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16
Early and late outcomes aer
coronary artery bypassgraing
Stephen E. Fremes, Joseph F. Sabik, III, David P. Taggart,
Derrick Y. Tam, and Reena Karkhanis
Earlyoutcomes
Introduction
A review of outcomes following coronary artery bypass graing
(CABG) must be studied in the context of changing patient risk
proles. While overall CABG volumes have declined in Western nations over the last decade, there has been an increase in the number
of patients referred with prior percutaneous coronary intervention
(PCI), and those presenting with worse distal disease. e advent
of extracorporeal life support and mechanical circulatory support has allowed extremely high- risk patients to proceed to CABG
where risk would have been historically prohibitive. Clinical trial
evidence strongly supports CABG over PCI in patients with severe
multivessel coronary artery disease, diabetes, and low ejection fraction. Unprotected le main disease was not previously judged appropriate for PCI; recent trials suggest that PCI is non- inferior to
CABG in low SYNTAX (‘Synergy Between Percutaneous Coronary
Intervention with Taxus and Cardiac Surgery’) score patients with
le main stenosis (SYNTAX score <22). As such, those currently
referred to surgery will oen have more complex coronary disease
than those previously.
Thirty- daymortality
e current denition of operative mortality in the Society of
oracic Surgeons National Database (STS- ND) is death from any
cause within the rst 30days of the index operation or death within
the index hospitalization. According to the STS- ND, the predicted
surgical risk increased from 2.6% to 3.4% from 1990 to 1999 while
observed operative mortality decreased to 3.0%; operative mortality continued to decline from 2.4% in 2000 to 1.9% in 2009 while
the predicted surgical risk also declined to 2.3%. In the Japanese
Adult Cardiovascular Surgery Database, 30- day mortality was 2.0%
between 2000 to 2005 and in the Australasia Society of Cardiac
and oracic Surgeons database, 30- day mortality declined from
2.2% in 2002 to 1.8% in 2006 in an analysis of 9372 patients from
six Victoria hospitals. e most common causes of death include
stroke, renal failure, reoperation, and prolonged ventilation in a review of 11,808 deaths of isolated CABG in the STS- ND. Mortality
rates in recent CABG clinical trials range from 1.2% in the Arterial
Revascularisation Trial (ART) (single (SITA) vs bilateral internal
thoracic artery (BITA) graing) to 2.5% in the CABG O- or OnPump Revascularization Study (CORONARY); we summarize
perioperative events and late outcomes from recent randomized
controlled trials (RCTs) in Table 16.1.,
Postoperative low cardiac output syndrome
and left ventriculardysfunction
In the STS- ND from 2000 to 2009, approximately 10% of patients required an intra- aortic balloon pump (IABP) either prior to, during,
or aer CABG. In a study of 11,838 patients undergoing nonemergent isolated CABG between 2001 and 2009 in northern New
England, United States, the rate of low cardiac output syndrome
(LCOS), dened as the need for more than two inotropes at 48 hours,
or intra- or postoperative IABP requirement or return to cardiopulmonary bypass, was 4.3%. e observed rates varied from 1.1% to
10.2% between 32 surgeons at eight reporting institutions, despite
similar predicted risk of low output, suggesting that the variability in
surgical practice inuenced outcomes for low cardiac output.
