorable bleeding rates in patients on antithrombotic drugs requiring bypass surgery.
Asunto(s)
Puente de Arteria Coronaria Off-Pump , Humanos , Masculino , Persona de Mediana Edad , Anciano , Femenino , Puente de Arteria Coronaria Off-Pump/efectos adversos , Fibrinolíticos , Ticagrelor , Rivaroxabán , Puente de Arteria Coronaria , Resultado del TratamientoRESUMEN
OBJECTIVES: Blood transfusion plays a crucial role in coronary artery bypass grafting (CABG). The choice between autologous cell saver (CS) and allogenic blood transfusion (ABT) has been a continuous debate in the medical community, especially within cardiac surgery. This study aimed to assess the outcomes of off-pump CABG (OPCAB) surgery in patients receiving blood solely via cell salvage compared to those receiving ABT or a combination of ABT and CS perioperatively. METHODS: A total of 414 patients who underwent isolated OPCAB surgery at our cardiovascular clinic were analyzed. Among them, 250 patients (60.4%) received blood via CS alone, while 164 patients (39.6%) received either ABT or a mix of ABT and CS. Stabilized inverse probability treatment weighted (IPTW) matching technique ensured balance in baseline covariates. RESULTS: We found no significant differences in 30-day mortality rates between the CS and ABT groups. The CS group displayed significantly lower rates of overall complications, encompassing stroke, acute kidney injury, atrial fibrillation, and pulmonary complications. Rates of sepsis, readmission, gastrointestinal complications, heparin-induced thrombosis, and deep venous thrombosis were comparable between the two groups. However, in contrast to the ABT group, the CS group exhibited significantly shorter median lengths of hospital stay (LOHS), ICU stay, and ventilation time, along with higher rates of discharge to home rather than acute care facilities. CONCLUSION: Our data suggest that autologous blood transfusion via CS results in fewer perioperative complications and faster recovery following OPCAB procedures as compared to ABT.
Asunto(s)
Puente de Arteria Coronaria Off-Pump , Recuperación de Sangre Operatoria , Complicaciones Posoperatorias , Humanos , Puente de Arteria Coronaria Off-Pump/efectos adversos , Puente de Arteria Coronaria Off-Pump/métodos , Puente de Arteria Coronaria Off-Pump/mortalidad , Masculino , Femenino , Estudios Retrospectivos , Anciano , Persona de Mediana Edad , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Recuperación de Sangre Operatoria/efectos adversos , Recuperación de Sangre Operatoria/métodos , Resultado del Tratamiento , Transfusión de Sangre Autóloga/métodos , Transfusión de Sangre Autóloga/efectos adversos , Tiempo de Internación/estadística & datos numéricos , Factores de Tiempo , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Factores de Riesgo , Medición de RiesgoRESUMEN
Severe left ventricular (LV) dysfunction is an independent risk factor for early and long-term mortality after coronary-artery bypass grafting (CABG). Off-pump CABG (OPCAB) significantly reduces the early incidence of major complications in high-risk patients. Moreover, bilateral internal thoracic artery (BITA) grafting after CABG is associated with improved long-term outcomes. We aimed to evaluate the impact of multivessel OPCAB with BITA grafting for complete revascularization on postoperative and long-term outcomes in patients with low LV ejection fraction (EF). We included 121 patients with EF ≤ 30.0% who underwent isolated multivessel OPCAB (average LVEF, 24.8%) between April 2007 and December 2019. Sixty-six patients received BITA grafts, while 55 had single internal thoracic artery (SITA) grafts. We conducted multivariate analyses to examine the correlation between perioperative data and late mortality rate. The early mortality rate was 1.65%. After excluding in-hospital mortality cases, we performed long-term follow-up of 119 patients. Early postoperative echocardiography showed significant LVEF improvement in 89 (75.2%) patients. However, LVEF remained ≤ 30.0% in 30 (24.8%) patients. We recorded 15 and 30 cases of cardiac death and cardiac events, respectively, during the long-term follow-up period. Postoperative LVEF ≤ 30.0% (P < 0.01) and no use of BITA grafting (P = 0.03) were significant predictors of cardiac death and events; moreover, hemodialysis was a significant predictor of all-cause mortality rather than cardiac death. Multivessel OPCAB in patients with severe LV dysfunction was associated with acceptable in-hospital mortality and early postoperative improvement in LV function. Additionally, OPCAB with BITA grafting may provide long-term benefits with respect to cardiac death and events. However, the long-term benefits were significantly limited in patients without early postoperative improvement in LV function and patients with chronic hemodialysis.Clinical registration number: 5590 (14/5/2020 Tokyo Women's Medical University).
