Cirugía de revascularización miocárdica: comparación de supervivencia a 10 años de la cirugía coronaria con y sin circulación extracorpórea mediante Propensity Score Matching / Ten-year survival after off-pump coronary artery bypass grafting compared with traditional bypass grafting

BACKGROUND: Long-term outcomes of Off-Pump Coronary Artery Bypass Grafting (OPCAB) as an alternative to the traditional Coronary Artery Bypass Grafting (CABG) technique with cardiopulmonary bypass (CPB) are not well defined. AIM: To compare 10-year survival of isolated OPCAB versus CABG with CPB. MATERIAL AND METHODS: Analysis of information obtained from databases, clinical records and surgical protocols of patients treated with isolated CABG between January 2006 and November 2008 at a Regional Hospital. Of 658 isolated CABG, 192 (29.2%) were OPCAB and 466 (79.9%) CPB. Propensity Score Matching (PSM) was performed to compare both groups. After PSM, two groups of 192 cases were obtained. Mortality data was obtained from the Chilean public identification service. Ten-year survival was calculated and compared with Kaplan-Meier and log-rank methods. RESULTS: Follow-up data was obtained in all cases. No statistically significant differences were found when comparing 10-year survival between OPCAB versus CPB (78.6% and 80.2% respectively, p 0.720). There was also no statistical difference in cardiovascular death free survival (90.1% with CPB versus 89.1% OPCAB, p 0.737). Survival was comparable when analyzing subgroups with diabetes mellitus, left ventricular dysfunction or chronic kidney disease, among others. CONCLUSIONS: In our series, OPBAB has a comparable 10-year survival with CABG with CPB.

Cirugía coronaria sin circulación extracorpórea después de 20 años. Resultado y seguimiento en 1.353 pacientes en el sur de Chile / Off pump coronary artery bypass surgery long term results after 20 years in a cardiac center in Chile

BACKGROUND: The benefits of off-pump coronary artery bypass graft (OPCAB) compared with conventional on-pump coronary artery bypass graft are not well established although several studies show excellent long-term results. AIM: To assess and report the long-term results of OPCAB surgery in a 20-year period in a Chilean Regional Cardiac Surgery Center. PATIENTS AND METHODS: Retrospective analysis of the medical records and surgical protocols of 1353 patients aged 61.3 ± 6.5 years, (69% males) subjected to OPCAB between June 1999 and December 2019. RESULTS: Thirty-four percent of patients presented with unstable angina. On angiography, the left main coronary artery had a proximal obstruction in 15% of patients. Thirty five percent presented with a myocardial infarction of different territories. Thirty percent of patients were managed previously with angioplasty. Preoperative left ventricular function was 45.3% (30-65%). The mean surgical risk Euroscore was 2.84. The mean number of bypasses was 2.7 ± 0.63. 2.6%. Conversion to on pump technique was required in 2.6% of patients. Operative mortality was 2%, myocardial infarction occurred in 3.4%, a new revascularization procedure was required in 2.3% and 2.4% of patients had a stroke. Long term follow up was complete in most patients and 93% are in NHYA functional capacity I. Actuarial survival was 100, 98, 89, 75 and 66% at 1, 5, 10, 15 and 20 years. Actuarial combined cardiovascular events free survival was 100, 98, 87, 68 and 51% at 1,5,10, 15 and 20 years. CONCLUSIONS: OPCAB surgery is a safe surgical technique, with an excellent bypass durability and permeability. It also provides a prolonged time free from cardiac events such as mortality, angina, myocardial infarction, and freedom from a new coronary procedure.

Effect of age on clinical outcomes following on-/off-pump coronary artery bypass: meta-analysis and meta-regression

Abstract Objective: There is currently much debate about which patients would benefit more after on- or off-pump coronary artery bypass grafting (CABG). The aim of this meta-analysis and meta-regression is to investigate the effect of age on short-term clinical outcomes after these approaches. Methods: To identify potential studies, systematic searches were carried out in the Excerpta Medica dataBASE (EMBASE), PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL). The search strategy included the key concepts of "cardiopulmonary bypass" AND "coronary artery bypass grafting" AND "off pump" OR "on pump". This was followed by a meta-analysis and meta-regression investigating the effect of age on the incidences of stroke, myocardial infarction (MI), and mortality. Results: Thirty-seven studies including 15,324 participants were analysed. Overall, there was a significant odds reduction for patients receiving off-pump CABG suffering a stroke (odds ratio [OR] 0.770, 95% confidence intervals [CI] 0.594, 0.998, P=0.048); however, when patients were subdivided according to different age bands, this difference disappeared. There were also no significant differences in the odds of mortality (OR 0.876, 95% CI 0.703, 1.093, P=0.241) or MI (OR 0.937, 95% CI 0.795, 1.105, P=0.439). Meta-regression analysis revealed no significant relationship between age and stroke (P=0.652), age and mortality (P=548), and age and MI (P=0.464). Conclusion: Patients undergoing CABG are becoming older and may suffer from multiple comorbidities increasing their risk profile. However, with respect to short-term clinical outcomes, the patient's age does not help in determining whether off- or on-pump is superior.

Left ventricular dissecting hematoma caused by tissue stabilizer

Abstract Coronary artery bypass grafting is a commonly performed procedure for coronary revascularization. We describe the successful management of left ventricular dissecting hematoma, caused by the tissue stabilizer, while performing off-pump coronary artery bypass graft procedure.

