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Off-Pump Coronary Artery Bypass Grafting and Stroke-Exploratory Analysis of the GOPCABE Trial and Methodological
Wilko Reents1, Michael Zacher1, Jochen Boergermann2
1Herzchirurgie, Herz- und Gefäßklinik Bad Neustadt, Bad Neustadt, Germany.
Insights
Off-pump coronary artery bypass grafting (CABG) did not show lower stroke rates compared to on-pump CABG in elderly patients. Surgical aortic manipulation also did not significantly impact stroke rates in the off-pump group.
Area of Science:
- Cardiovascular Surgery
- Neurosurgery
- Geriatric Medicine
Background:
- Coronary artery bypass grafting (CABG) is a common surgical procedure.
- Off-pump CABG aims to reduce adverse events compared to traditional on-pump CABG.
- Stroke is a significant concern following cardiac surgery.
Purpose of the Study:
- To investigate the impact of surgical aortic manipulation on stroke rates in off-pump CABG.
- To compare stroke rates between off-pump and on-pump CABG in elderly patients.
- To analyze stroke incidence in relation to different aortic manipulation techniques during off-pump CABG.
Main Methods:
- Post-hoc analysis of the German Off-Pump Coronary Artery Bypass Grafting in Elderly patients trial.
- Comparison of stroke rates within 30 days post-surgery between off-pump and on-pump CABG groups.
- Stratification of stroke rates within the off-pump group based on degree of aortic manipulation (tangential clamping, clampless device, no manipulation).
- Aggregate analysis of stroke rates from four major trials involving over 10,000 patients.
Main Results:
- No significant difference in 30-day stroke rates between off-pump (2.2%) and on-pump (2.7%) CABG (OR 0.83).
- Within the off-pump group, varying degrees of aortic manipulation did not yield significantly different stroke rates.
- Aggregate analysis of over 10,000 patients confirmed comparable stroke rates for both techniques (off-pump 1.4%, on-pump 1.7%).
Conclusions:
- Off-pump CABG does not appear to reduce stroke rates compared to on-pump CABG in recent trials.
- Potential benefits of off-pump CABG may be counteracted by surgical complexity and multifactorial stroke mechanisms.
- Further research is needed to fully elucidate the role of surgical technique in perioperative stroke prevention.
Background:
Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (off-pump CABG) may reduce severe adverse events including stroke.
Methods:
In the German Off-Pump Coronary Artery Bypass Grafting in Elderly patients trial, the rate of major adverse cardiovascular events was compared in 2,394 elderly (≥ 75 years) patients undergoing CABG with (on-pump) or without (off-pump) cardiopulmonary bypass. This exploratory post-hoc analysis investigated the impact of surgical aortic manipulation on the rate of stroke.
Results:
There was no significant difference in the rate of stroke within 30 days after surgery between both groups (off-pump: 2.2%; on-pump: 2.7%; odds ratio [OR]: 0.83 [0.5-1.38]; p = 0.47). Within the off-pump group, different degrees of aortic manipulation did not lead to significant different stroke rates (tangential clamping: 2.3%; OR 0.86 [0.46-1.60]; clampless device: 1.8%; OR 0.67 [0.26-1.75]; no aortic manipulation: 2.4%; OR 0.88 [0.37-2.14]). An aggregate analysis including more than 10,000 patients out of the four recent major trials also yielded comparable stroke rates for on- and off-pump CABG (off-pump: 1.4%; on-pump: 1.7%; OR 0.87 [0.64-1.20]).
Conclusion:
Within recent prospective randomized multicenter trials off-pump CABG did not result in lower stroke rates. The possible intrinsic benefit of off-pump CABG may be offset by the complexity of the operative therapy as well as the multiple pathomechanisms involved in perioperative stroke.
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