BEST EVIDENCE TOPIC – ADULT CARDIAC
Interactive CardioVascular and Thoracic Surgery 19 (2014) 295–301 doi:10.1093/icvts/ivu116 Advance Access publication 2 May 2014
Should we consider off-pump coronary artery bypass grafting in patients undergoing coronary endarterectomy? Erdinc Soylu, Leanne Harling*, Hutan Ashrafian and Thanos Athanasiou Department of Surgery and Cancer, Imperial College London, London, UK * Corresponding author. Department of Surgery and Cancer, Imperial College London, 10th floor QEQM Building, St Mary’s Hospital, Praed Street, London W2 1NY, UK. Tel: +44-203-3127651; fax: +44-203-3126302; e-mail: [email protected] (L. Harling). Received 3 February 2014; received in revised form 15 March 2014; accepted 26 March 2014
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether off-pump coronary artery bypass grafting with coronary endarterectomy (OPCAB-CE) is a safe and feasible method of myocardial revascularization in patients presenting with diffuse coronary artery disease. Seventy-one papers were identified by a systematic search, of which nine were judged to best answer the clinical question. All were observational studies. Of these, two were comparative and the remaining seven were case series. The authors, journal, date, country of publication, patient group, study type, relevant outcomes and results were tabulated. In total, these 9 studies included 341 patients (225 OPCAB-CE, 116 ONCAB-CE) undergoing coronary endarterectomy in combination with coronary artery bypass grafting. CE was performed either by an open method whereby the atheroma is removed through an arteriotomy made along the length of the stenosis or by a closed method whereby the atheroma is removed by gentle traction through a small arteriotomy made over a proximal area of the plaque. Overall, OPCAB-CE was associated with a low perioperative mortality ranging from zero in smaller case series to 2.8% in the largest study (n = 70). Two comparative studies demonstrate at least equivalent 30-day mortality between OPCAB-CE and ONCAB-CE, although the sample sizes are small. The overall incidence of postoperative myocardial infarction (MI) was 6.1% (11/180) and seems comparable between OPCAB-CE and ONCAB-CE. Notably, both postoperative MI and mortality appeared higher in patients undergoing multiple endarterectomies performed using a closed technique and CE to the right coronary artery was associated with increased postoperative MI. In summary, OPCAB-CE in the setting of diffuse coronary artery disease appears both safe and feasible, yielding comparable results to ONCAB-CE. Where possible, open arteriotomy with on-lay patch angioplasty may improve postoperative outcomes. Large, prospective database studies are now required with explicit sub-group criteria and stratification to number, territory and technique of endarterectomy in order to isolate the patients in whom OPCAB-CE may confer the greatest benefit. Keywords: Off-pump • Coronary • Endarterectomy
INTRODUCTION A best evidence topic was constructed according to a structured protocol as fully described in the ICVTS [1].
coronary artery (LAD) stenosis. Transthoracic echo shows a hypokinetic anterior wall and an ejection fraction of 35%. You are asked to consider him for elective CABG. You suspect that you may have to perform coronary endarterectomy and your trainee asks whether you would perform this case ‘off-pump’?
THREE-PART QUESTION In [ patients presenting with diffuse coronary artery disease], is [off-pump coronary artery bypass with coronary endarterectomy] or [on-pump coronary bypass with coronary endarterectomy] the best method in terms of [survival and freedom from myocardial infarction]?
SEARCH STRATEGY A literature search was performed using PubMed, Ovid, Embase and Cochrane databases using the terms ‘off-pump’, ‘heart’, ‘coronary’ and ‘endarterectomy’. The last search date was 20th January 2014.