Early outcomes of low postoperative bleeding after off-pump coronary artery bypass grafting

Abstract Objective: To investigate whether low bleeding influences the early outcomes after off-pump coronary artery bypass grafting (CABG). Methods: Retrospective analysis of ischemic heart disease patients who underwent off-pump CABG from January 2013 to December 2017. Patients were divided into low-bleeding group (n=659) and bleeding group (n=270), according to total drainage from chest tube during the first postoperative 12 hours. Clinical material and early outcomes were compared between the groups. Results: Baseline was similar in the two groups. Operation time was 270±51 min in the low-bleeding group and 235±46 min in the bleeding group (P<0.0001). The low-bleeding group presented smaller drainage during the first 12 h (237±47 ml) and shorter mechanical ventilation time (6.86±3.78 h) than the bleeding group (557±169 ml and 10.66±5.19 h, respectively) (P<0.0001). Hemodynamic status was more stable in the low-bleeding group (P<0.0001) and usage rate of more than two vasoactive agents in this group was lower than in the bleeding group (P<0.0001). Number of distal anastomosis, reoperation for bleeding, suddenly increase in chest tube output, intensive care unit (ICU) stay, hospital stay, and other early outcomes had no statistical significance between the groups (P>0.05). Conclusion: Postoperative bleeding < 300 ml/12 h in off-pump CABG patients did not require blood product transfusion and reoperation and that would contribute to reduction in mechanical ventilation time and maintaining hemodynamic stability. Bleeding < 800 ml during the first postoperative 12 h did not increase infection rates and ICU length of stay.

Short-Term and Mid-Term Clinical Outcomes Following Hybrid Coronary Revascularization Versus Off-Pump Coronary Artery Bypass: A Meta-Analysis / Resultados Clínicos de Curto e Médio Prazo após Revascularização Coronariana Híbrida versus Revascularização Miocárdica sem Circulação Extracorpórea: Uma Meta-Análise

Abstract Background: Off-pump coronary artery bypass grafting (OPCAB) is one of the standard treatments for coronary artery disease (CAD) while hybrid coronary revascularization (HCR) represents an evolving revascularization strategy. However, the difference in outcomes between them remains unclear. Objective: We performed a meta-analysis to compare the short-term and mid-term outcomes of HCR versus OPCAB for the treatment of multivessel or left main CAD. Methods: We searched the PubMed, EMBASE, Web of Science and Cochrane databases to identify related studies and a routine meta-analysis was conducted. Results: Nine studies with 6121 patients were included in the analysis. There was no significant difference in short-term major adverse cardiac and cerebrovascular event (MACCE) rate (RR: 0.55, 95% CI: 0.30-1.03, p = 0.06) or mortality (RR: 0.51, 95% CI: 0.17-1.48, p = 0.22). HCR required less ventilator time (SMD: -0.36, 95% CI: -0.55- -0.16, p < 0.001), ICU stay (SMD: -0.35, 95% CI: -0.58 - -0.13, p < 0.01), hospital stay (SMD: -0.29, 95% CI: -0.50- -0.07, p < 0.05) and blood transfusion rate (RR: 0.57, 95% CI: 0.49-0.67, p < 0.001), but needed more operation time (SMD: 1.29, 95% CI: 0.54-2.05, p < 0.001) and hospitalization costs (SMD: 1.06, 95% CI: 0.45-1.66, p < 0.001). The HCR group had lower mid-term MACCE rate (RR: 0.49, 95% CI: 0.26-0.92, p < 0.05) but higher rate in mid-term target vessel revascularization (TVR, RR: 2.20, 95% CI: 1.32-3.67, p < 0.01). Conclusions: HCR had similar short-term mortality and morbidity comparing to OPCAB. HCR decreased the ventilator time, ICU stay, hospital stay, blood transfusion rate and increased operation time and hospitalization costs. HCR has a lower mid-term MACCE rate while OPCAB shows better in mid-term TVR.

Resumo Fundamentos: A revascularização do miocárdio sem circulação extracorpórea (CRM sem CEC) é um dos tratamentos padrão para a doença arterial coronária (DAC), enquanto que a revascularização coronária híbrida (RCH) é uma estratégia de revascularização em evolução. No entanto, a diferença nos resultados entre eles ainda não está clara. Objetivo: Realizamos uma meta-análise para comparar os resultados a curto e médio prazo da RCH versus a CRM sem CEC para o tratamento de DAC de múltiplos vasos ou artéria principal esquerda. Métodos: Pesquisamos as bases de dados PubMed, EMBASE, Web of Science e Cochrane para identificar estudos relacionados e realizamos uma meta-análise de rotina. Resultados: Nove estudos com 6121 pacientes foram incluídos na análise. Não houve diferença significativa na taxa de eventos cardíacos e cerebrovasculares adversos maiores de curto prazo (ECCAM) (RR de 0,55, IC de 95% 0,30-1,03, p = 0,06) ou mortalidade (RR: 0,51, IC 95%: 0,17-1,48, p = 0,22). A RCH requereu menos tempo de ventilação (DMP -0,36; IC de 95%: -0,16 -0,55-, p < 0,001), tempo de UTI (DMP: -0,35, IC de 95%: -0,58- -0,13, p < 0,01), estadia hospitalar (DMP: -0,29; IC de 95%: -0.50 - -0,07, p < 0,05) e taxa de transfusão de sangue (RR: Cl 0,57, 95% de 0,49-0,67, p < 0,001), mas necessitou mais tempo de cirurgia (DMP): 1,29, IC de 95% 0,54-2,05, p < 0,001) e custos de hospitalização (DMP: 1,06, 95 %: 0,45-1,66, p < 0,001). O grupa RCH tinha uma taxa mais baixa de ECCAM a médio prazo (RR de 0,49, IC de 95% 0,26-0,92, p < 0,05), mas uma taxa mais elevada a médio prazo em revascularização de vaso alvo (RVA, RR: 2,20, IC 95%: 1,32). 3,67, p < 0,01). Conclusões: A RCH teve mortalidade e morbidade semelhantes no curto prazo comparada ao CRM sem CEC. A RCH diminuiu o tempo de ventilação, a internação na UTI, a internação hospitalar, a taxa de transfusão de sangue e o aumento do tempo de operação e os custos de hospitalização. A RCH tem uma taxa ECCAM mais baixa no médio prazo, enquanto a CRM sem CEC se mostra melhor em RVA a médio prazo.