ere have been recent trials to prevent or reduce postoperative
LCOS. Most trials dene LCOS as the need for mechanical support
(IABP, ventricular assist device, or extracorporeal life support) or
by haemodynamic criteria (i.e. cardiac index <2.0 despite maximal
inotropic support). e use of acadesine (an adenosine regulating
agent) did not reduce LCOS as dened as the need for postoperative mechanical support (2.3% in control and acadesine- treated patients); prophylactic use of levosimendan (a calcium sensitizer) was
associated with a reduction in haemodynamically dened LCOS in
patients undergoing cardiac surgery (Table 16.1) with preoperative
le ventricular dysfunction although the co- primary endpoints did
not dier statistically.,
In a secondary analysis of the Reduction in Cardiovascular Events
by Acadesine in Patients Undergoing CABG (RED- CABG) trial, a
Table16.1 Asummary ofrecent randomized controlled trials
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Trial Median
CABG Off- or
On- Pump
Revascularization
Study
(CORONARY)
Future
Revascularization
Evaluation
in Patients
with Diabetes
Mellitus:Optimal
Management
of Multivessel
Disease
(FREEDOM)
Reduction in
Cardiovascular
Events by
Acadesine
in Patients
Undergoing
CABG
(RED- CABG)
Levosimendan
in Patients with
Left Ventricular
Systolic
Dysfunction
Undergoing
Cardiac Surgery
Requiring
Cardiopulmonary
Bypass
(LEVO- CTS)
Nordic– Baltic–
British left Main
Revascularization
Study (NOBLE)
follow- up
4.8years On- pump
3.8years DES 8/ 953 (0.8%) – 3/ 953 (0.3%) 17/ 953 (1.8%) 114/ 953 (16.3%) 20/ 953 (2.4%) 98/ 953 (13.9%) 114/ 953 (16.3%) Death from any
Perioperative Placebo 27/ 1544 (1.8%) 35/ 1544 (2.3%) 26/ 1544 (1.7%) – – – – – –
Perioperative Levosimendan 15/ 428 (3.5%) 78/ 428 (18.2%) 15/ 428 (3.5%) 67/ 428 (15.7%) – – – – –
5years DES 2/ 592 (<1%) – 0/ 592 (0%) 19/ 592 (0%) 36/ 592 (12%) 16/ 592 (5%) 29/ 592 (7%) 121/ 592 (29%) Death from
Interventions Early outcomes Late outcomes
Mortality LCOS Stroke MI Mortality Stroke MI MACCE MACCE
CABG
Off- pump
CABG
Overall 119/ 4752 (2.5%) – 51/ 4752 (1.1%) 328/ 4752 (6.9%) 668/ 4752 (14.1%) 121/ 4752 (2.5%) 372/ 4752 (7.8%) 1108/ 4752 (23.3%)
CABG 15/ 947 (1.7%) – 16/ 947 (1.8%) 15/ 947 (1.7%) 83/ 947 (10.9%) 37/ 947 (5.2%) 48/ 947 (6%) 83/ 947 (10.9%)
Acadesine 29/ 1536 (1.9%) 34/ 1536 (2.3%) 26/ 1536 (1.7%) – – – – – –
Overall 56/ 3080 (1.8%) 69/ 3080 (2.3%) 52/ 3080 (1.7%) – – – – – –
Placebo 19/ 421 (4.5%) 108/ 421 (25.7%) 10/ 421 (2.4%) 63/ 421 (15%) – – – – –
Overall 34/ 849 (4%) 186/ 849 (21.9%) 25/ 849 (2.9%) 130/ 849 (15.3%) – – – – –
CABG 7/ 592 (1%) – 4/ 592 (0.7%) 16/ 592 (0%) 33/ 592 (9%) 7/ 592 (2%) 10/ 592 (2%) 19/ 592 (81%)
59/ 2377 (2.5%) – 27/ 2377 (1.1%) 170/ 2377 (7.2%) 322/ 2377 (13.5%) 66/ 2377 (2.8%) 194/ 2377 (8.2%) 560/ 2377 (23.6%) Death from any
60/ 2375 (2.5%) – 24/ 2375 (1.0%) 158/ 2375 (6.7%) 346/ 2375 (14.6%) 55/ 2375 (2.3%) 178/ 2375 (7.5%) 548/ 2375 (23.1%)
definition
cause, non- fatal
MI, non- fatal
stroke, new renal
failure requiring
dialysis, repeat
revascularization
cause, non- fatal
MI, non- fatal
stroke
any cause,
non- procedural
MI, repeat
revascularization,
or stroke
Evaluation of
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XIENCE versus
Coronary Artery
Bypass Surgery