Asunto(s)
Puente de Arteria Coronaria Off-Pump , Enfermedad de la Arteria Coronaria , Volumen Sistólico , Disfunción Ventricular Izquierda , Función Ventricular Izquierda , Humanos , Femenino , Masculino , Disfunción Ventricular Izquierda/fisiopatología , Disfunción Ventricular Izquierda/diagnóstico , Puente de Arteria Coronaria Off-Pump/efectos adversos , Puente de Arteria Coronaria Off-Pump/métodos , Anciano , Estudios Retrospectivos , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/diagnóstico , Persona de Mediana Edad , Factores de Tiempo , Función Ventricular Izquierda/fisiología , Volumen Sistólico/fisiología , Resultado del Tratamiento , Factores de Riesgo , Estudios de Seguimiento , Complicaciones Posoperatorias/epidemiología , Mortalidad Hospitalaria , EcocardiografíaRESUMEN
BACKGROUND: Ticagrelor is reportedly more effective than clopidogrel in preventing atherothrombotic events in patients with percutaneous coronary intervention. However, the optimal antiplatelet therapy strategy after off-pump coronary artery bypass grafting (OPCABG) is yet to be established. MATERIALS AND METHODS: This study was performed using the prospectively-maintained database at our institution. Patients who underwent OPCABG were divided into the clopidogrel and the ticagrelor groups. Propensity score matching analysis was performed between the two groups. The clinical outcome was the occurrence of major adverse cardiovascular event (MACE), defined as a composite of vascular death, myocardial infarction, or stroke 1-year after surgery. RESULTS: In total, 545 patients completed the entire follow-up assessment. After propensity score matching, 232 patients each were included in the clopidogrel and ticagrelor groups. The primary outcome occurred in 7.8 and 4.3% of patients in the clopidogrel and ticagrelor groups, respectively ( P =0.113). CYP2C19 variants (*2, *3, and *17) did not impact the clinical outcomes, regardless of the use of clopidogrel or ticagrelor. The rates of MACE were significantly lower in patients carrying the ABCB1 C3435T CT/TT genotypes in the ticagrelor group than in those carrying the ABCB1 C3435T CC genotype in the clopidogrel group (1.4 vs. 9.1%, adjusted P =0.030), as well as those carrying the ABCB1 C3435T CC genotype in the ticagrelor group (1.4 vs. 8.9%, adjusted P =0.036). The ABCB1 C3435T CC genotype was significantly associated with the incidence of 1-year MACE (HR=1.558, 95% CI: 1.109-2.188, P =0.011). Patients who experienced severe perioperative bleeding exhibited a significantly higher incidence of MACE than those who did not experience severe perioperative bleeding (14.0 vs. 4.9%, adjusted P =0.007). CONCLUSION: There was no significant difference in the 1-year MACE between patients receiving clopidogrel and those receiving ticagrelor after OPCABG. Notably, The ABCB1 C3435T CC genotype was related to a higher risk of MACE.
Asunto(s)
Clopidogrel , Puente de Arteria Coronaria Off-Pump , Inhibidores de Agregación Plaquetaria , Ticagrelor , Humanos , Ticagrelor/uso terapéutico , Clopidogrel/uso terapéutico , Clopidogrel/efectos adversos , Clopidogrel/administración & dosificación , Masculino , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Anciano , Puente de Arteria Coronaria Off-Pump/efectos adversos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Inhibidores de Agregación Plaquetaria/efectos adversos , Inhibidores de Agregación Plaquetaria/administración & dosificación , Resultado del Tratamiento , Puntaje de Propensión , Estudios de CohortesRESUMEN
BACKGROUND: A significant impact of surgeons' experience on outcomes of off-pump coronary artery bypass (OPCAB) has been recognized through previous large-scale studies. However, a safe, effective, and concrete OPCAB training was yet to be identified. We evaluate a safety of our OPCAB training model with single left internal mammary artery (LIMA)-left anterior descending artery (LAD) as a reasonable first step. METHODS: Between January 2010 and June 2019, 180 patients with an isolated single coronary bypass of the LAD using LIMA as an in situ graft via median sternotomy fulfilled the inclusion criteria. Coronary arterial bypass under cardiopulmonary bypass (CPB), utilizing other graft material, minimal invasive direct coronary arterial bypass through left-sided thoracotomy, and multiple diseased coronary artery disease were excluded. The primary outcome is an early postoperative outcome (major adverse cardiac and cerebrovascular events [MACCEs]: myocardial infarction, coronary re-revascularization, stroke, acute renal failure, and all causes of death) between residents in training under supervision (group 1: n = 63) and experienced surgeons (group 2: n = 117). Trainees were already experienced in on-pump coronary artery bypass grafting. RESULTS: Preoperative variables were comparable. There was no significant difference in the rate of MACCEs between the two groups including hospital mortality (p = 1.000), perioperative myocardial infarction (p = 0.246), stroke (p = 0.655), and acute renal failure (p = 0.175). CONCLUSION: The early postoperative outcome of off-pump LIMA to the LAD performed by trainees was comparable to those by experienced surgeons. Single LIMA-LAD was safely performed by trainees under supervision without CPB. In order to master OPCAB technique, single LAD bypass might be a reasonable first step to get into touch with the technical characteristics of this special procedure.