Selenium, vitamin c and n-acetylcysteine do not reduce the risk of acute kidney injury after off-pump cabg: a randomized clinical trial

Abstract Objective: The aim of this study was to investigate the impact of perioperative administration of N-acetylcysteine, selenium and vitamin C on the incidence and outcomes of acute kidney injury after off-pump coronary bypass graft surgery. Methods: 291 patients requiring elective off-pump coronary bypass graft surgery were randomized to receive either N-acetylcysteine, vitamin C and selenium 600 mg, 1500 mg, 0.5 mg, and nothing orally twice a day, respectively, from the day before to 2 days after surgery. They were assessed for the development of acute kidney injury using Acute Kidney Injury Network criteria, time of onset, its severity and duration, duration of mechanical ventilation, intensive care unit and hospital length of stay, and in-hospital mortality. Results: 272 patients completed the study. The total incidence of acute kidney injury was 22.1% (n=60) with 14 (20.9%), 15 (22.1%), 21 (31.8%), and 10 (14.1%) patients in the vitamin C, NAC, selenium, and control groups, respectively (P=0.096). We did not register significant differences in the incidence, the time of occurrence, the severity and the duration of acute kidney injury, as well as the duration of mechanical ventilation, the intensive care unit and hospital length of stay, and the in-hospital mortality among the four groups. Conclusion: We found that perioperative administration of N-acetylcysteine, vitamin C and selenium were not effective in preventing acute kidney injury and associated morbidity and mortality after off-pump coronary bypass graft surgery.

Three-vessel coronary artery disease may predict changes in biochemical brain injury markers after off-pump coronary artery bypass grafting / 浙江大学学报（英文版）（B辑：生物医学和生物技术）

Neurological injury is a frequent and important complication of coronary artery bypass grafting (CABG). Several risk factors for this type of sequela have been identified, among them aortic arch atherosclerosis. Our previous study indicated that atherosclerotic burden in coronary arteries may likewise predict postoperative neurological complications (Pawliszak et al., 2016b). We assessed the severity of this condition by using the SYNTAX score calculator. However, diagnosing angiographic three-vessel coronary artery disease (3VD) could be an even simpler method of achieving this goal.

Off-pump versus on-pump coronary artery bypass grafting in frail patients: study protocol for the fragile multicenter randomized controlled trial

Abstract Introduction: Advances in modern medicine have led to people living longer and healthier lives. Frailty is an emerging concept in medicine yet to be explored as a risk factor in cardiac surgery. When it comes to CABG surgery, randomized controlled clinical trials have primarily focused on low-risk (ROOBY, CORONARY), elevated-risk (GOPCABE) or high-risk patients (BBS), but not on frail patients. Therefore, we believe that off-pump CABG could be an important technique in patients with limited functional capacity to respond to surgical stress. In this study, the authors introduce the new national, multicenter, randomized, controlled trial "FRAGILE", to be developed in the main cardiac surgery centers of Brazil, to clarify the potential benefit of off-pump CABG in frail patients. Methods: FRAGILE is a two-arm, parallel-group, multicentre, individually randomized (1:1) controlled trial which will enroll 630 patients with blinded outcome assessment (at 30 days, 6 months, 1 year, 2 years and 3 years), which aims to compare adverse cardiac and cerebrovascular events after off-pump versus on-pump CABG in pre-frail and frail patients. Primary outcomes will be all-cause mortality, acute myocardial infarction, cardiac arrest with successful resuscitation, low cardiac output syndrome/cardiogenic shock, stroke, and coronary reintervention. Secondary outcomes will be major adverse cardiac and cerebrovascular events, operative time, mechanical ventilation time, hyperdynamic shock, new onset of atrial fibrillation, renal replacement therapy, reoperation for bleeding, pneumonia, length of stay in intensive care unit, length of stay in hospital, number of units of blood transfused, graft patency, rate of complete revascularization, neurobehavioral outcomes after cardiac surgery, quality of life after cardiac surgery and costs. Discussion: FRAGILE trial will determine whether off-pump CABG is superior to conventional on-pump CABG in the surgical treatment of pre-frail and frail patients. Trial registration: ClinicalTrials.gov, ID: NCT02338947. Registered on August 29th 2014; last updated on March 21st 2016.