for Effectiveness
of Left Main
Revascularization
(EXCEL)
Arterial
Revascularisation
Trial (ART)
SYNergy between
percutaneous
coronary
intervention
with TAXus and
cardiac surgery
(SYNTAX)
3years DES 9/ 948 (1%) – 6/ 948 (0.6%) 37/ 948 (3.9%) 71/ 948 (8.2%) 20/ 948 (2.3%) 72/ 948 (8%) 137/ 948 (15.4%) Death from any
cause, stroke,
or MI
CABG 10/ 957 (1.1%) – 12/ 957 (1.3%) 59/ 957 (6.2%) 53/ 957 (5.9%) 26/ 957 (2.9%) 77/ 957 (8.3%) 135/ 957 (14.7%)
5years SITA 18/ 1554 (1.2%) – 19/ 1554 (1.2%) 23/ 1554 (1.5%) 130/ 1554 (8.4%) 49/ 1554 (3.2%) 54/ 1554 (3.5%) 198/ 1554 (12.7%) Death from any
cause, MI, or
stroke
BITA 19/ 1548 (1.2%) – 15/ 1548 (1%) 22/ 1548 (1.4%) 134/ 1548 (8.7%) 38/ 1548 (2.5%) 52/ 1548 (3.4%) 189/ 1548 (12.2%)
Overall 37/ 3102 (1.2%) – 34/ 3102 (1.1%) 45/ 3102 (1.5%) 264/ 3102 (8.5%) 87/ 3102 (2.8%) 106/ 3102 (3.4%) 387/ 3102 (12.5%)
5years DES 39/ 903 (4.4%) – 5/ 903 (0.6%) 43/ 903 (4.8%) 123/ 903 (13.7%) 20/ 903 (2.2%) 83/ 903 (9.2%) 330/ 903 (36.7%) Death from any
cause, stroke,
MI, or repeat
revascularization
CABG 30/ 897 (3.5%) – 19/ 897 (2.2%) 28/ 897 (3.3%) 94/ 897 (10.6%) 31/ 897 (3.5%) 33/ 897 (3.7%) 226/ 897 (25.4%)
SECTION 3 General outcomes of coronary artery bypass graft surgery142
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history of heart failure was a stronger predictor for the need of postoperative mechanical support than reduced le ventricular ejection
fraction. In the IABP Shock Trial, a multicentre RCT of 600 patients
with acute myocardial infarction (MI) complicated by cardiogenic
shock undergoing early revascularization, there was no dierence in
30- day mortality between the IABP and no IABP group (relative risk
with IABP, 0.96; 95% condence interval (CI) 0.79– 1.17; P=0.69).
In an analysis of the STS- ND from 2002 to 2005, patients with preoperative cardiogenic shock (dened as hypoperfusion or need for
mechanical support) constituted 2.1% of patients undergoing isolated CABG; mortality was 20%.
Postoperativestroke
e incidence of stroke aer CABG varies between observational
registries and clinical trials, where routine neurological assessment
may be performed as per trial protocol. In earlier iterations of the STSND, stroke was dened as a central neurological decit persisting for
more than 72 hours; the most recent denition is a postoperative
neurological decit that does not resolve in 24 hours. e denition
is oen stricter in clinical trials:in CORONARY, a new acute neurological decit of vascular origin lasting more than 24 hours was
considered a stroke aer conrmation by a neurologist; conrmation by neuroimaging was required in the Future Revascularization
Evaluation in Patients with Diabetes Mellitus:Optimal Management
of Multivessel Disease (FREEDOM) trial.
In the STS- ND, the rate of stroke at 30days decreased from 1.6%
in 2000 to 1.2% in 2009 (P <0.0001). Ameta- analysis of 16 observational studies comparing o- pump to on- pump CABG showed
a stroke rate of 1.3% in 9744 patients undergoing o- pump CABG
compared to 2.4% in 8566 patients undergoing on- pump CABG.
Ameta- analysis of 27 RCTs comparing o- and on- pump CABG
showed an overall stroke rate of 1.3%. e rates of stroke in recent
revascularization clinical trials vary and range from 1.0% to 2.2%
(Table 16.1).
