Reoperative coronary surgery patients are usually sicker and older, and the procedure is more technically demanding. Comparisons between coronary surgery with (coronary artery bypass [CAB] surgery on cardiopulmonary bypass [CPB]) and without (off-pump CAB [OPCAB]) the pump have been conducted; however, few studies showed results in reoperative cases. We investigate the potential superiority of one technique over the other in redo coronary surgeries.
Methods
Our institutional Society of Thoracic Surgery database was used to gather the data for 266 isolated reoperative coronary artery surgeries from January 2004 to July 2011. These were divided into the CAB surgery in CPB group (n = 204) and the OPCAB group (n = 62).
Results
Baseline characteristics of the two groups were similar, except for a significantly higher prevalence of cerebrovascular disease among the off-pump group (P = 0.01). There was also a trend toward fewer vessels bypassed among the same group (P = 0.07). Risk adjustment was done using multivariable analyses for detection of independent effects. The use of CPB was an independent predictor of increased rates of postoperative events (odds ratio, 3.9; P = 0.004) and atrial fibrillation (odds ratio, 5.9; P < 0.005) and longer intensive care unit (0.006) and hospital stay (0.004).
Conclusions
Redo OPCAB seems to offer favorable short-term outcomes compared with redo CAB. Our results suggest a reduced rate of overall postoperative events, decreased new postoperative atrial fibrillation, reduced hours stayed in the intensive care unit, and fewer days stayed from surgery to discharge. This was not associated with an increase in morbidity and mortality. A randomized study with a larger number of patients and with a longer follow-up is needed.
AscioneR., LloydC.T., UnderwoodM.J., LottoA.A., PitsisA.A., AngeliniG.D.Inflammatory response after coronary revascularization with or without cardiopulmonary bypass. Ann Thorac Surg.2000; 69: 1198–1204.
2.
KirklinJ.W., DonaldD.E., HarshbargerH.G.Studies in extracorporeal circulation. I. Applicability of Gibbon-type pump-oxygenator to human intracardiac surgery: 40 cases. Ann Surg.1956; 144: 2–8.
3.
StoneyW.S.Evolution of cardiopulmonary bypass. Circulation2009; 119: 2844–2853.
4.
GibbonJ.H.Jr.Application of a mechanical heart and lung apparatus to cardiac surgery. Minn Med.1954; 37: 171–185.
5.
CohnW.E.Alternative approaches to coronary artery bypass grafting. In: SellkeF.W., del NidoP.J., SwansonS.J., eds. Sabiston and Spencer Surgery of the Chest.Philadelphia, PA: Saunders; 2010: 1397–1398.
6.
LeeW.H.Jr., KrumhaarD., FonkalsrudE.W., SchjeideO.A., MaloneyJ.V.Jr.Denaturation of plasma proteins as a cause of morbidity and death after intracardiac operations. Surgery.1961; 50: 29–39.
7.
ChenowethD.E., CooperS.W., HugliT.E., StewartR.W., BlackstoneE.H., KirklinJ.W.Complement activation during cardiopulmonary bypass: evidence for generation of C3a and C5a anaphylatoxins. N Engl J Med.1981; 304: 497–503.
van DijkD., NierichA.P., JansenE.W., for the Octopus Study Group. Early outcome after off-pump versus on-pump coronary bypass surgery: results from a randomized study. Circulation.2001; 104: 1761–1766.
10.
PuskasJ.D., WilliamsW.H., DukeP.G.Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg.2003; 125: 797–808.
11.
PuskasJ.D., WilliamsW.H., MahoneyE.M.Off-pump vs conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial. JAMA.2004; 291: 1841–1849.
12.
MotallebzadehR., BlandJ.M., MarkusH.S., KaskiJ.C., JahangiriM.Neurocognitive function and cerebral emboli: randomized study of on-pump versus off-pump coronary artery bypass surgery. Ann Thorac Surg.2007; 83: 475–482.
13.
KobayashiJ., TashiroT., OchiM.for the Japanese Off-Pump Coronary Revascularization Investigation (JOCRI) Study Group. Early outcome of a randomized comparison of off-pump and on-pump multiple arterial coronary revascularization. Circulation.2005; 112(suppl): I338–I343.
14.
KhanN.E., De SouzaA., MisterR.A randomized comparison of off-pump and on-pump multivessel coronary-artery bypass surgery. N Engl J Med.2004; 350: 21–28.
15.
SedrakyanA., WuA.W., ParasharA., BassE.B., TreasureT.Off-pump surgery is associated with reduced occurrence of stroke and other morbidity as compared with traditional coronary artery bypass grafting: a meta-analysis of systematically reviewed trials. Stroke.2006; 37: 2759–2769.
16.
PlomondonM.E., ClevelandJ.C.Jr., LudwigS.T.Off-pump coronary artery bypass is associated with improved risk-adjusted outcomes. Ann Thorac Surg.2001; 72: 114–119.