Asunto(s)
Competencia Clínica , Puente de Arteria Coronaria Off-Pump , Enfermedad de la Arteria Coronaria , Educación de Postgrado en Medicina , Complicaciones Posoperatorias , Humanos , Puente de Arteria Coronaria Off-Pump/efectos adversos , Puente de Arteria Coronaria Off-Pump/educación , Puente de Arteria Coronaria Off-Pump/mortalidad , Femenino , Masculino , Resultado del Tratamiento , Anciano , Persona de Mediana Edad , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Anastomosis Interna Mamario-Coronaria/efectos adversos , Anastomosis Interna Mamario-Coronaria/mortalidad , Internado y Residencia , Curriculum , Medición de Riesgo , Cirujanos/educaciónAsunto(s)
Puente de Arteria Coronaria Off-Pump , Puente de Arteria Coronaria , Humanos , Puente de Arteria Coronaria Off-Pump/efectos adversos , Puente de Arteria Coronaria/efectos adversos , Resultado del Tratamiento , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Factores de Riesgo , Puente Cardiopulmonar/efectos adversosRESUMEN
BACKGROUND: Elderly patients are at increased risk of perioperative morbidity and mortality after conventional on-pump coronary artery bypass grafting (ONCABG). This study was to determine whether such high-risk population would benefit from off-pump coronary artery bypass grafting (OPCABG). METHODS: A retrospective analysis was performed on patients aged 65 years or older who underwent isolated coronary artery bypass grafting for the first time in Wuhan Union Hospital from January 2015 to January 2021. We used propensity score matching to adjust for differences in baseline characteristics between the ONCABG and OPCABG groups. Morbidity and mortality within 30 days after surgery were compared between the two groups. All operations were performed by experienced cardiac surgeons. RESULTS: A total of 511 patients (ONCABG 202, OPCABG 309) were included. After 1:1 matching, the baseline characteristics of the two groups were comparable (ONCABG 173, OPCABG 173). The OPCABG group had higher rate of incomplete revascularization (13.9% vs. 6.9%; P = .035) than the ONCABG group. However, OPCABG reduced the risk of postoperative renal insufficiency (15.0% vs. 30.1%; P = .001) and reoperation for bleeding (0.0% vs. 3.5%; P = .030). There were no significant differences in early postoperative mortality, myocardial infarction, stroke, and other outcomes between the two groups. CONCLUSIONS: OPCABG is an alternative revascularization method for elderly patients. It reduces the risk of early postoperative renal insufficiency and reoperation for bleeding.
Asunto(s)
Puente de Arteria Coronaria Off-Pump , Puente de Arteria Coronaria , Complicaciones Posoperatorias , Puntaje de Propensión , Humanos , Masculino , Puente de Arteria Coronaria Off-Pump/métodos , Puente de Arteria Coronaria Off-Pump/efectos adversos , Femenino , Anciano , Estudios Retrospectivos , Complicaciones Posoperatorias/epidemiología , Puente de Arteria Coronaria/métodos , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , China/epidemiología , Factores de RiesgoRESUMEN
BACKGROUND: Although coronary artery bypass grafting (CABG) is performed via three different techniques, conventional, on-pump beating heart CABG (ONBHCAB), or off-pump CABG (OPCAB), data are limited to compare ONBHCAB with OPCAB. METHODS: We retrospectively investigated the postoperative cardiac biomarkers, creatine kinase-MB (CK-MB), and troponin I (cTnI), and early and late outcomes in 806 patients undergoing isolated ONBHCAB or OPCAB between February 2008 and September 2022. To eliminate the bias between different groups, propensity score matching was conducted to validate the findings. RESULTS: After matching, the number of each study group totaled 270 patients. In both complete and matched cohorts, early outcomes, including morbidities and mortalities, were similar. However, cTnI and CK-MB levels were significantly higher after ONBHCAB than after OPCAB with median peak cTnI of 9.85 versus 4.60 ng/mL and median peak CK-MB of 48.45 versus 17.10 ng/mL in the matched cohort, which were quite low, below the threshold for values defining perioperative myocardial infarction. At follow-up of 73 ± 45 months, the overall actuarial survival rates were similar between the ONBHCAB and OPCAB patients (86 vs. 87% at 5 years and 64 vs. 68% at 10 years, respectively, in the matched cohort). CONCLUSION: ONBHCAB may be a comparable alternative to OPCAB with similar early and late outcomes, despite higher elevation of postoperative cardiac biomarkers. ONBHCAB provides more efficient hemodynamic support, providing a better surgical visual field, than OPCAB while reducing the risk of incomplete revascularization.
