Coronary Artery Bypass Grafting With and Without Manipulation of the Ascending Aorta: A Network Meta-Analysis
Dong Fang Zhao1, J James Edelman2, Michael Seco2
1Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Baird Institute of Applied Heart and Lung Surgical Research, Sydney, New South Wales, Australia.
Insights
Anaortic off-pump coronary artery bypass grafting (anOPCABG) significantly reduces post-operative stroke risk compared to traditional CABG. This technique also lowers mortality, renal failure, and bleeding complications, offering improved patient outcomes.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Cardiac Surgery
- Interventional Cardiology
Background:
- Coronary artery bypass grafting (CABG) is standard for complex coronary disease but carries a higher stroke risk than percutaneous coronary intervention.
- Techniques minimizing cardiopulmonary bypass and aortic manipulation may reduce post-operative stroke incidence.
Purpose of the Study:
- To compare post-operative outcomes of various CABG techniques, including anaortic off-pump CABG (anOPCABG), off-pump CABG with Heartstring (OPCABG-HS), off-pump CABG with a partial clamp (OPCABG-PC), and traditional on-pump CABG.
- To evaluate the 30-day post-operative stroke rate across these surgical approaches.
Main Methods:
- A systematic literature search of 6 electronic databases identified relevant studies.
- A Bayesian network meta-analysis was conducted on 13 studies involving 37,720 patients, focusing on the 30-day stroke rate.
Main Results:
- Anaortic off-pump CABG (anOPCABG) demonstrated the greatest reduction in post-operative stroke risk (-78% vs. traditional CABG).
- anOPCABG also significantly decreased mortality, renal failure, bleeding complications, and atrial fibrillation, and shortened ICU stay compared to other methods.
Conclusions:
- Avoiding aortic manipulation in anOPCABG is associated with a reduced risk of post-operative stroke, particularly in high-risk patients.
- Eliminating cardiopulmonary bypass during anOPCABG may lead to lower risks of short-term mortality, renal failure, atrial fibrillation, and bleeding.
Background:
Coronary artery bypass grafting (CABG) remains the standard of treatment for 3-vessel and left main coronary disease, but is associated with an increased risk of post-operative stroke compared to percutaneous coronary intervention. It has been suggested that CABG techniques that eliminate cardiopulmonary bypass and reduce aortic manipulation may reduce the incidence of post-operative stroke.
Objectives:
A network meta-analysis was performed to compare post-operative outcomes between all CABG techniques, including anaortic off-pump CABG (anOPCABG), off-pump with the clampless Heartstring device (OPCABG-HS), off-pump with a partial clamp (OPCABG-PC), and traditional on-pump CABG with aortic cross-clamping.
Methods:
A systematic search of 6 electronic databases was performed to identify all publications reporting the outcomes of the included operations. Studies reporting the primary endpoint, 30-day post-operative stroke rate, were included in a Bayesian network meta-analysis.
Results:
There were 13 included studies with 37,720 patients. At baseline, anOPCABG patients had higher previous stroke than did the OPCABG-PC (7.4% vs. 6.5%; p = 0.02) and CABG (7.4% vs. 3.2%; p = 0.001) patients. AnOPCABG was the most effective treatment for decreasing the risk of post-operative stroke (-78% vs. CABG, 95% confidence interval [CI]: 0.14 to 0.33; -66% vs. OPCABG-PC, 95% CI: 0.22 to 0.52; -52% vs. OPCABG-HS, 95% CI: 0.27 to 0.86), mortality (-50% vs. CABG, 95% CI: 0.35 to 0.70; -40% vs. OPCABG-HS, 95% CI: 0.38 to 0.94), renal failure (-53% vs. CABG, 95% CI: 0.31 to 0.68), bleeding complications (-48% vs. OPCABG-HS, 95% CI: 0.31 to 0.87; -36% vs. CABG, 95% CI: 0.42 to 0.95), atrial fibrillation (-34% vs. OPCABG-HS, 95% CI: 0.49 to 0.89; -29% vs. CABG, 95% CI: 0.55 to 0.87; -20% vs. OPCABG-PC, 95% CI: 0.68 to 0.97), and shortening the length of intensive care unit stay (-13.3 h; 95% CI: -19.32 to -7.26; p < 0.0001).
Conclusions:
Avoidance of aortic manipulation in anOPCABG may decrease the risk of post-operative stroke, especially in patients with higher stroke risk. In addition, the elimination of cardiopulmonary bypass may reduce the risk of short-term mortality, renal failure, atrial fibrillation, bleeding, and length of intensive care unit stay.
