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Complete revascularization in coronary artery bypass grafting with and without cardiopulmonary bypass
1Department of Cardiothoracic Surgery, University of Vienna Medical School, Austria.
Insights
Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) is effective for many selected patients, but complete revascularization rates are lower compared to standard CABG with CPB.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Minimally Invasive Surgery
Background:
- Complete revascularization in multivessel disease is crucial for optimal outcomes.
- The efficacy of off-pump coronary artery bypass grafting (OPCAB) versus conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) remains under investigation for elective low-risk patients.
Purpose of the Study:
- To prospectively evaluate the feasibility and effectiveness of complete revascularization using OPCAB compared to CABG with CPB in selected low-risk patients with multivessel coronary artery disease.
Main Methods:
- Eighty low-risk patients with multivessel disease were randomized to undergo CABG with (n=40) or without CPB (n=40).
- Preoperative coronary angiography determined suitability for OPCAB.
- Completeness of revascularization and short- to mid-term clinical outcomes were monitored over a 13.4 ± 6.5 month follow-up period.
Main Results:
- Complete revascularization was achieved in 65% of patients undergoing OPCAB versus 85% with CPB (p=0.043).
- Reasons for incomplete revascularization in the OPCAB group included technical difficulties (12.5%) and hemodynamic instability (22.5%).
- Mean graft number was lower in the OPCAB group (2.6 ± 0.5) compared to the CPB group (3.1 ± 0.8). Clinical outcomes and hospital stay were similar, with no deaths or myocardial infarctions.
Conclusions:
- Off-pump CABG is a viable option for complete revascularization in a majority of selected low-risk patients.
- However, the current series indicates a higher rate of incomplete revascularization with OPCAB, potentially compromising the principle of complete revascularization.
Background:
The feasibility of complete revascularization on the beating heart without cardiopulmonary bypass (CPB) as compared with the standard operation with CPB in elective low-risk patients with multivessel disease has not been clearly demonstrated in a prospective trial.
Methods:
Eighty selected low-risk patients were enrolled. In preoperative study with coronary angiography, the decision was made whether complete revascularization without CPB could be performed. Patients were randomly assigned to receive CABG either with (n = 40) or without CPB (n = 40). Randomization criteria were age, sex, and left ventricular ejection fraction. Completeness of revascularization as well as short- and mid-term clinical outcome in a 13.4 +/- 6.5 month follow-up period were monitored.
Results:
Twenty-six of 40 (65%) patients undergoing CABG without CPB underwent complete revascularization. In 5 of these patients (12.5%) suitable vessels were discarded for technical reasons and 9 patients (22.5%) were switched to CABG with CPB owing to the deeply intramyocardial course of target vessels (n = 5) or to hemodynamic instability (n = 4). In the group of patients operated on with CPB, 34 of 40 patients (85%) received complete revascularization. In 6 patients (15%) suitable vessels were discarded for technical reasons. Mean number of bypass grafts was 3.1 +/- 0.8 with CPB and 2.6 +/- 0.5 without CPB (p = 0.043). Clinical outcome and hospital stay were comparable in both groups. No patient died during the study period. No myocardial infarction was observed. Three patients undergoing CABG without CPB underwent successful PTCA 3 months after surgery.
Conclusions:
CABG without the use of CPB is effective for complete revascularization in the majority of selected low-risk patients. Nevertheless, it has to be stated that the rate of incomplete revascularization in this early series of CABG without CPB is higher, and compromises the basic principle of complete revascularization.