Comparison of outcomes between off-pump versus on-pump coronary artery bypass surgery in elderly patients: a meta-analysis

The aim of this study was to analyze if off-pump coronary artery bypass surgery (CABG) is associated with better treatment outcomes in elderly patients (>70 years of age) than on-pump CABG, using meta-analysis. Medline, PubMed, Cochrane and Google Scholar databases were searched until September 13, 2016. Sensitivity and quality assessment were performed. Twenty-two studies, three randomized control trials (RCTs) and 20 non-RCTs were included with 24,127 patients. The risk of death associated with on-pump or off-pump CABG in the RCTs were similar (pooled OR=0.945, 95%CI=0.652 to 1.371, P=0.766). However, in the non-RCTs, mortality risk was lower in patients treated with off-pump CABG than on-pump CABG (pooled OR=0.631, 95%CI=0.587 to 0.944, P=0.003). No differences were observed between the two treatment groups in terms of the occurrence of 30-day post-operative stroke or myocardial infarction (P≥0.147). In the non-RCTs, off-pump CABG treatment was associated with a shorter length of hospital stay (pooled standardized difference in means=-0.401, 95%CI=-0.621 to -0.181, P≤0.001). The meta-analysis with pooled data from non-RCTs, but not RCTs, found that mortality was lower with off-pump compared with on-pump CABG, and suggested that there may be some benefit of off-pump CABG compared with on-pump CABG in the risk of mortality and length of hospital stay.

Incidence of postoperative atrial fibrillation in patients undergoing on-pump and off-pump coronary artery bypass grafting / Incidência de fibrilação atrial no pós-operatório de pacientes submetidos à cirurgia de revascularização do miocárdio com e sem circulação extracorpórea

AbstractObjective:To determine the incidence of postoperative atrial fibrillation in patients undergoing on-pump and off-pump coronary artery bypass grafting.Methods:A retrospective study with analysis of 230 medical records between January 2011 and October 2013 was conducted.Results:Fifty-six (24.3%) out of the 230 patients were female. The average age of patients undergoing on-pump coronary artery bypass grafting was 59.91±8.62 years old, and off-pump was 57.16±9.01 years old (P=0.0213). The average EuroSCORE for the on-pump group was 3.37%±3.08% and for the off-pump group was 3.13%±3% (P=0.5468). Eighteen (13.43%) patients who underwent off-pump coronary artery bypass grafting developed postoperative atrial fibrillation, whereas for the onpump group, 19 (19.79%) developed this arrhythmia, with no significant difference between the groups (P=0.1955).Conclusion:Off-pump coronary artery bypass grafting did not reduce the incidence of atrial fibrillation in the postoperative period. Important predictors of risk for the development of this arrhythmia were identified as: patients older than 70 years old and presence of atrial fibrillation in perioperative period in both groups, and non-use of beta-blockers drugs postoperatively in the on-pump group.

ResumoObjetivo:Determinar a incidência de fibrilação atrial no pós -operatório de pacientes submetidos à cirurgia de revascularização do miocárdio com e sem circulação extracorpórea.Métodos:Foi realizado um estudo retrospectivo com análise de 230 prontuários entre janeiro de 2011 e outubro de 2013.Resultados:Do total de 230 pacientes, 56 (24,3%) eram do sexo feminino. A média de idade dos pacientes submetidos à cirurgia de revascularização do miocárdio com circulação extracorpórea foi de 59,91±8,62 anos, e sem circulação extracorpórea, foi de 57,16±9,01 anos (P=0,0213). A média do Euroscore para o grupo com circulação extracorpórea foi de 3,37%±3,08% e para o grupo sem circulação extracorpórea foi de 3,13%±3% (P=0,5468). Entre os pacientes que realizaram a cirurgia de revascularização do miocárdio sem circulação extracorpórea, 18 (13,43%) desenvolveram fibrilação atrial no pós-operatório, enquanto no grupo com circulação extracorpórea, 19 (19,79%) desenvolveram esta arritmia, não havendo diferença significativa entre os grupos (P=0,1955).Conclusão:A cirurgia de revascularização do miocárdio sem circulação extracorpórea não diminuiu a incidência de fibrilação atrial no período pós-operatório. Identificamos como preditores de risco para o desenvolvimento desta arritmia: idade superior a 70 anos e presença de fibrilação atrial no período transoperatório em ambos os grupos estudados, e o não uso de medicamentos betabloqueadores no pós-operatório do grupo com circulação extracorpórea.

Cardiopulmonary bypass increases the risk of vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure / O uso da circulação extracorpórea aumenta o risco de síndrome vasoplégica em pacientes com insuficiência renal crônica hemodialítica submetidos à revascularização cirúrgica do miocárdio