Asunto(s)
Biomarcadores , Puente de Arteria Coronaria Off-Pump , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Forma MB de la Creatina-Quinasa , Troponina I , Humanos , Puente de Arteria Coronaria Off-Pump/efectos adversos , Puente de Arteria Coronaria Off-Pump/mortalidad , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Anciano , Biomarcadores/sangre , Resultado del Tratamiento , Forma MB de la Creatina-Quinasa/sangre , Factores de Tiempo , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/sangre , Troponina I/sangre , Factores de Riesgo , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Medición de Riesgo , Puente Cardiopulmonar/efectos adversos , Puente Cardiopulmonar/mortalidadRESUMEN
OBJECTIVE: To evaluate the effects of time of surgery on the short-term outcomes of patients undergoing off-pump coronary artery bypass grafting (OPCABG). DESIGN: A retrospective cohort study. SETTING: A single large-volume cardiovascular center. PATIENTS: Patients undergoing elective OPCABG between September 2019 and July 2022. INTERVENTIONS: Patients were divided into the following 2 groups according to the start time of surgery: morning (AM group, before 11 AM) and afternoon (PM group, after 11 AM). Propensity-score matching (PSM) with a 1:1 matching ratio was used to create comparable cohorts. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the composite incidence of mortality and morbidities during hospitalization. Secondary endpoints included postoperative bleeding and transfusion, mechanical ventilation duration (MVD), and lengths of stay (LOS) in the intensive care unit (ICU) and hospital. From a consecutive series of 1,039 patients, PSM yielded 317 well-matched pairs. There was no difference in the composite incidence of in-hospital mortality and morbidities between the AM and PM groups (16.4% v 17.4%, p = 0.832). However, patients in the PM group were associated with less postoperative blood loss over the first 24 hours (470 v 540 mL, p = 0.002), decreased MVD (14 v 16 hours, p < 0.001), and shorter LOS in ICU (46 v 68 hours, p = 0.002) compared to patients in AM group. CONCLUSIONS: The current study suggested a lack of relevance regarding the time of surgery with in-hospital mortality and morbidities in patients undergoing OPCABG.
Asunto(s)
Puente de Arteria Coronaria Off-Pump , Humanos , Estudios Retrospectivos , Puente de Arteria Coronaria Off-Pump/efectos adversos , Unidades de Cuidados Intensivos , Tiempo de Internación , Morbilidad , Hemorragia Posoperatoria/etiología , Resultado del TratamientoRESUMEN
PURPOSE: To validate the predictive value of the aortic knob index for identifying new-onset postoperative atrial fibrillation (POAF) after off-pump coronary artery bypass grafting (OPCAB). METHODS: Among 156 patients who underwent isolated OPCAB, 138 consecutive patients without a history of atrial fibrillation were enrolled in this retrospective observational cohort study. The patients were divided into two groups based on the development of POAF. We compared the baseline clinical characteristics; preoperative radiographic characteristics of the aorta, including aortic knob measurements; and perioperative data, between the groups. Logistic regression analysis was performed to identify the predictors of new-onset POAF. RESULTS: New-onset POAF developed in 35 (25.4%) patients. Multivariate logistic regression analysis revealed that the aortic knob index was an independent predictor of POAF and yielded that the risk of POAF increased by 1.85 times when the aortic knob index increased by 0.1 (odds ratio, 1.853; confidence interval, 1.326-2.588; P < 0.001). Receiver operating characteristic analysis revealed that an aortic knob index of 1.364 constituted a cutoff value for new-onset POAF with 80.0% sensitivity and 65.0% specificity. CONCLUSIONS: The aortic knob index on preoperative chest radiography was a significant and independent predictor of new-onset POAF following OPCAB.