Living with Off-Pump Coronary Artery Surgery: Evolution, Development, and Clinical Potential for Coronary Heart Disease Patients
AbstractThe enormous progress in interventional cardiology during the last 10 years has resulted in a major change in the spectrum of patients referred for coronary bypass surgery. These patients are older and sicker and frequently have had previous percutaneous coronary interventions. Consequently, cardiac surgery is responding by adding new surgical techniques: off-pump open-chest coronary bypass surgery (OPCAB), minithoracotomy bypass surgery, videothoracoscopic (robotic) procedures, etc. Several registries published to date have proved OPCAB to be safe and clinically effective. Randomized studies and meta-analysis research in this field provide scientific support and suggest that myocardial, renal, and neurological functions, amongst others, are better preserved by OPCAB than by classic techniques that use a cardiopulmonary bypass pump (CPB). Moreover, avoidance of CPB yields significantly reduced oxidative stress and systemic inflammatory response. This results in higher safety for ischemic heart disease patients undergoing revascularization, thus offsetting the propensity to lower costs. The present review examines the physiological advantages and clinical outcomes of this simple mode of myocardial revascularisation and evaluates the wider implications arising from its evolution.
Al-Ruzzeh S, Athanasiou T, George S, Amrani M. 2004. Methodological approach in adopting off-pump coronary artery bypass surgery in a British cardiothoracic unit: Harefield experience. Perfusion 19:61-6.nAlwan K, Falcoz PE, Alwan J, et al. 2004. Beating versus arrested heart coronary revascularization: evaluation by cardiac troponin I release. Ann Thorac Surg 77:2051-5.nAnderson RE, Li TQ, Hindmarsh T, Settergren G, Vaage J. 1999. Increased extracellular brain water after coronary artery bypass grafting is avoided by off-pump surgery. J Cardiothorac Vasc Anesth 13:698-702.nArom KV, Flavin TF, Emery RW, Kshettry VR, Janey PA, Petersen RJ. 2000. Safety and efficacy of off-pump coronary artery bypass grafting. Ann Thorac Surg 69:704-10.nAscione R, Lloyd CT, Underwood MJ, Gomes WJ, Angelini GD. 1999. On-pump versus off-pump coronary revascularization: evaluation of renal function. Ann Thorac Surg 68:493-8.nAscione R, Lloyd CT, Underwood MJ, Lotto AA, Pitsis AA, Angelini GD. 1999. Economic outcome of off-pump coronary artery bypass surgery: a prospective randomized study. Ann Thorac Surg 68:2237-42.nAscione R, Reeves BC, Rees K, Angelini GD. 2002. Effectiveness of coronary artery bypass grafting with or without cardiopulmonary bypass in overweight patients. Circulation 106:1764-70.nAthanasiou T, Aziz O, Mangoush O, et al. 2004. Do off-pump techniques reduce the incidence of postoperative atrial fibrillation in elderly patients undergoing coronary artery bypass grafting? Ann Thorac Surg 77:1567-74.nAthanasiou T, Aziz O, Mangoush O, et al. 2004. Does off-pump coronary artery bypass reduce the incidence of post-operative atrial fibrillation? A question revisited. Eur J Cardiothorac Surg 26:701-10.nAtkins CW, Boucher CA, Pohot GM. 1992. Preservation of interventricular septal function in patient having coronary artery bypass grafts without cardiopulmonary bypass. Ann Thorac Surg 54:1085-91.nBenetti FJ, Naselli G, Wood M, Geffner L. 1991. Direct myocardial revascularization without extracorporeal circulation. Experience in 700 patients. Chest 100:312-6.nBonaros N, Schachner T, Ohlinger A, Friedrich G, Laufer G, Bonatti J. 2005. Assessment of health-related quality of life after coronary revascularization. Heart Surg Forum 8:380-5.nBuffolo E, Branco JN, Gerola LR, et al. 2006. Off-pump myocardial revascularization: critical analysis of 23 years' experience in 3,866 patients. Ann Thorac Surg 81:85-9.nBuffolo E, de Andrade CS, Branco JN, Teles CA, Aguiar LF, Gomes WJ. 1996. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 61:63-6.nCaputo M, Reeves BC, Rogers CA, Ascione R, Angelini GD. 2004. Monitoring the performance of residents during training in off-pump coronary surgery. J Thorac Cardiovasc Surg 128:907-15.nCasati V, Gerli C, Franco A, et al. 2001. Activation of coagulation and fibrinolysis during coronary surgery: on-pump versus off-pump techniques. Anesthesiology 95:1103-9.nChakravarthy M, Jawali V, Manohar M, et al. 2005. Conscious off pump coronary artery bypass surgery-an audit of our first 151 cases. Ann Thorac Cardiovasc Surg 11:93-7.nChakravarthy M, Jawali V, Patil TA, Jayaprakash K, Shivananda NV. 2003. High thoracic epidural anesthesia as the sole anesthetic for performing multiple grafts in off-pump coronary artery bypass surgery. J Cardiothorac Vasc Anesth 17:160-4.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.nCheng DC, Bainbridge D, Martin JE, Novick RJ; Evidence-Based Peri-operative Clinical Outcomes Research Group. 