CLINICAL SCENARIO A 65-year old man with a history of two previous anterior myocardial infarctions (MIs) is referred with worsening exertional chest pain. His percutaneous coronary angiogram reveals triple-vessel disease with a long segment of diffuse left anterior descending
SEARCH OUTCOMES Seventy-one papers were found of which nine [2–10] provide the best evidence for this topic. A summary is presented in Table 1.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
BEST EVIDENCE TOPIC
Abstract
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Table 1: Best evidence papers Author, date, journal and country Study type (level of evidence)
Patient group
Naseri et al. (2003), Heart Surg Forum, Turkey [7]
44 patients (mean age = 65.4 ± 4.8 and male % = 61.4%) undergoing OPCAB + CE matched for age, sex and risk factors and compared with 44 patients (mean age = 63.4 ± 7.6 and male % = 55.8%) undergoing ONCAB + CE between 1999 and 2001
Case controlretrospective (level 3)
Poor EF ( 0.1)
CVA
0% in OPCAB vs 16% in the ONCAB group (P < 0.001)
IABP
4.5% in OPCAB vs 20.4% in the ONCAB group (P < 0.001)
AF
13% in OPCAB vs 6.8% in the ONCAB group (P < 0.05)
Blood transfusion (units)
0.8 ± 0.3 in OPCAB vs 2.7 ± 1.6 in the ONCAB group (P < 0.01)
Intubation time
3.4 ± 1.4 in OPCAB vs 9.8 ± 2.6 in the ONCAB group (P < 0.01)
Renal failure
0% in OPCAB vs 4.5% in the ONCAB group (P < 0.001)
ICU and hospital stay (days)
ICU stay = 1.1 ± 0.6 in OPCAB vs 2.1 ± 0.8 in ONCAB group (P < 0.05)
Limitations: Retrospective study design. Small cohort of patients
Technique: RCA: arteriotomy + closed (traction) + bypass graft or others: arteriotomy + open + LITA ± SV patch (for LAD)
Hospital length of stay = 4.2 ± 1.3 in OPCAB vs 9.2 ± 2.8 in the ONCAB group (P < 0.05)
Hussain et al. (2008), J Ayub Med Coll Abbottabad, Pakistan [5] Prospective comparative study (level 2)
43 patients (mean age = 52.63 ± 1.40 and male % = 93%) undergoing OPCAB + CE compared with 72 patients (mean age = 55.68 ± 1.06 and male % = 90.4%) undergoing ONCAB + CE between 2006 and 2007
Patency
Angiography at an average of 13 months: 16/22 (73%) in OPCAB vs 13/17 (76%) in the ONCAB group of endarterectomized vessels were patent (P < 0.1)
Follow-up clinical status
All are in NYHA Class I and II
Mortality
1 (2.3%) in OPCAB vs 4 (5.6%) in the ONCAB group (P = 0.649)
MI
8 (18.5%) in OPCAB vs 8 (11.2%) in the ONCAB group (P = 0.576)
IABP
0 (0%) in OPCAB vs (4) 5.6% in the ONCAB group (P = 0.295)
AF
4 (9.3%) in the OPCAB vs 13 (18.1%) in the ONCAB group (P = 0.197)
Respiratory complications
6 (14.0%) in the OPCAB vs 11 (15.3%) in the ONCAB group (P = 0.211)
Intubation time (median, h)
5.0 ± 4.0 in OPCAB vs 6.78 ± 9.34 in the ONCAB group (P = 0.060)
Renal dysfunction
4 (9.3%) in OPCAB vs 18 (25.0%) in the ONCAB group (P = 0.075)
Conclusions: CE has higher postoperative morbidity and mortality but the postoperative outcome after the procedure on either technique is comparable and CE is feasible on off-pump technique as well
Limitations: Small cohort of patients. Exclusion criteria are not explicit
Continued
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Table 1: (Continued) Author, date, journal and country Study type (level of evidence)
Patient group
Outcomes
Key results
ICU and hospital stay
ICU stay (median, days) = (4.0 ± 1.0) in OPCAB vs (4.0 ± 3.0) in the ONCAB group (P = 0.007)
Comments
Hospital length of stay (median, days) = (10.0 ± 7) in OPCAB vs (10.5 ± 6.0) in the ONCAB group (P = 0.368)
Case seriesprospective (level 4)
70 patients (56 males and 14 females) with a mean age of 63.3 ± 9.3 years underwent OPCAB + CE between 1995 and 2004 Poor EF (
Interactive CardioVascular and Thoracic Surgery 19 (2014) 295–301 doi:10.1093/icvts/ivu116 Advance Access publication 2 May 2014
