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Off-pump coronary surgery: surgical strategy for the high-risk patient
Y Van Belleghem1, F Caes, L Maene
1Department of Cardiac Surgery, University Hospital, De Pintelaan 185, B 9000 Ghent, Belgium. Yves.vanbelleghem@rug.ac.be
Insights
Beating heart surgery for coronary artery disease is a safe alternative to conventional extracorporeal circulation, particularly benefiting high-risk patients. This technique offers reduced ICU stays and improved renal function, becoming a preferred choice for elderly patients with comorbidities.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Cardiac Surgery
- Cardiac Anesthesia
Background:
- Conventional coronary artery bypass grafting (CABG) often utilizes extracorporeal circulation (ECC).
- Beating heart surgery (BHS) aims to perform CABG without ECC, potentially reducing complications.
- Patient selection and risk stratification are crucial for comparing surgical outcomes.
Purpose of the Study:
- To compare the outcomes of BHS versus ECC in patients undergoing coronary artery disease surgery.
- To evaluate the safety and efficacy of BHS, especially in high-risk patient populations.
- To identify specific benefits of BHS in terms of postoperative complications and resource utilization.
Main Methods:
- A retrospective study compared two groups of consecutive patients (n=230 ECC, n=228 BHS) operated by the same team in 2000.
- High-risk patients were identified using a EuroSCORE threshold of 6.
- Preoperative variables, surgical details (number of distal anastomoses), and postoperative outcomes (atrial fibrillation, ICU stay, renal insufficiency, length of hospital stay) were analyzed.
Main Results:
- BHS group (group 2) showed a significantly lower incidence of atrial fibrillation, shorter ICU stay, and less renal insufficiency compared to the ECC group (group 1).
- While both groups achieved full revascularization, ECC involved more distal anastomoses.
- Benefits of BHS were more pronounced in high-risk patients, including a 1-day reduction in ICU stay, better renal function preservation, and over two days shorter hospital stay.
Conclusions:
- Beating heart surgery is a safe and effective alternative to conventional coronary artery bypass surgery.
- High-risk patients, particularly the elderly or those with significant comorbidities, experience the most significant benefits from BHS.
- BHS has become the preferred surgical approach for specific patient groups in this center's experience.
Objective:
In a retrospective study, we compared two groups of consecutive patients operated by the same team during the year 2000 for coronary artery disease with the use of extracorporeal circulation (group 1, n=230) or on the beating heart using the Octopus II plus stabiliser (group 2, n=228). High-risk patients were identified by a EuroSCORE plus 6. EuroSCORE definitions and predicted risk models were utilized to compare the variables of the groups.
Methods:
There were no significant differences between the preoperative variables of the groups in age, gender, left ventricular function, diabetes and peripheral vascular and renal disease as is indicated by the Euroscore (resp. 4.7/5.1 p=0.107). Calcification of the ascending aorta and chronic obstructive lung disease were statistically significant more prevalent in the beating heart group. No differences in preoperative variables in the high-risk patients group (Euroscore 8.5/8.1 p=0.356) except for calcification of the ascending aorta.
Results:
All patients underwent a full revascularisation through a midline sternotomy. Significant more distal anastomoses were performed in group 1 (3.7 per patient (1-6)) with regard to group 2 (2.9 per patient (1-6)). Anesthesia, postoperative treatment and follow up were equal for both groups. A significant lower incidence of atrial fibrillation (p=0.010), shorter ICU stay (p=0.031) and renal insufficiency (p=0.033) was reported in group 2. In the low risk group, we could not diagnose any difference between the two groups, except for atrial fibrillation. The benefits of the beating heart surgery however were more pronounced in the high-risk patient as is indicated by a significant reduction of the ICU stay by 1 day (3.5d/2.5d (p=0.028)), better preservation of the renal function (p=0.017) and a significant reduction of the length of hospital stay by more than two days (p=0.040). A lower incidence of atrial fibrillation, however not significant.
Conclusion:
In our experience, beating heart surgery is a safe alternative for conventional coronary heart surgery. High-risk patients do benefit most from this technique. It became our first choice in the elderly patient and patients presenting with higher co-morbidities.