On-pump and off-pump coronary artery bypass grafting for patients needing at least two grafts: comparative outcomes at 20 years.

OBJECTIVES: Despite evidence from several randomized controlled trials and observational studies validating short-term safety and efficacy of off-pump coronary artery bypass grafting (CABG), concerns persist regarding the impact of off-pump CABG on long-term survival and freedom from reintervention. This persistent scepticism regarding off-pump CABG prompted us to review our practice of CABG over the last 20 years with a view to comparing the impact of off-pump and on-pump CABG on short-term and long-term outcomes in a high-volume off-pump coronary surgery centre. METHODS: We retrospectively analysed prospectively collected data from the Patients Analysis and Tracking System database (Dendrite Clinical Systems, Oxford, UK) for all isolated first-time CABG procedures with at least 2 grafts performed at our institution from January 1996 to September 2017. Over the study period, 5995 off-pump CABG and 4875 on-pump CABG were performed by surgeons with exclusive off-pump and on-pump practices, respectively. Multivariable logistic regression and the Cox model were used to investigate the effect of off-pump versus on-pump procedures on short-term outcomes and long-term survival. Propensity score matching was used to compare the 2 matched groups. RESULTS: Off-pump CABG was associated with a lower risk for 30-day mortality [odds ratio (OR) 0.42, 95% confidence interval (CI) 0.32-0.55; P < 0.001], reintubation/tracheostomy (OR 0.58, 95% CI 0.47-0.72; P < 0.001) and re-exploration for bleeding (OR 0.48, 95% CI 0.37-0.62; P < 0.001). The benefit in terms of operative deaths from off-pump was significant in those with Society of Cardio-Thoracic Surgery logistic EuroSCORE >2 (interaction P = 0.04). When compared with on-pump CABG, off-pump CABG did not significantly reduce the risk of stroke (OR 0.96, 95% CI 0.88-1.12; P = 0.20) and postoperative haemofiltration (OR 0.98, 95% CI 0.86-1.20; P = 0.35). At the median follow-up of 12 years (interquartile range 6-17, max 21), off-pump CABG did not affect late survival [log rank P = 0.24; hazard ratio (HR) 0.95, 95% CI 0.89-1.02] or the need for reintervention (log rank P = 0.12; HR 1.19, 95% CI 0.95-1.48). CONCLUSIONS: This large volume, single-centre study with the longest reported follow-up confirms that off-pump CABG performed by experienced surgeons, who perform only off-pump procedures in a high-volume off-pump coronary surgery centre, is associated with lower risk of operative deaths, fewer postoperative complications and similar 20-year survival and freedom from reintervention rates compared with on-pump CABG.

Use of endoscopic vein harvesting (EVH) during coronary artery bypass grafting in United Kingdom: The EVH survey.

OBJECTIVE: Endoscopic vein harvesting (EVH) is growing in popularity and is the method of choice in many centers worldwide as it is associated with lower complication rates compared to the open vein harvesting. The aim of this study was to determine the current use of EVH during coronary artery bypass grafting among cardiac surgeons in United Kingdom and identify the main concerns that limit the use of this technique. METHODS: We developed an online survey with 16 questions about the use of EVH. An invitation to participate was sent to all the adult cardiac surgeons currently in practice in United Kingdom. RESULTS: A total of 139 surgeons (52%) of 267 currently in practice across 48 different hospitals completed the survey. Twenty five percent of responding surgeons always use EVH while 44% use it for <10% cases. Forty eight percent of responders regard EVH as an expensive technique and 90% believe that EVH is associated with fewer leg wound issues. Seventy five percent of responding surgeons will use it for their patients due to no leg wound issues while 25% believe that the concerns about patency of EVH are genuine. CONCLUSION: The majority of UK cardiac surgeons responding to this survey will preferentially consider EVH for obese and diabetic patients and are convinced by its beneficial impact in reducing leg wound complications. However, the reported routine use of EVH is low. Concerns about cost and patency of the endoscopically harvested vein are the possible barriers for universal adoption of EVH in the United Kingdom.

Comparison of minimally invasive direct coronary artery bypass and drug-eluting stents for management of isolated left anterior descending artery disease: a systematic review and meta-analysis of 7,710 patients.

BACKGROUND: In the contemporary era of drug-eluting stents (DES) the issue of optimal revascularization strategy for patients with isolated disease of the left anterior descending (LAD) artery has gained more significance. We aimed to evaluate the current best evidence on the subject by performing a systematic review and meta-analysis of the studies comparing minimally invasive direct coronary artery bypass (MIDCAB) grafting with DES in patients with isolated LAD disease. METHODS: A literature search was conducted from 1966 through March 2018 using MEDLINE, EMBASE, and other scientific databases to identify relevant articles. Analyzed outcomes included all-cause mortality, myocardial infarction (MI), major adverse cardiac and cerebrovascular events (MACCE) and target vessel revascularization (TVR). The random effects model was used to calculate the outcomes of both binary and continuous data to control any heterogeneity between the studies. Heterogeneity amongst the trials was determined by means of the Cochran Q value and quantified using the I2 inconsistency test. All P values were 2-sided and a 5% level was considered significant. RESULTS: A total of 7,710 patients from 12 studies were identified. There was no significant difference in mortality rate [pooled odds ratio (OR) =0.92; 95% confidence interval (CI), 0.65 to 1.32; P=0.66], MI rate (pooled OR =1.13, 95% CI, 0.62 to 2.06; P=0.69) or MACCE (pooled OR =1.31; 95% CI, 0.58 to 2.95; P=0.52). However, TVR rate was significantly more for patients having percutaneous intervention with DES (pooled OR =0.27; 95% CI, 0.16 to 0.45; P<0.0001) compared to MIDCAB. CONCLUSIONS: MIDCAB offers superior freedom from TVR with similar mortality, MI rate, and MACCE compared to percutaneous intervention with DES for revascularization in patient with isolated proximal LAD stenosis.