Should we consider off-pump coronary artery bypass grafting in patients undergoing coronary endarterectomy? Erdinc Soylu, Leanne Harling*, Hutan Ashrafian and Thanos Athanasiou Department of Surgery and Cancer, Imperial College London, London, UK * Corresponding author. Department of Surgery and Cancer, Imperial College London, 10th floor QEQM Building, St Mary’s Hospital, Praed Street, London W2 1NY, UK. Tel: +44-203-3127651; fax: +44-203-3126302; e-mail: [email protected] (L. Harling). Received 3 February 2014; received in revised form 15 March 2014; accepted 26 March 2014
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether off-pump coronary artery bypass grafting with coronary endarterectomy (OPCAB-CE) is a safe and feasible method of myocardial revascularization in patients presenting with diffuse coronary artery disease. Seventy-one papers were identified by a systematic search, of which nine were judged to best answer the clinical question. All were observational studies. Of these, two were comparative and the remaining seven were case series. The authors, journal, date, country of publication, patient group, study type, relevant outcomes and results were tabulated. In total, these 9 studies included 341 patients (225 OPCAB-CE, 116 ONCAB-CE) undergoing coronary endarterectomy in combination with coronary artery bypass grafting. CE was performed either by an open method whereby the atheroma is removed through an arteriotomy made along the length of the stenosis or by a closed method whereby the atheroma is removed by gentle traction through a small arteriotomy made over a proximal area of the plaque. Overall, OPCAB-CE was associated with a low perioperative mortality ranging from zero in smaller case series to 2.8% in the largest study (n = 70). Two comparative studies demonstrate at least equivalent 30-day mortality between OPCAB-CE and ONCAB-CE, although the sample sizes are small. The overall incidence of postoperative myocardial infarction (MI) was 6.1% (11/180) and seems comparable between OPCAB-CE and ONCAB-CE. Notably, both postoperative MI and mortality appeared higher in patients undergoing multiple endarterectomies performed using a closed technique and CE to the right coronary artery was associated with increased postoperative MI. In summary, OPCAB-CE in the setting of diffuse coronary artery disease appears both safe and feasible, yielding comparable results to ONCAB-CE. Where possible, open arteriotomy with on-lay patch angioplasty may improve postoperative outcomes. Large, prospective database studies are now required with explicit sub-group criteria and stratification to number, territory and technique of endarterectomy in order to isolate the patients in whom OPCAB-CE may confer the greatest benefit. Keywords: Off-pump • Coronary • Endarterectomy
INTRODUCTION A best evidence topic was constructed according to a structured protocol as fully described in the ICVTS [1].
coronary artery (LAD) stenosis. Transthoracic echo shows a hypokinetic anterior wall and an ejection fraction of 35%. You are asked to consider him for elective CABG. You suspect that you may have to perform coronary endarterectomy and your trainee asks whether you would perform this case ‘off-pump’?
THREE-PART QUESTION In [ patients presenting with diffuse coronary artery disease], is [off-pump coronary artery bypass with coronary endarterectomy] or [on-pump coronary bypass with coronary endarterectomy] the best method in terms of [survival and freedom from myocardial infarction]?
SEARCH STRATEGY A literature search was performed using PubMed, Ovid, Embase and Cochrane databases using the terms ‘off-pump’, ‘heart’, ‘coronary’ and ‘endarterectomy’. The last search date was 20th January 2014.