17.
HernandezF., CohnW.E., BaribeauY.R.for the Northern New England Cardiovascular Disease Study Group. In-hospital outcomes of off-pump versus on-pump coronary artery bypass procedures: a multicenter experience. Ann Thorac Surg.2001; 72: 1528–1533.
18.
ParolariA., AlamanniF., CannataA.Off-pump versus on-pump coronary artery bypass: meta-analysis of currently available randomized trials. Ann Thorac Surg.2003; 76: 37–40.
19.
FengZ.Z., ShiJ., ZhaoX.W., XuZ.F.Meta-analysis of on-pump and off-pump coronary arterial revascularization. Ann Thorac Surg.2009; 87: 757–765.
20.
OmeroğluS.N., KiraliK., GülerM.Midterm angiographic assessment of coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg.2000; 70: 844–849.
21.
Al-RuzzehS., GeorgeS., BustamiM.Effect of off-pump coronary artery bypass surgery on clinical, angiographic, neurocognitive, and quality of life outcomes: randomised controlled trial. BMJ.2006; 332: 1365.
22.
HattlerB., MessengerJ.C., ShroyerA.L.for the Veterans Affairs Randomized On/Off Bypass (ROOBY) Study Group. Off-pump coronary artery bypass surgery is associated with worse arterial and saphenous vein graft patency and less effective revascularization: results from the Veterans Affairs Randomized On/Off Bypass (ROOBY) trial. Circulation.2012; 125: 2827–2835.
23.
LamyA., DevereauxP.J., PrabhakaranD.for the CORONARY Investigators. Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year. N Engl J Med.2013; 368: 1179–1188.
24.
DiegelerA., BörgermannJ., KappertU.for the GOPCABE Study Group. Off-pump versus on-pump coronary-artery bypass grafting in elderly patients. N Engl J Med.2013; 368: 1189–1198.
CalafioreA.M., Di MauroM., CanosaC., Di GiammarcoG., IacoA.L., ContiniM.Early and late outcome of myocardial revascularization with and without cardiopulmonary bypass in high risk patients (EuroSCORE > or =6). Eur J Cardiothorac Surg.2003; 23: 360–367.
LytleB.W., McElroyD., McCarthyP.Influence of arterial coronary bypass grafts on the mortality in coronary reoperations. J Thorac Cardiovasc Surg.1994; 107: 675–682.
29.
HannanE.L., WuC., BennettE.V.Risk stratification of in-hospital mortality for coronary artery bypass graft surgery. J Am Coll Cardiol.2006; 47: 661–668.
30.
BrenerS.J., LytleB.W., CasserlyI.P., EllisS.G., TopolE.J., LauerM.S.Predictors of revascularization method and long-term outcome of percutaneous coronary intervention or repeat coronary bypass surgery in patients with multivessel coronary disease and previous coronary bypass surgery. Eur Heart J.2006; 27: 413–418.
31.
PucelikovaT., MehranR., KirtaneA.J.Short- and long-term outcomes after stent-assisted percutaneous treatment of saphenous vein grafts in the drug-eluting stent era. Am J Cardiol.2008; 101: 63–68.
32.
MishraM., MalhotraR., KarlekarA., MishraY., TrehanN.Propensity case-matched analysis of off-pump versus on-pump coronary artery bypass grafting in patients with atheromatous aorta. Ann Thorac Surg.2006; 82: 608–614.
33.
CzernyM., ZimpferD., KiloJ.Coronary reoperations: recurrence of angina and clinical outcome with and without cardiopulmonary bypass. Ann Thorac Surg.2003; 75: 847–852.
34.
StamouS.C., PfisterA.J., DangasG.Beating heart versus conventional single-vessel reoperative coronary artery bypass. Ann Thorac Surg.2000; 69: 1383–1387.
35.
AzouryF.M., GillinovA.M., LytleB.W., SmediraN.G., SabikJ.F.Off-pump reoperative coronary artery bypass grafting by thoracotomy: patient selection and operative technique. Ann Thorac Surg.2001; 71: 1959–1963.
36.
ShapiraOM, NatarajanV, KaushikS, DeAndradeKM, SheminRJ. Off-pump versus on-pump reoperative CABG via a left thoracotomy for circumflex coronary artery revascularization. J Card Surg.2004; 19: 113-118.
37.
StamouSC, PfisterAJ, DullumMK, Late outcome of reoperative coronary revascularization on the beating heart. Heart Surg Forum. 2001; 4:69-73.
TugtekinSM, AlexiouK, KappertU, Coronary reoperation with and without cardiopulmonary bypass. Clin Res Cardiol.2006; 95: 93-98.
41.
RamchandaniM, BedeirK.Vascular connector devices increase the availability of minimally invasive cardiac surgery to ischemic heart patients. HSR Proc Intensive Care Cardiovasc Anesth.2011; 3: 239-243.