AbstractObjective:Coronary artery bypass grafting is currently the best treatment for dialysis patients with multivessel coronary artery involvement. Vasoplegic syndrome of inflammatory etiology constitutes an important postoperative complication, with highly negative impact on prognosis. Considering that these patients have an intrinsic inflammatory response exacerbation, our goal was to evaluate the incidence and mortality of vasoplegic syndrome after myocardial revascularization in this group.Methods:A retrospective, single-center study of 50 consecutive and non-selected dialysis patients who underwent myocardial revascularization in a tertiary university hospital, from 2007 to 2012. The patients were divided into 2 groups, according to the use of cardiopulmonary bypass or not (off-pump coronary artery bypass). The incidence and mortality of vasoplegic syndrome were analyzed. The subgroup of vasoplegic patients was studied separately.Results:There were no preoperative demographic differences between the cardiopulmonary bypass (n=20) and off-pump coronary artery bypass (n=30) group. Intraoperative data showed a greater number of distal coronary arteries anastomosis (2.8 vs. 1.8, P<0.0001) and higher transfusion rates (65% vs. 23%, P=0.008) in the cardiopulmonary bypass group. Vasoplegia incidence was statistically higher (P=0.0124) in the cardiopulmonary bypass group (30%) compared to the off-pump coronary artery bypass group (3%). Vasoplegia mortality was 50% in the cardiopulmonary bypass group and 0% in the off-pump coronary artery bypass group. The vasoplegic subgroup analysis showed no statistically significant clinical differences.Conclusion:Cardiopulmonary bypass increased the risk for developing postoperative vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure.

ResumoObjetivo:O melhor tratamento atual para os pacientes dialíticos com acometimento coronariano multiarterial é a revascularização cirúrgica do miocárdio. Dentre as complicações pós-operatórias, a síndrome vasoplégica de etiopatogenia inflamatória torna-se importante pelo impacto altamente negativo no prognóstico. Considerando que esses pacientes possuem uma exacerbação intrínseca da resposta inflamatória, nosso objetivo foi avaliar a incidência e a mortalidade da síndrome vasoplégica no pós-operatório de revascularização miocárdica nesse grupo.Métodos:Estudo retrospectivo, unicêntrico, de 50 pacientes dialíticos consecutivos e não selecionados, submetidos à revascularização miocárdica, em um hospital terciário universitário, no período de 2007 a 2012. Esses pacientes foram divididos em 2 grupos, de acordo com o emprego ou não da circulação extracorpórea. A incidência e a mortalidade da vasoplegia foram analisadas nos grupos. Após a identificação dos pacientes quanto à presença de vasoplegia, este subgrupo foi estudado separadamente.Resultados:Não houve diferenças demográficas pré-operatórias entre os grupos com circulação extracorpórea (n=20) e sem circulação extracorpórea (n=30). Dados intraoperatórios demonstraram maior número de artérias coronárias revascularizadas (2,8 vs. 1,8; P<0,0001) e maior necessidade de transfusão (65% vs. 23%; P=0,008) no grupo circulação extracorpórea. A incidência de vasoplegia foi estatisticamente maior (P=0,0124) no grupo circulação extracorpórea (30%) em comparação ao grupo sem circulação extracorpórea (3%). A mortalidade dos pacientes com vasoplegia foi 50% no grupo circulação extracorpórea e 0% no grupo sem circulação extracorpórea. A análise do subgrupo vasoplégico não demonstrou diferenças clínicas estatisticamente significantes.Conclusão:O emprego da circulação extracorpórea na revascularização cirúrgica do miocárdio em pacientes com insuficiência renal crônica dialítica aumentou o risco para desenvolvimento de síndrome vasoplégica pós-operatória.

Effect of using pump on postoperative pleural effusion in the patients that underwent CABG / Efeito da circulação extracorpórea no derrame pleural pós-operatório em pacientes submetidos à revascularização do miocárdio

AbstractObjective:The present study investigated effect of using pump on postoperative pleural effusion in patients who underwent coronary artery bypass grafting.Methods:A total of 256 patients who underwent isolated coronary artery bypass grafting surgery in the Cardiovascular Surgery clinic were enrolled in the study. Jostra-Cobe (Model 043213 105, VLC 865, Sweden) heart-lung machine was used in on-pump coronary artery bypass grafting. Off-pump coronary artery bypass grafting was performed using Octopus and Starfish. Proximal anastomoses to the aorta in both on-pump and off-pump techniques were performed by side clamps. The patients were discharged from the hospital between postoperative day 6 and day 11.Results:The incidence of postoperative right pleural effusion and bilateral pleural effusion was found to be higher as a count in Group 1 (on-pump) as compared to Group 2 (off-pump). But the difference was not statistically significant [P>0.05 for right pleural effusion (P=0.893), P>0.05 for bilateral pleural effusion (P=0.780)]. Left pleural effusion was encountered to be lower in Group 2 (off-pump). The difference was found to be statistically significant (P<0.05, P=0.006).Conclusion:Under the light of these results, it can be said that left pleural effusion is less prevalent in the patients that underwent off-pump coronary artery bypass grafting when compared to the patients that underwent on-pump coronary artery bypass grafting.

