Off-Pump Surgery Is Not a Contraindication for Patients with a Severely Decreased Ejection Fraction
DOI:
https://doi.org/10.1532/HSF98.20111027Abstract
Background: A severely impaired left ventricular ejection fraction (EF) (30%) increases the risk of surgical myocardial revascularization. We evaluated the safety and feasibility of off-pump coronary artery bypass (OPCAB) surgery in patients with a severely decreased EF.
Methods: We compared 79 patients with an EF ?30% (group A) with 863 patients with an EF >30% (group B) who underwent myocardial revascularization between 2003 and 2008. The relationship between EF and outcome after OPCAB was assessed by univariate and logistic regression analyses. A composite end point was constructed from 30-day mortality, renal failure, length of stay in the intensive care unit (ICU) >2 days, neurologic complications, and use of an intra-aortic balloon pump (IABP). Additionally, the completeness of revascularization was assessed.
Results: The mortality rates for groups A and B were comparable (1.3% and 2.0%, respectively; P = .55), and the 2 groups did not differ with regard to serious postoperative complications, such as stroke (2.5% versus 1.4% for groups A and B, respectively; P = .42), peripheral neurologic complications (2.5% versus 0.7%, P = .14), renal failure (0% versus 1.1%, P = 1.00), use of an IABP (1.3% versus 0.8%, P = .50), ICU length of stay >2 days (17.7% versus 19.6%, P = .77). Similarly, groups A and B did not differ with regard to ventilation time (11.2 ± 12.7 hours versus 12.4 ± 15.5 hours, P = .82), indicating similar postoperative courses for the 2 groups of patients. In contrast, the composite end point occurred significantly more frequently in group A (43.0% versus 29.7%, P = .02), a result driven by the increased rate of rethoracotomy for bleeding in that group (11.4% versus 2.9%, P = .001). The 2 groups were similar with respect to the total number of grafts used per patient (3.82 ± 0.89 versus 3.63 ± 1.01, P = .10) and the completeness of revascularization (94% versus 93%, P = .49).
Conclusion: A standardized OPCAB approach is safe for patients with a severely decreased EF, and its use does not come at the cost of less complete revascularization.
References
Al-Ruzzeh S, Nakamura K, Athanasiou T 2003. Does off-pump coronary artery bypass (OPCAB) surgery improve the outcome in highrisk patients?: a comparative study of 1398 high-risk patients. Eur J Cardiothorac Surg 23:50-5.nArom KV, Flavin TF, Emery RW, Kshettry VR, Petersen RJ, Janey PA. 2000. Is low ejection fraction safe for off-pump coronary bypass operation? Ann Thorac Surg 70:1021-5.nChamberlain MH, Ascione R, Reeves BC, Angelini GD. 2002. Evaluation of the effectiveness of off-pump coronary artery bypass grafting in high-risk patients: an observational study. Ann Thorac Surg 73:1866-73.nCleveland JC Jr, Shroyer AL, Chen AY, Peterson E, Grover FL. 2001. Off-pump coronary artery bypass grafting decreases risk-adjusted mortality and morbidity. Ann Thorac Surg 72:1282-8; discussion 1288-9.nEagle KA, Guyton RA, Davidoff R 2004. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation 110:e340-437.nEmmert MY, Salzberg SP, Seifert B 2010. Despite modern off-pump coronary artery bypass grafting women fare worse than men. Interact Cardiovasc Thorac Surg 10:737-41.nHannan EL, Wu C, Smith CR 2007. Off-pump versus on-pump coronary artery bypass graft surgery: differences in short-term outcomes and in long-term mortality and need for subsequent revascularization. Circulation 116:1145-52.nLattouf OM, Thourani VH, Kilgo PD 2008. Influence of on-pump versus off-pump techniques and completeness of revascularization on long-term survival after coronary artery bypass. Ann Thorac Surg 86:797-805.nMagee MJ, Coombs LP, Peterson ED, Mack MJ. 2003. Patient selection and current practice strategy for off-pump coronary artery bypass surgery. Circulation 108(suppl 1):II9-14.nMoshkovitz Y, Sternik L, Paz Y 1997. Primary coronary artery bypass grafting without cardiopulmonary bypass in impaired left ventricular function. Ann Thorac Surg 63:S44-7.nO'Connor GT, Plume SK, Olmstead EM 1992. Multivariate prediction of in-hospital mortality associated with coronary artery bypass graft surgery. Northern New England Cardiovascular Disease Study Group. Circulation 85:2110-8.nPlomondon ME, Cleveland JC Jr, Ludwig ST 2001. Off-pump coronary artery bypass is associated with improved risk-adjusted outcomes. Ann Thorac Surg 72:114-9.nPuskas JD, Kilgo PD, Lattouf OM 2008. Off-pump coronary bypass provides reduced mortality and morbidity and equivalent 10-year survival. Ann Thorac Surg 86:1139-46; discussion 1146.nPuskas JD, Thourani VH, Kilgo P 2009. Off-pump coronary artery bypass disproportionately benefits high-risk patients. Ann Thorac Surg 88:1142-7.nPuskas JD, Williams WH, Duke PG 2003. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg 125:797-808.nShennib H, Endo M, Benhamed O, Morin JF. 2002. Surgical revascularization in patients with poor left ventricular function: on- or off-pump? Ann Thorac Surg 74:S1344-7.nShroyer AL, Grover FL, Hattler B 2009. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med 361:1827-37.nStamou SC, Jablonski KA, Hill PC, Bafi AS, Boyce SW, Corso PJ. 2005. Coronary revascularization without cardiopulmonary bypass versus the conventional approach in high-risk patients. Ann Thorac Surg 79:552-7.nTaylor KM. 1998 Central nervous system effects of cardiopulmonary bypass. Ann Thorac Surg 66:S20-4; discussion S25-8.nThomas GN, Martinez EC, Woitek F 2009. Off-pump coronary bypass grafting is safe and efficient in patients with left main disease and higher EuroScore. Eur J Cardiothorac Surg 36:616-20.nWan IY, Arifi AA, Wan S 2004. Beating heart revascularization with or without cardiopulmonary bypass: evaluation of inflammatory response in a prospective randomized study. J Thorac Cardiovasc Surg 127:1624-31.nWeerasinghe A, Athanasiou T, Al-Ruzzeh S 2005. Functional renal outcome in on-pump and off-pump coronary revascularization: a propensity-based analysis. Ann Thorac Surg 79:1577-83.nYeatman M, Caputo M, Ascione R, Ciulli F, Angelini GD. 2001. Off-pump coronary artery bypass surgery for critical left main stem disease: safety, efficacy and outcome. Eur J Cardiothorac Surg 19:239-44.n
Published
How to Cite
Issue
Section
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).