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Off-pump versus on-pump reoperative CABG via a left thoracotomy for circumflex coronary artery revascularization
Oz M Shapira1, Vijay Natarajan, Shantesh Kaushik
1Department of Cardiothoracic Surgery, Boston University School of Medicine, Boston, Massachusetts, USA. oz.shapira@bmc.org
Insights
Reoperative CABG via left thoracotomy (RCLT) is safe for circumflex artery revascularization. Off-pump beating heart (OPCAB) technique reduces blood use and hospital stay, making it more cost-effective.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
Background:
- Reoperative CABG via left thoracotomy (RCLT) offers a viable option for high-risk patients needing circumflex coronary artery revascularization.
- This study evaluates two techniques: on-pump RCLT using cardiopulmonary bypass (CPB) and off-pump RCLT (OPCAB) with a beating heart.
Purpose of the Study:
- To compare the outcomes of on-pump versus off-pump reoperative CABG via left thoracotomy for circumflex artery revascularization.
- To assess safety, efficacy, and cost-effectiveness of both techniques.
Main Methods:
- Retrospective analysis of 32 patients undergoing RCLT over 10 years.
- Comparison of 14 patients (CPB) with 18 patients (OPCAB).
- 100% follow-up, with a focus on perioperative outcomes and long-term survival.
Main Results:
- No significant difference in mortality, perioperative myocardial infarction, or atrial fibrillation rates.
- OPCAB group showed significantly lower allogeneic blood product use, shorter ICU, and hospital stays (p<0.05).
- Three-year survival (74%) and reintervention rates (19%) were similar between groups, with predominantly non-cardiac deaths.
Conclusions:
- RCLT is a safe and effective approach for circumflex revascularization using either CPB or OPCAB.
- OPCAB technique demonstrates superior cost-effectiveness due to reduced resource utilization.
Objective:
Reoperative CABG via a left thoracotomy (RCLT) has become a useful approach for revascularization of the circumflex coronary territory for patients who are at high risk for conventional approach. This study compares the results of RCLT using cardiopulmonary bypass (CPB) with those of a beating heart technique (OPCAB).
Methods:
Thirty-two patients who underwent RCLT over the past 10 years were included. Fourteen patients undergoing on-pump RCLT (CPB) were compared to 18 patients undergoing off-pump RCLT (OPCAB). Baseline characteristics of the study groups were similar. Follow-up was 100% complete. A single graft was performed in all patients except one who had two grafts.
Results:
There were no deaths or perioperative myocardial infarctions in either group. The incidence of atrial fibrillation (CPB: 29% vs. OPCAB: 11%) and the percentage of patients requiring ventilator support longer than 24 hours (21% vs. 6%) was not significantly different between the groups. However, allogeneic blood product utilization (0.9 +/- 1.2 vs. 0.3 +/- 0.7 units, p = 0.04), ICU stay (65 +/- 79 vs. 28 +/- 16 hours, p = 0.04) and total hospital length of stay (8 +/- 4 vs. 5 +/- 1 days, p = 0.001) were significantly lower in the OPCAB group. Average follow-up for the entire cohort was 33 +/- 9.8 months (range 2-102 months). Three-year survival was 74 +/- 9% with 9 deaths (28%) during the follow-up, but only 3 (9%) were cardiac related. Reinterventions were indicated in 6 patients (19%) (PTCA; 5, CABG: 1). Follow-up was longer for the CPB group (51 +/- 33 vs. 19.5 +/- 14 months, p = 0.001). Three-year survival (CPB 69 +/- 13%, OPCAB: 82 +/- 12%, p = 0.47) and reintervention rates (CPB: 3 [21%], OPCAB: 3 [17%], p = 0.33) were similar between the groups.
Conclusions:
RCLT is an effective and safe approach for circumflex artery revascularization with excellent short- and mid-term results using either technique. The OPCAB technique is associated with reduced blood product utilization and shorter ICU and hospital length of stay and, therefore, is more cost-effective.
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