ResumoIntrodução:O presente estudo investigou efeito da utilização de bomba em derrame pleural pós-operatório nos casos de pacientes que se submeteram à cirurgia de revascularização miocárdica.Métodos:Um total de 256 pacientes que foram submetidos à cirurgia de revascularização isolada no ambulatório de Cirurgia Cardiovascular foram incluídos no estudo. Máquina coração-pulmão Jostra-Cobe (Modelo 043213 105, VLC 865, Suécia) foi utilizada em cirurgia de revascularização miocárdica com circulação extracorpórea. Cirurgia de revascularização miocárdica sem circulação extracorpórea foi realizada utilizando Octopus e Starfish. Anastomose proximal na aorta, em ambas as técnicas, foi realizada por grampos laterais. Os pacientes receberam alta do hospital entre os dias 6 e 11 de pós-operatório.Resultados:A incidência de derrame pleural à direita pós-operatória e derrame pleural bilateral encontrada foi mais elevada em contagem do Grupo 1 (com circulação extracorpórea) em relação ao Grupo 2 (sem circulação extracorpórea). Mas a diferença não foi estatisticamente significativa [P>0,05 para derrame pleural à direita (P=0,893), P>0,05 para derrame pleural bilateral (P=0,780)]. O derrame pleural esquerdo encontrado foi menor no Grupo 2 (CEC). A diferença foi estatisticamente significativa (P<0,05, P=0,006).Conclusão:Sob a luz destes resultados, pode-se dizer que derrame pleural esquerdo é menos prevalente nos pacientes que foram submetidos à revascularização do miocárdio sem circulação extracorpórea em comparação com os pacientes que foram submetidos à revascularização do miocárdio com circulação extracorpórea.

Assessment of feasibility and efficacy of Class IV laser therapy for postoperative pain relief in off-pump coronary artery bypass surgery patients: A pilot study.

Background: Laser therapy, for its established analgesic properties with minimal side effects, has been used for the treatment of chronic pain. However, it has not been used for the treatment of acute postoperative pain. This pilot study was designed to assess the feasibility and efficacy of Class IV laser on postoperative pain relief following off-pump coronary artery bypass graft (OPCABG) surgery, as a component of multimodal analgesia (MMA) technique. Methods: This open observational prospective study comprised of 100 adult patients (84 male, 16 female) who underwent OPCABG through sternotomy. For postoperative analgesia, they were subjected to laser therapy subjected to laser therapy in addition to the standard institutional pain management protocol comprising of IV infusion/bolus of tramadol and paracetamol and fentanyl bolus as rescue analgesic. Pain intensity was measured by Verbal Rating Scale (VRS). The laser therapy was scheduled as once a day regime for three consecutive postoperative days (PODs) starting on POD 1, 30 min following tracheal extubation. The subsequent laser applications were also scheduled at the same time of the day as on day 1 if VRS was ≥5. 10 W Class IV laser was applied over 150 cm2 sternal wound area for 150 s. VRS was used to assess pain severity and was recorded for statistical analysis using Friedman Test. Results: The mean (standard deviation [SD]) VRS of all the 100 patients just before application of the first dose of laser was 7.31 (0.94) while on MMT; the same fell to 4.0 (1.279) and 3.40 (2.697) at 1 h and 24 h respectively following first dose of laser. The change of VRS over first 24 h among all the 100 patients was statistically significant (P = 0.000). Laser was re-applied in 40 patients whose VRS was ≥5 (mean [SD] – 6.38 [0.868]) at 24th h. After receiving the 2nd dose of laser the VRS scores fell significantly (P = 0.000) and became 0 at 54th h. No patients required 3rd dose of the laser. No patient required rescue analgesic while on laser therapy. Conclusion: Class IV laser can be an effective technique for postoperative analgesia following OPCABG surgery through sternotomy when included as a component of MMA technique.

Pleural subxyphoid drain confers better pulmonary function and clinical outcomes in chronic obstructive pulmonary disease after off-pump coronary artery bypass grafting: a randomized controlled trial / Dreno pleural subxifoide confere melhor função pulmonar e resultados clínicos na doença pulmonar obstrutiva crônica após cirurgia de revascularização miocárdica sem circulação extracorpórea: ensaio clínico controlado e randomizado

Objective: To evaluate the lung function and clinical outcome in severe chronic obstructive pulmonary disease in patients undergoing off-pump coronary artery bypass grafting with left internal thoracic artery graft, comparing the pleural drain insertion in the intercostal versus subxyphoid region. Methods: A randomized controlled trial. Chronic obstructive pulmonary disease patients were randomized into two groups according pleural drain site: II group (n=27) - pleural drain in intercostal space; SI group (n=29) - pleural drain in the subxyphoid region. Spirometry values (Forced Vital Capacity - and Forced expiratory volume in 1 second) were obtained on preoperative and 1, 3 and 5 postoperative days. Chest x-ray from preoperative until postoperative day 5 (POD5) was performed for monitoring respiratory events, such as atelectasis and pleural effusion. Pulmonary shunt fraction and pain score was evaluate preoperatively and on postoperative day 1. Results: In both groups there was a significant decrease of the spirometry values (Forced Vital Capacity and Forced expiratory volume in 1 second) until POD5 (P<0.05). However, when compared, SI group presented less decrease in these parameters (P<0.05). Pulmonary shunt fraction was significantly lower in SI group (P<0.05). Respiratory events, pain score, orotracheal intubation time and postoperative length of hospital stay were lower in the SI group (P<0.05). Conclusion: Subxyphoid pleural drainage in severe Chronic obstructive pulmonary disease patients determined better preservation and recovery of pulmonary capacity and volumes with lower pulmonary shunt fraction and better clinical outcomes on early postoperative off-pump coronary artery bypass grafting. .