Studies have demonstrated that o- pump coronary artery bypass
including a no- touch aortic approach leads to a reduction in stroke,
especially in high- risk patients. Routine preoperative imaging with
carotid dopplers and non- contrast computed tomography of the
chest in addition to routine intraoperative imaging of the ascending
aorta with epiaortic ultrasound may help identify patients at higher
risk of stroke and change the operative technique to one that modies or entirely avoids aortic manipulation. In addition, le atrial
appendage occlusion at the time of surgery may reduce the risk of
postoperative stroke and remains the subject of an ongoing clinical trial (LAAOS III; ClinicalTrials.gov identier:NCT01561651).
Finally, early extubation and mobilization of patients may aid in the
early detection of any new neurological decits; these patients may
be candidates for novel neuroendovascular rescue therapies (i.e.
thrombectomy).
Early myocardialinfarction
e incidence of perioperative MI varies between observational
studies (2.7%) and RCTs (6.2%) according to a large meta- analysis
of over 200,000 patients. ese dierences can be attributed in
large part to variable denitions of perioperative MI; dening perioperative MI is a challenging and controversial task, as biomarkers
for myocardial ischaemia/ infarction, electrocardiogram (ECG)
ndings, and echocardiographic indices all have controversial
thresholds for clinical signicance. Early trials have generally used
the Minnesota code criterion for detection of early and late MI, a
grading system based on the abnormality of Q waves. While the definition for early perioperative MI has changed with practice over
the years, late MI (aer 72 hours) continues to be dened as a rise in
cardiac biomarkers with at least one value above the 99th percentile
of the upper reference limit and with at least one of the following:(1)
ECG changes (new ST- T changes, new le bundle branch block, or
development of pathological Q waves) or (2)symptoms of ischaemia
or (3)imaging evidence of new loss of viable myocardium or new
regional wall motion abnormality.
In CORONARY, early perioperative MI (occurring within
72 hours) was dened as either (1)a creatine kinase- MB measurement of at least 5 × 99th percentile upper reference limit with or
without ECG changes (pathological Q waves or new le bundle
branch block), or (2)angiographic evidence of new gra or native
coronary artery occlusion, or (3)imaging evidence of new loss of
viable myocardium. e 30- day results showed no signicant difference between on- pump versus o- pump rates of MI (6.7% vs
7.2%). Acomprehensive meta- analysis from RCTs comparing PCI
with drug- eluting stents (DESs) versus CABG for unprotected le
main coronary artery disease showed a similar risk of MI in the PCI
(6.0%) and CABG (4.8%) groups. e rate of early MI in clinical
trials is summarized in Table 16.1.
ere remains a signicant challenge in determining the clinical signicance of high- sensitivity troponins with respect to
perioperative MI in association with CABG. In a single- centre
retrospective study, 818 patients with type 5 MI diagnosis based
on high- sensitivity troponin measured 12– 24 hours aer CABG
were followed for a mean of 1.8 ± 0.6years. ey concluded that
high- sensitivity troponin with a cut point of 10 × 99th percentile
upper reference limit with ECG and/ or echocardiographic criteria predicted 30- day (hazard ratio (HR) 4.92, 95% CI 1.34– 18.1;
P=0.017) and medium- term mortality (HR 3.44, 95% CI 1.13– 10.5;
P=0.03). is uncertainty may be addressed in the Vascular events
In Surgery patients cOhort evaluatioN (VISION) Cardiac Surgery
study (NCT01842568), an international, multicentre, prospective
cohort study of 15,000 adult patients undergoing cardiac surgery.
e main objective is to determine the relationship between postoperative high- sensitivity troponin Imeasurements and the 30- day
risk of death using the third universal denition of type 5 MI. It is
likely that the current denition is very sensitive but with many false
positives.
Postoperative renalfailure
While almost 30% of patients undergoing cardiac surgery experience acute kidney injury, the rate of renal failure requiring dialysis
remains low. Between 2000 and 2009, the incidence of renal failure
in all patients undergoing CABG remained fairly constant at 3.6%.
