On- and off-pump coronary surgery and perioperative myocardial infarction: an issue between incomplete and extensive revascularization.

OBJECTIVE: Complete myocardial revascularization is the standard for coronary artery bypass grafting. It has been shown, however, that off-pump coronary bypass surgery (OPCAB) may reduce completeness of revascularization without affecting perioperative myocardial infarction rates. We evaluated the influence of OPCAB on major postoperative events in a large consecutive cohort of patients, with special emphasis on risk factors for perioperative myocardial infarction. METHODS: From 1995 to 2004, 5935 patients underwent isolated coronary bypass surgery; of these, 4623 (77.9%) and 1312 (22.1%) underwent on-pump coronary surgery (CABG) and OPCAB, respectively. Patients undergoing OPCAB were matched to patients undergoing CABG by propensity score; logistic regression analysis models were used to study predictors of perioperative myocardial infarction. RESULTS: In matched pairs, postoperative mortality, myocardial infarction, stroke, and atrial fibrillation were similar between groups, while reoperation for bleeding, time on ventilator and red blood cell use were lower in patients undergoing OPCAB. The number of distal anastomoses was lower in patients undergoing OPCAB (2.2+/-0.80 in OPCAB vs 2.9+/-0.86 in CABG, p<0.001), as well as complete revascularization rates (61.9% in OPCAB vs 90.0% in CABG, p<0.001). Multivariate analyses, performed on preoperative and intraoperative variables, showed that both incomplete revascularization and increasing numbers of distal anastomoses (even when controlling for completeness of revascularization) were significant predictors of perioperative myocardial infarction, while CABG/OPCAB strategy did not influence it. CONCLUSIONS: The choice of surgical technique did not influence the occurrence of major perioperative complications and of myocardial infarction, which is negatively affected by incomplete or too extensive revascularization strategies.

High thoracic epidural anesthesia in coronary artery bypass surgery: a propensity-matched study.

OBJECTIVES: To assess if 2 different anesthesia strategies, high-thoracic epidural anesthesia (HTEA) plus inhalation anesthesia and total intravenous anesthesia (TIVA) with sufentanil/propofol had different influence on outcomes of coronary artery bypass graft (CABG) surgery patients. DESIGN: Retrospective comparison of outcomes between HTEA and TIVA patients using propensity score pair-wise matching of patients. SETTING: A university teaching hospital. PARTICIPANTS: A study of 1,473 consecutive patients undergoing elective CABG surgery; of these, 476 (32%) received HTEA combined with inhalation anesthesia, whereas 997 (68%) underwent TIVA alone. INTERVENTIONS: The patients undergoing CABG surgery were offered the epidural-inhalation anesthetic approach. MEASUREMENTS AND MAIN RESULTS: Propensity matching yielded 389 pairs of patients. Patients were well matched in preoperative and operative features. Postoperative mortality, myocardial infarction, stroke, acute renal failure rates, and intensive care unit (ICU) stay were not statistically different in HTEA and TIVA groups. On the other hand, patients treated with HTEA had shorter ventilation times (5.8 +/- 3.11 v 6.9 +/- 5.0 hours, HTEA and TIVA, respectively, p < 0.001); in addition, vasoconstrictors were more frequently used in cases of HTEA, whereas vasodilators were mainly used with TIVA both intra- and postoperatively. No neurologic complications related to the use of HTEA were observed. CONCLUSIONS: HTEA and TIVA provided similar early outcomes after CABG surgery, and there were no major differences between these 2 strategies in the average risk CABG patient populations. Although HTEA did not cause neurologic problems and yielded a significant reduction in time to extubation, a consistent benefit over standard techniques could not be shown.