Objetivo: Avaliar a função pulmonar e os resultados clínicos em pacientes com doença pulmonar obstrutiva crônica grave submetidos à cirurgia de revascularização do miocárdio sem circulação extracorpórea, com enxerto da artéria torácica interna esquerda, comparando a inserção do dreno pleural intercostal versus subxifoide. Métodos: Estudo clínico, controlado e randomizado. Pacientes com doença pulmonar obstrutiva crônica foram randomizados em dois grupos de acordo com a posição do dreno pleural: grupo II (n=27) - dreno pleural intercostal; grupo IS (n=29) - dreno pleural na região subxifóide. Os valores espirométricos (Capacidade Vital Forçada e Volume expiratório forçado no 1 segundo) foram obtidos no pré-operatório, e no 1º, 3º e 5º dias de pós-operatório. Foi realizada radiografia de tórax no préoperatório até o 5º dia pós-operatório (5PO) para monitoração de eventos respiratórios, como atelectasia e derrame pleural. A fração de shunt pulmonar e a escala de dor foram avaliadas no 1º dia pós-operatório. Resultados: Em ambos os grupos houve queda significativa dos valores espirométricos (Capacidade Vital Forçada e Volume expiratório forçado no 1 segundo) até o 5PO (P<0.05), porém, quando comparados, o grupo IS apresentou menor queda destes parâmetros (P<0.05). A fração de shunt pulmonar foi significativamente menor no grupo IS (P<0.05). Os eventos respiratórios, escala da dor, tempo de intubação orotraqueal e dias internação hospitalar no pós-operatório foram menores no grupo IS (P<0.05). Conclusão: Drenagem pleural subxifoide em pacientes com doença pulmonar obstrutiva crônica grave determinou melhor preservação e recuperação dos volumes e capacidades pulmonares, com menor fração de shunt pulmonar e melhores resultados clínicos no pós-operatório precoce de cirurgia de revascularização do miocárdio sem circulação extracorpórea. .

Perioperative optic neuropathy in patients undergoing off‑pump coronary artery bypass graft surgery.

Aims and Objectives: Perioperative optic neuropathy (PON) is a rare, but devastating complication following coronary artery bypass graft surgery (CABG). We performed a retrospective study of PON associated with off‑pump CABG (OPCABG) to identify possible risk factors. Materials and Methods: 1442 patients underwent OPCABG over a 10‑month period from October 2008 to August 2009; PON was identified in four (0.28%) patients. A retrospective review of the charts was done to identify the patient characteristics, pre‑operative status, intra‑operative details, and ophthalmic examination details. Friedman test was used to compare the hematocrit (Hct) and the mean arterial pressure (MAP) values across the three time periods: Pre‑, intra‑ and post‑operative periods. Results: All four patients were male, diabetic, and in the age range 51‑69 years. All patients noted unilateral or bilateral severe visual loss in the immediate post‑operative period, which was permanent. All the four patients had statistically significant decrease in the Hct (P < 0.039) and mean arterial blood pressure (P < 0.018) in the intraoperative and post‑operative period when compared to pre‑operative value. Conclusions: PON is a rare but definite possibility in patients undergoing OPCABG. Diabetes mellitus may be a risk factor. Perioperative hemodynamic abnormalities like decrease in MAP and anemia may play a role in the development of PON in OPCABG.

Revascularização cirúrgica do miocárdio com versus sem circulação extracorpórea: O que mostram as evidências? / On-pump versus off-pump coronary artery bypass graft surgery: What do the evidence show?

A proposta da revascularização do miocárdio sem emprego da circulação extracorpórea visa à diminuição da morbimortalidade decorrente dos potenciais efeitos deletérios da circulação extracorpórea. Todavia, embora a maioria dos estudos demonstre que a revascularização sem circulação extracorpórea é factível e forneça resultados similares à operação com circulação extracorpórea, no que se refere à morbimortalidade hospitalar, e pode mesmo diminuir a incidência de alguns eventos, sua eficácia a médio e longo prazo tem sido questionada. Alguns estudos demonstram menor sobrevida em pacientes submetidos à revascularização do miocárdio sem circulação extracorpórea, levantando a hipótese de que a revascularização incompleta e/ou a pior evolução dos enxertos realizados na operação sem circulação extracorpórea em comparação à operação com circulação extracorpórea, observadas em alguns estudos, seriam responsáveis por essa evolução desfavorável.

The main purpose of the off-pump coronary artery bypass surgery is to reduce morbidity and mortality due cardiopulmonary bypass. However, even though many studies have shown that off-pump coronary artery bypass is feasible and provides hospital morbidity and mortality similar to the on-pump coronary artery bypass graft surgery, probably better in some aspects, its long-term results have been questioned, since some trials have shown reduced survival with off-pump coronary artery bypass. It is likely that incomplete revascularization and/or poor graft patency with off-pump coronary artery bypass probably are responsible for such unfavorable outcome.

Resultados inmediatos y a mediano plazo de la cirugía coronaria sin circulación extracorpórea: Experience in 220 patients / Off-pump coronary surgery