In a non- emergent cohort, the rate of renal failure decreased from
2.1% to 1.6% over a decade. e classications of acute kidney injury include RIFLE (Renal risk, Injury, Failure, Loss of kidney function and End- stage renal disease), the Acute Kidney Injury Network
(AKIN), and the Kidney Disease: Improving Global Outcomes
(KDIGO) denitions. In the STS- ND, renal failure was dened as
an increase in serum creatinine above 2.0 mg/ dL, or a doubling of
serum creatinine from baseline or de novo dialysis. In contrary, both
RIFLE and AKIN use a higher threshold for dening renal failure:a
16 Early and late outcomes after coronary artery bypassgrafting 143
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tripling of baseline creatinine, serum creatinine above 4.0 mg/ dL, or
de novo dialysis. In a meta- analysis of observational and RCTs, 176
studies including 205,717 patients, the rate of renal failure requiring
dialysis was 0.79– 0.39% in RCTs and 0.98% in cohort studies.
Deep sternal woundinfections
Deep sternal wound infection (DSWI) is a quality- of- care metric.
Medicare has deemed DSWI to be a ‘never- event’ and will not reimburse for the cost of care associated with this complication. e US
Centers for Disease Control and Prevention denition of mediastinitis includes one of the following criteria within 90days of the initial surgical procedure:organism cultured from mediastinal tissue
or uid obtained by needle aspiration or during surgery, evidence
of mediastinitis observed in surgery; fever, chest pain, or sternal instability and purulent discharge from sternum or positive blood cultures. e rate of DSWI requiring sternal reconstruction has been
estimated to be 1% in a clinical trial comparing SITA versus BITA
graing strategies. e use of bilateral pedicled internal thoracic
artery almost doubles the risk of DSWI while the risk is neutralized with skeletonized harvest of BITAs. Given the proven benets
of BITA graing and total arterial revascularization in many populations, precautions to further reduce the risk of DSWI should be
utilized and include perioperative glucose control, skeletonization
of internal thoracic arteries during harvesting, selective use of rigid
plate xation for sternal closure, and the use of antibiotic impregnated adjuncts to reduce infection risk. Early and judicious use of
negative- pressure wound therapy in the setting of DSWI may reduce
the need for muscle ap closure at reoperation, potentially reducing
morbidity and mortality associated with this complication.
common causes of death between 30days and 10years of follow- up
were heart failure (36%), fatal MI (29%), cancer (24%), stroke (18%),
and infection (11%). Mortality at 13years was 40% in this cohort
of patients.
At a median follow- up of 2.9years in a propensity score- matched
study of 2126 patients with multivessel coronary artery disease from
NewYork state undergoing CABG or PCI with DES, there was no
dierence in mortality (DES 25.22% vs CABG 21.03%; P= 0.91)
between the two. When PCI with DES (n=1824) was compared
to CABG (n = 1154) in the CREDO- Kyoto PCI/ CABG Registry,
all- cause death was signicantly lower in the CABG group (17.5%
vs 20.5%; P=0.03) at 5years. Table 16.1 compares late mortality
between PCI and CABG in recent contemporary revascularization
trials.
Late myocardial infarction and repeat
revascularization
At 5 years of follow- up, the overall rates of MI and repeat
revascularization in CORONARY were 7.8% and 2.5% respectively;
there was no signicant dierence between the on- pump and opump groups. In ART, the rates of repeat revascularization (3.5%
vs 3.4%; P= 0.86) and MI (6.6% vs 6.5%; P=0.91) were similar
between the SITA and BITA arms at 5years; these results must
be interpreted with the caveat that 14% of BITA patients actually
received SITA and 22% of SITA patients actually received a second
arterial gra, oen a radial artery conduit. In elderly patients with
multivessel coronary artery disease, CABG and PCI demonstrated
similar mortality and MI outcomes at 2.5years of follow- up in a propensity score- matched study of 1932 CABG– PCI pairs. However,
repeat revascularization rates were signicantly higher in the PCI
Lateoutcomes
e primary endpoint of revascularization clinical trials is oen
a composite of major cardiovascular and cerebrovascular events
which include death, MI, stroke, and repeat revascularization. e
late benets of CABG over PCI in contemporary clinical trials have
been driven by a substantial decrease in repeat revascularization,
with smaller reductions in death or MI while overall stroke is usually increased in the perioperative period.
