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Published on: March 27, 2018
Does off-pump coronary revascularization reduce mortality in re-operative coronary artery surgery? A meta-analysis of
A H Sepehripour1, S Saso, L Harling
1Department of Surgery and Cancer, Imperial College London, UK.
Insights
Off-pump coronary artery bypass grafting (OPCAB) may reduce early mortality in re-operative patients. However, this survival benefit does not extend to mid-term outcomes, and OPCAB may lead to incomplete revascularization.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Cardiac Surgery
Background:
- Re-operative coronary artery bypass grafting (CABG) presents significant challenges, particularly in high-risk patients.
- Off-pump coronary artery bypass grafting (OPCAB) is hypothesized to offer advantages over traditional cardiopulmonary bypass (CPB) due to reduced invasiveness and physiological stress.
Purpose of the Study:
- To evaluate the impact of OPCAB on patient outcomes in the context of re-operative CABG.
- To compare early and mid-term mortality rates between OPCAB and conventional CABG in re-operative settings.
Main Methods:
- A systematic literature review identified twelve studies involving 3471 patients.
- Random-effects modeling was employed for meta-analysis of the selected studies.
- Primary endpoints included 30-day and mid-term mortality; secondary endpoints assessed revascularization completeness and graft numbers.
Main Results:
- OPCAB was associated with significantly lower 30-day mortality (OR 0.51).
- No significant difference in mid-term mortality was observed between OPCAB and conventional CABG.
- OPCAB resulted in significantly less complete revascularization and fewer grafts per patient.
Conclusions:
- Off-pump techniques may reduce early mortality in select re-operative CABG patients, but this benefit is not sustained long-term.
- Intra-operative conversion rates did not impact 30-day mortality in this analysis, though data were limited.
- OPCAB may increase the risk of incomplete revascularization, necessitating longer-term follow-up for full assessment.
Background:
Re-operative coronary artery bypass grafting (CABG) is a challenging operation that is often performed in a high-risk patient group. Avoiding cardiopulmonary bypass (CPB) in these patients is hypothesised to be advantageous due to the reduced invasiveness and physiological stress of off-pump coronary artery bypass grafting (OPCAB). The aims of this study were to assess whether OPCAB may improve outcomes in patients undergoing re-operative CABG.
Methods:
Twelve studies, incorporating 3471 patients, were identified by systematic literature review. These were meta-analysed using random-effects modelling. Primary endpoints were 30-day and mid-term mortality. Secondary endpoints were completeness of revascularization, mean number of grafts per patient and the effect of intra-operative conversion on mortality.
Results:
A significantly lower rate of 30-day mortality was observed with OPCAB (OR 0.51, 95% CI [0.35, 0.74]), however, no difference was demonstrated in mid-term mortality. Significantly less complete revascularization and mean number of grafts per patient were observed in the OPCAB group. Meta-regression revealed no change in 30-day mortality when the effect of conversion from one technique to the other was assessed.
Conclusions:
Off-pump techniques may reduce early mortality in selected patients undergoing re-operative CABG; however, this does not persist into mid-term follow-up. OPCAB may also lead to intra-operative conversion and, although this did not affect outcomes in this study, these results are constrained by the limited data available. Furthermore, OPCAB may increase target vessel revascularization and, consequently, incomplete revascularization which, whilst not reflected in the short-term outcomes, requires longer-term follow-up in order to be fully assessed.
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