Background: Coronary artery bypass graft surgery without cardiopulmonary bypass (CPB) is an alternative technique for myocardial revascularization. Aim: To report the early results and 4 yearsfollow up ofthefirst 220 cases operated with this technique. Patients and Methods: Descriptive study of 220 patients aged 60.6 ±8.8 years (171 men) undergoing off-pump coronary surgery between 2004 and 2008. One hundred seventy six (80%) patients had hypertension, 59 (26.8%) had diabetes, 86 (39%) dyslipidemia and 85 (38.6%) were smokers. One hundred forty one patients (64.1%) had stable angina. Fiftyfour (24.5%) had a recent infarction (< 90 days) and 46 (20.9%) had a previous angioplasty. Ejection fraction was < 30% in 9 (4.1%), 30% - 50% in 57 (25.9%) and > 50% in 154 (70%). Additive and logistic EuroSCORE were 3.32 and 3.55% respectively. We studied the complications and mortality at 30 days. Long term follow up (late mortality and major cardiovascular events such as myocardial infarction (MI) stroke and re-intervention were assessed using data of medical records and National Identification Registry Service until June 30, 2011. Results: A total of 481 bypasses were performed (2.27 bypassesl patient). There were 4 (1.8%) conversions and no incomplete revascularization. Post-Operative complications occurred in 42 patients. Eight neurological (five strokes), five renal (two required dialysis), 16 cardiovascular (four myocardial infarctions), 15 surgical and 11 infections. Three patients died (1.36%). After a follow up of 4.26 ± 1.02 years, overall survival was 92.3%, and survival free of myocardial infarction, stroke or re - intervention was 96.8%, 96.8% and 95.9% respectively. Conclusions: Off-pump coronary surgery in selected patients has immediate and late results comparable to traditional surgery.

Off-pump versus on-pump coronary artery bypass surgery: meta-analysis and meta-regression of 13,524 patients from randomized trials / Cirurgia de revascularização miocárdica com CEC versus sem CEC: meta-análise e meta-regressão de 13.524 pacientes de estudos randomizados

BACKGROUND: Most recent published meta-analysis of randomized controlled trials (RCTs) showed that off-pump coronary artery bypass graft surgery (CABG) reduces incidence of stroke by 30% compared with on-pump CABG, but showed no difference in other outcomes. New RCTs were published, indicating need of new meta-analysis to investigate pooled results adding these further studies. METHODS: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for RCTs that compared outcomes (30-day mortality for all-cause, myocardial infarction or stroke) between off-pump versus on-pump CABG until May 2012. The principal summary measures were relative risk (RR) with 95% Confidence Interval (CI) and P values (considered statistically significant when <0.05). The RR's were combined across studies using DerSimonian-Laird random effects weighted model. Meta-analysis and meta-regression were completed using the software Comprehensive Meta-Analysis version 2 (Biostat Inc., Englewood, New Jersey, USA). RESULTS: Forty-seven RCTs were identified and included 13,524 patients (6,758 for off-pump and 6,766 for on-pump CABG). There was no significant difference between off-pump and on-pump CABG groups in RR for 30-day mortality or myocardial infarction, but there was difference about stroke in favor to off-pump CABG (RR 0.793, 95% CI 0.660-0.920, P=0.049). It was observed no important heterogeneity of effects about any outcome, but it was observed publication bias about outcome "stroke". Meta-regression did not demonstrate influence of female gender, number of grafts or age in outcomes. CONCLUSION: Off-pump CABG reduces the incidence of post-operative stroke by 20.7% and has no substantial effect on mortality or myocardial infarction in comparison to on-pump CABG. Patient gender, number of grafts performed and age do not seem to explain the effect of off-pump CABG on mortality, myocardial infarction or stroke, respectively.

INTRODUÇÃO: A meta-análise mais recente de estudos randomizados controlados (ERC) mostrou que cirurgia de revascularização (CRM) sem circulação extracorpórea (CEC) reduz a incidência de acidente vascular cerebral em 30% em comparação com CRM com CEC, mas não mostrou diferença em outros resultados. Novos ERCs foram publicados, indicando necessidade de nova meta-análise para investigar resultados agrupados adicionando esses estudos. MÉTODOS: MEDLINE, EMBASE, CENTRAL / CCTR, SciELO, LILACS, Google Scholar e listas de referências de artigos relevantes foram pesquisados para ERCs que compararam os resultados de 30 dias (mortalidade por todas as causas, infarto do miocárdio ou acidente vascular cerebral - AVC) entre CRM com CEC versus sem CEC até maio de 2012. As medidas sumárias principais foram o risco relativo (RR) com intervalo de confiança de 95% (IC) e os valores de P (considerado estatisticamente significativo quando <0,05). Os RR foram combinados entre os estudos usando modelo de efeito randômico de DerSimonian-Laird. Meta-análise e meta-regressão foram concluídas usando o software versão Meta-Análise Abrangente 2 (Biostat Inc., Englewood, Nova Jersey, EUA). RESULTADOS: Quarenta e sete ERCs foram identificados e incluíram 13.524 pacientes (6.758 sem CEC e 6.766 com CEC). Não houve diferença significativa entre CRM com CEC e sem CEC no RR de mortalidade em 30 dias ou infarto do miocárdio, mas houve diferença em favor da CRM sem CEC no desfecho AVC (RR 0,793, IC 95% 0,660-0,920, P = 0,049). Não foi observado importante heterogeneidade dos efeitos sobre qualquer resultado, mas observou-se um viés de publicação sobre o desfecho "AVC". Meta-regressão não demonstrou influência do sexo feminino, o número de pontes ou idade nos resultados. CONCLUSÃO: CRM sem uso da CEC reduz a incidência de acidente vascular cerebral pós-operatória de 20,7% e não tem efeito significativo sobre a mortalidade ou infarto do miocárdio em comparação com CRM com CEC. Sexo do paciente, número de enxertos realizados e idade não parecem explicar o efeito de RM sem CEC sobre a mortalidade, infarto do miocárdio ou acidente vascular cerebral, respectivamente.