Latemortality
In the Danish National Patient Register of 38,830 patients undergoing CABG from 1996 to 2012, the median survival was 14.7years
for patients between 60 and 69years of age, 10.7 years for 70–
74years, 8.9years for 75– 79years, and 7.2years for those greater
than 80years at a median follow- up of 9.9years for the entire cohort. A linkage study of multiple large administrative databases
in Ontario, Canada, of 81,197 patients undergoing CABG between
1996 and 2007 demonstrated a late mortality of 34.9% at 10- year
follow- up. In recent CABG RCTs with long- term follow- up, late
mortality ranged from 8.5% in ART to 14.0% in CORONARY at
5years (Table13.1) and approximately 20% in ART at 10years.
In the SYNTAX trial, at 5- year follow- up, the most common
causes of death in the CABG group were heart failure, arrhythmia,
and other cardiac causes. e most common non- cardiac cause of
death was cancer. In a retrospective analysis of 2000 patients undergoing CABG in western Sweden between 1988 and 1991, the most
group (24.1% vs 4.5%, HR 7.48, 95% CI 5.61– 9.98; P <0.0001). In a
pooled analysis of 5775 patients from three clinical registries comparing PCI to CABG, there was no dierence in a composite outcome
of death, new Q- wave MI, or stroke; PCI was associated with increased repeat revascularization. Similar ndings have also driven
the results of CABG superiority over PCI in recent RCTs comparing
CABG to PCI in multivessel disease (FREEDOM, SYNTAX) and in
CABG versus PCI trials for le main disease (e Nordic– Baltic–
British le Main Revascularization Study (NOBLE), Evaluation of
XIENCE versus Coronary Artery Bypass Surgery for Eectiveness
of Le Main Revascularization (EXCEL)). Importantly, in
FREEDOM, a RCT enrolling patients with diabetes and coronary
artery disease, the primary outcome of major adverse cardiac and
cerebrovascular events (MACCE; all- cause death, non- fatal MI,
and non- fatal stroke) occurred signicantly more frequently in PCI
compared to CABG at 5years.
Further reduction in MACCE events may be seen with increased
utilization of BITA strategies and total arterial graing techniques
to improve long- term gra patency. However, whether repeat
revascularization should be retained as a clinically signicant secondary outcome or part of the primary MACCE outcome composite
remains a contentious topic.
Latestroke
In a national Swedish study of 53,820 patients undergoing isolated
CABG between 2000 and 2011, the rate of stroke was 8.0% at a mean
follow- up time of 7.4years. Similarly, in a study of 387 patients that
underwent epiaortic scanning at the time of CABG, the cumulative
SECTION 3 General outcomes of coronary artery bypass graft surgery144
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rate of stroke was 7%. In the FREEDOM trial, the cumulative incidence of stroke in the CABG arm (n=898) was 4%; 50% of the
strokes occurred in the perioperative period (<30days post procedures) while the remainder occurred within the 5- year follow- up period. In a meta- analysis of 57 studies of 80,314 patients from 1994
to 2013 with at least 1year of follow- up, there was a signicantly
lower risk of stroke in the PCI group compared to CABG at 1year
(odds ratio 0.55, 95% CI 0.42– 0.71) and 5years (odds ratio 0.79,
95% CI 0.69– 0.91). ese results were also demonstrated in the
FREEDOM trial, in which the early postoperative risk of stroke was
elevated in CABG compared to PCI (2.7% vs 1.5%) and the incidence
rates continued to signicantly diverge at 5years (5.2% vs 2.4%).
Conversely, in a meta- analysis of RCTs of patients with le main
disease or multivessel disease (EXCEL, NOBLE, PRECOMBAT,
SYNTAX), there was no dierence in late strokes (≥3years) between
PCI and CABG (HR 0.86, 95% CI 0.39– 1.92; P=0.72).