CLINICAL SCENARIO A 65-year old man with a history of two previous anterior myocardial infarctions (MIs) is referred with worsening exertional chest pain. His percutaneous coronary angiogram reveals triple-vessel disease with a long segment of diffuse left anterior descending
SEARCH OUTCOMES Seventy-one papers were found of which nine [2–10] provide the best evidence for this topic. A summary is presented in Table 1.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
BEST EVIDENCE TOPIC
Abstract
E. Soylu et al. / Interactive CardioVascular and Thoracic Surgery
296
Table 1: Best evidence papers Author, date, journal and country Study type (level of evidence)
Patient group
Naseri et al. (2003), Heart Surg Forum, Turkey [7]
44 patients (mean age = 65.4 ± 4.8 and male % = 61.4%) undergoing OPCAB + CE matched for age, sex and risk factors and compared with 44 patients (mean age = 63.4 ± 7.6 and male % = 55.8%) undergoing ONCAB + CE between 1999 and 2001
Case controlretrospective (level 3)
Poor EF ( 0.1)
CVA
0% in OPCAB vs 16% in the ONCAB group (P < 0.001)
IABP
4.5% in OPCAB vs 20.4% in the ONCAB group (P < 0.001)
AF
13% in OPCAB vs 6.8% in the ONCAB group (P < 0.05)
Blood transfusion (units)
0.8 ± 0.3 in OPCAB vs 2.7 ± 1.6 in the ONCAB group (P < 0.01)
Intubation time
3.4 ± 1.4 in OPCAB vs 9.8 ± 2.6 in the ONCAB group (P < 0.01)
Renal failure
0% in OPCAB vs 4.5% in the ONCAB group (P < 0.001)
ICU and hospital stay (days)
ICU stay = 1.1 ± 0.6 in OPCAB vs 2.1 ± 0.8 in ONCAB group (P < 0.05)
Limitations: Retrospective study design. Small cohort of patients
Technique: RCA: arteriotomy + closed (traction) + bypass graft or others: arteriotomy + open + LITA ± SV patch (for LAD)
Hospital length of stay = 4.2 ± 1.3 in OPCAB vs 9.2 ± 2.8 in the ONCAB group (P < 0.05)
Hussain et al. (2008), J Ayub Med Coll Abbottabad, Pakistan [5] Prospective comparative study (level 2)
43 patients (mean age = 52.63 ± 1.40 and male % = 93%) undergoing OPCAB + CE compared with 72 patients (mean age = 55.68 ± 1.06 and male % = 90.4%) undergoing ONCAB + CE between 2006 and 2007
Patency
Angiography at an average of 13 months: 16/22 (73%) in OPCAB vs 13/17 (76%) in the ONCAB group of endarterectomized vessels were patent (P < 0.1)
Follow-up clinical status
All are in NYHA Class I and II
Mortality
1 (2.3%) in OPCAB vs 4 (5.6%) in the ONCAB group (P = 0.649)
MI
8 (18.5%) in OPCAB vs 8 (11.2%) in the ONCAB group (P = 0.576)
IABP
0 (0%) in OPCAB vs (4) 5.6% in the ONCAB group (P = 0.295)
AF
4 (9.3%) in the OPCAB vs 13 (18.1%) in the ONCAB group (P = 0.197)
Respiratory complications
6 (14.0%) in the OPCAB vs 11 (15.3%) in the ONCAB group (P = 0.211)
Intubation time (median, h)
5.0 ± 4.0 in OPCAB vs 6.78 ± 9.34 in the ONCAB group (P = 0.060)
Renal dysfunction
4 (9.3%) in OPCAB vs 18 (25.0%) in the ONCAB group (P = 0.075)
Conclusions: CE has higher postoperative morbidity and mortality but the postoperative outcome after the procedure on either technique is comparable and CE is feasible on off-pump technique as well
Limitations: Small cohort of patients. Exclusion criteria are not explicit
Continued
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Table 1: (Continued) Author, date, journal and country Study type (level of evidence)
Patient group
Outcomes
Key results
ICU and hospital stay
ICU stay (median, days) = (4.0 ± 1.0) in OPCAB vs (4.0 ± 3.0) in the ONCAB group (P = 0.007)
Comments
Hospital length of stay (median, days) = (10.0 ± 7) in OPCAB vs (10.5 ± 6.0) in the ONCAB group (P = 0.368)
Case seriesprospective (level 4)
70 patients (56 males and 14 females) with a mean age of 63.3 ± 9.3 years underwent OPCAB + CE between 1995 and 2004 Poor EF (
