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Does avoidance of cardiopulmonary bypass decrease the incidence of stroke in diabetics undergoing coronary surgery?
R Abraham1, H L Karamanoukian, M R Jajkowski
1State University of New York at Buffalo, Department of Cardiothoracic Surgery, Kaleida Health-Buffalo General Hospital, Buffalo, New York 14203, USA.
Insights
Off-pump coronary artery bypass grafting (CABG) showed a threefold reduction in stroke incidence compared to conventional CABG in diabetic patients. This technique appears favorable for high-risk diabetics needing coronary revascularization.
Area of Science:
- Cardiovascular Surgery
- Diabetology
Background:
- Diabetes mellitus adversely affects coronary circulation, increasing cardiovascular event risk.
- Diabetic patients undergoing coronary artery bypass grafting (CABG) often have higher baseline risks, including prior myocardial infarction, heart failure, and hypertension.
- Despite improvements in surgical techniques and anesthetic management, stroke remains a significant concern in diabetic patients undergoing CABG.
Purpose of the Study:
- To compare the stroke rate between off-pump CABG (OPCAB) and conventional CABG (CPB) in patients with a history of preoperative diabetes.
- To determine if OPCAB techniques can decrease stroke incidence in this higher-risk diabetic population.
Main Methods:
- A retrospective analysis of 1,227 diabetic patients undergoing CABG between 1995 and 1999.
- Patients were divided into two groups: conventional CABG with cardiopulmonary bypass (CPB) (973 patients) and off-pump CABG (OPCAB) (254 patients).
- Preoperative risk factors, including age, sex, urgency of surgery, carotid disease, ejection fraction, congestive heart failure, hypertension, and previous myocardial infarction, were analyzed and found to be similar between groups.
Main Results:
- The stroke rate was 3.6% in the CPB group versus 1.2% in the OPCAB group.
- Although not statistically significant on its own, this represents a threefold reduction in stroke incidence with OPCAB.
- The OPCAB group had a significantly higher percentage of high-risk criteria for stroke, including re-do CABG (26.4% vs. 8.7%) and calcified aortas (7.1% vs. 2.9%), suggesting a potential benefit of OPCAB in this higher-risk cohort.
Conclusions:
- Off-pump CABG (OPCAB) demonstrated a threefold reduction in stroke incidence compared to conventional CABG (CPB) in diabetic patients.
- While not statistically significant in this retrospective study, the reduction may be clinically significant given the higher-risk profile of the OPCAB group.
- OPCAB is a favorable technique for high-risk diabetic patients requiring coronary revascularization, and further research with larger series is warranted to confirm statistical significance.
Background:
The adverse effects of diabetes mellitus on the coronary circulation and the higher incidence of cardiovascular events in diabetic patients are well documented [Johnson 1982]. Improvements in myocardial protection, revascularization techniques, and anesthetic management have had favorable impacts on coronary artery bypass grafting (CABG) outcome in diabetic patients. Despite that, diabetic patients are significantly more likely to have a prior history of myocardial infarction, congestive heart failure, peripheral vascular disease, and hypertension, as well as having a significantly greater baseline serum creatinine. The aim of our study was to record, compare, and analyze the stroke rate among patients with a history of preoperative diabetes undergoing "off-pump" CABG (OPCAB) with conventional cardiopulmonary bypass (CPB) CABG to determine whether the stroke rate in this higher risk population could be decreased by off-pump techniques.
Methods:
The records of 1,227 patients with a pre-operative history of diabetes undergoing conventional CABG (973 patients, 79.3%) using cardiopulmonary bypass and off-pump CABG 254 (20.7%) were analyzed from 1995 through 1999. There were no differences in age, sex, or elective/urgent status of patients. Preoperative risk factors (gender distribution, carotid disease, ejection fraction, CHF, hypertension, previous MI) were identical in both groups. The goal of the operations were complete revascularization, which was achieved via median sternotomy in both groups.
Results:
Our reported series reveals a stroke rate of 3.6% in the CPB group and 1.2% in the off-pump group. This evidence alone was not statistically significant, but two other high-risk criteria for stroke, re-do CABG and calcified aortas, revealed that the off-pump series had a higher percentage of each (26.4% redos in off-pump vs. 8.7% CPB redos, p < 0.005; 7.1% calcified aorta cases in the off-pump group vs. 2.9% in the CPB group, p < 0.004). The threefold reduction in stroke may be clinically significant in light of the higher-risk profile of the off-pump group. The limitations of this study are that it was retrospective, there were a small number of events, and different surgeons were involved in the two different approaches to these patients.
Conclusions:
Improvements in myocardial protection, revascularization techniques, and anesthetic management have made significant, favorable impacts on CABG outcome in diabetic patients. New diagnostic and therapeutic strategies must be developed to lessen the medical and economic implications of stroke. A larger series or a more effective way of analyzing preoperative risk may well have shown a statistically significant difference in the stroke incidence given the differences in preoperative risk factors/stroke predictors. Until such advances occur, a threefold reduction of stroke incidence using OPCAB certainly makes this technique a favorable one for high-risk diabetics requiring coronary revascularization.