Conclusion
e early and late outcomes aer CABG have improved signicantly
over the past two decades, despite an increasingly complex and
morbid patient population. ese results compare favourably with
those achieved with PCI in numerous patient populations, notably
those with complex multivessel disease, diminished le ventricular
function, and diabetes. Focused clinical trials are needed to more
clearly dene those patients who benet most from CABG and to
identify best practices in surgical technique and medical management that can further improve patient outcomes aer CABG.
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17
Evidence base foroff- pump
coronary artery bypassgraing
Pros and cons
Emmanuel Moss, Michael E. Halkos, and John D. Puskas
Introduction
e relative merits of o- pump (OPCAB) versus on- pump coronary
artery bypass graing (ONCAB) have been compared for almost
three decades. OPCAB was pioneered in the 1990s on the premise
that avoiding the use of the heart– lung machine could minimize the
morbidity associated with coronary artery bypass gra (CABG) surgery, particularly in high- risk patient subgroups. More recently, the
correlation between extent of aortic manipulation and incidence of
perioperative stroke has been cited as another potential benet of
OPCAB surgery when it is performed with a no- aortic- touch technique.– e trade- o for avoiding the heart– lung machine is a
more technically demanding operation that, according to some reports, may lead to a less complete revascularization and decreased
long- term gra patency.
e on- versus o- pump ‘debate’ is complex and choosing the appropriate technique for a given patient ultimately depends on individual patient characteristics and operator expertise. While some
surgeons perform OPCAB as the preferred approach in the majority
of cases, others use it selectively as dictated by the clinical scenario,
such as a porcelain aorta or single- vessel minimally invasive CABG,
while many surgeons perform all CABG on- pump. e goal of this
chapter is to present a balanced view of the evidence, allowing the
reader to make an informed decision regarding the use of either
technique.
Operativemortality
A meta- analysis of 51 randomized controlled trials (RTCs), which
included 16,904 patients, found similar in- hospital mortality rates
when comparing OPCAB and on- pump CABG (ONCAB). Some
have been critical of these ndings, suggesting that the benet of
OPCAB may be lost in most RCTs as they tend to enrol lower- risk
patients. Indeed, the largest comparative RCTs enrolled relatively
low- risk populations. In the Veterans Aairs Randomized On/
O Bypass (ROOBY) trial, which demonstrated similar 30day mortality in both the OPCAB and ONCAB groups (1.9% vs
1.8%; P = 0.25), most patients had preserved ejection fraction
and the overall population had a predicted risk of mortality less
than 2%. Similarly, in the 4752- patient CABG O- or On- Pump
Revascularization Study (CORONARY), which also showed
equivalent 30- day mortality rates (2.5%), only 18% of patients had
a EuroSCORE greater than 5 (predicted risk of mortality 2.9%)
despite an eort to enrol more patients at increased risk of perioperative complications. In the German O Pump Coronary
Artery Bypass in Elderly (GOPCABE) trial, also reporting similar
30- day survival between groups, the mean EuroSCORE of 8.3 was
driven mainly by age and 67% of patients had an ejection fraction
greater than 50%. Equivalent 30- day, as well as 1- year, mortality
was also reected in the 2015 International Society for Minimally
Invasive Cardiothoracic Surgery Consensus document on opump CABG. at document cites mean 30- day mortality rates of
1.5% for both OPCAB and ONCAB, and 1- year mortality of 4.8%
versus 4.7% for OPCAB and ONCAB, respectively in a review of
all published RCTs.
While randomized trials have consistently failed to show a difference in operative mortality between OPCAB and ONCAB,
large retrospective analyses have generally favoured OPCAB. An
intention- to- treat analysis of over 40,000 patients from the Society
of oracic Surgeons (STS) National Cardiac Database demonstrated a reduction in risk- adjusted mortality and other adverse
events aer OPCAB and this benet was greater for women than
for men.
Neurologicaloutcomes
Cardiopulmonary bypass and aortic manipulation are thought to be
signicant causes of perioperative stroke, due to atheroembolism
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