2005. Does off-pump coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with conventional coronary artery bypass? A meta-analysis of randomized trials. Anesthesiology 102:188-203.nCooley DA. 2000. Con: beating-heart surgery for coronary revascularization: is it the most important development since the introduction of the heart-lung machine? Ann Thorac Surg 70:1779-81.nCumpeeravut P, Visudharom K, Jotisakulratana V, Pitiguagool V, Banyatpiyaphod S, Pamornsing P. 2003. Off-pump coronary artery bypass surgery: evaluation of extubation time and predictors of failed early extubation. J Med Assoc Thai 86:28-35.nDemikhov VP. 1962. Experimental transplantation of vital organs (authorized translation from Russian by Basil Haigh). In: Consultant's Bureau Enterprises, New York, NY; 220-227.nDiegeler A, Falk V, Walther T, Mohr FW. 1997. Minimally invasive coronary-artery bypass surgery without extracorporeal circulation. N Engl J Med 336:1454.nDi Giammarco G, Di Mauro M, Contini M, et al. 2004. Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease patients. Ital Heart J 5:378-83.nEdmunds LH. 1998. Inflammatory response to CPB. Ann Thorac Surg 66:12-16.nEryilmaz S, Inan MB, Eren NT, Yazicioglu L, Corapcioglu T, Akalin H. 2003. Coronary endarterectomy with off-pump coronary artery bypass surgery. Ann Thorac Surg 75:865-9.nFavaloro RG, Effler DB, Groves LK, Sheldon WC, Sones FM Jr. 1970. Direct myocardial revascularization by saphenous vein graft. Present operative technique and indications. Ann Thorac Surg 10:97-111.nFukushima S, Kobayashi J, Tagusari O, et al. 2005. Early results of off-pump coronary artery bypass grafting for patients on chronic renal dialysis. Jpn J Thorac Cardiovasc Surg 53:186-92.nGlance LG, Dick AW, Osler TM, Mukamel DB. 2005. The relation between surgeon volume and outcome following off-pump vs on-pump coronary artery bypass graft surgery. Chest 128:829-37.nGray DT, Veenstra DL. 2003. Comparative economic analyses of minimally invasive direct coronary artery bypass surgery. J Thorac Cardiovasc Surg 125:618-24.nHart JC, Spooner TH, Pym J, et al. 2000. A review of 1528 consecutive Octopus off-pump coronary bypass patients. Ann Thorac Surg 70:1017-20.nHernandez F, Cohn WE, Baribeau YR, et al; Northern New England Cardiovascular Disease Study Group. 2001. In-hospital outcomes of off-pump versus on-pump coronary artery bypass procedures: a multicentre experience. Ann Thorac Surg 72:1528-34.nImmer FF, Berdat PA, Immer-Bansi AS, et al. 2003. Benefit to quality of life after off-pump versus on-pump coronary bypass surgery. Ann Thorac Surg 76:27-31.nKaragoz HY, Kurtoglu M, Bakkaloglu B, Sonmez B, Cetintas T, Bayazit K. 2003. Coronary artery bypass grafting in the awake patient: three years' experience in 137 patients. J Thorac Cardiovasc Surg 125:1401-4.nKaramanoukian HL, Panos AL, Bergsland J, Salerno TA. 2000. Perspectives of a cardiac surgery resident in-training on off-pump coronary bypass operation. Ann Thorac Surg 69:42-5.nKarthik S, Musleh G, Grayson AD, et al. 2004. Coronary surgery in patients with peripheral vascular disease: effect of avoiding cardiopulmonary bypass. Ann Thorac Surg 77:1245-9.nKhan NE, De Souza A, Mister R, et al. 2004. A randomized comparison of off-pump and on-pump multivessel coronary-artery bypass surgery. N Engl J Med 350:21-8.nKirklin JK, Westaby S, Blackstone EH, Kirklin JW, Chenoweth DE, Pacifico AD. 1983. Complement and the damaging effects of cardiopulmonary bypass. J Thorac Cardiovasc Surg 86: 845-57.nKunt AS, Darcin OT, Demirbag R, Andac MH. 2005. Coronary endarterectomy with beating heart in patients with diffuse atheromatous coronary artery disease and poor ventricular function: early and midterm results. Heart Surg Forum 8:124-8.nMoller CH, Steinbruchel DA. 2003. Platelet function after coronary artery bypass grafting: is the procoagulant activity after off-pump compared with on-pump surgery? Scand Cardiovasc J 37:149-53.nMontes FR, Maldonado JD, Paez S, Ariza F. 2004. Off-pump versus on-pump coronary artery bypass surgery and postoperative pulmonary dysfunction. J Cardiothorac Vasc Anesth 18:698-703.nMotallebzadeh R, Kanagasabay R, Bland M, Kaski JC, Jahangiri M. 2004. S100 protein and its relation to cerebral microemboli in on-pump and off-pump coronary artery bypass surgery. Eur J Cardiothorac Surg 25:409-14.nNaseri E, Sevinc M, Erk MK. 2003. Comparison of off-pump and conventional coronary endarterectomy. Heart Surg Forum 6:216-9.nNathoe HM, van Dijk D, Jansen EW, et al; Octopus Study Group. 2003. A comparison of on-pump and off-pump coronary bypass surgery in lowrisk patients. N Engl J Med 348:394-402.nOsaka S, Ohsawa H, Miyazawa M, Honda J. 2001. Off-pump coronary artery bypass grafting in patients on chronic hemodialysis. J Card Surg 16:302-9.nPatel NC, Grayson AD, Jackson M, et al; North West Quality Improvement Programme in Cardiac Interventions. 2002. The effect of off-pump coronary artery bypass surgery on in-hospital mortality and morbidity. Eur J Cardiothoracic Surg 22:255-60.nLockowandt U, Franco-Cereceda A. 2001. Off-pump coronary bypass surgery causes less immediate postoperative coronary endothelial dysfunction compared to on-pump coronary bypass surgery. Eur J Cardiothorac Surg 20:1147-51.nMack MJ. 2000. Pro: beating-heart surgery for coronary revascularization: is it the most important development since the introduction of the heart-lung machine? Ann Thorac Surg 70:1774-8.nMatata BM, Sosnowski AW, Galinanes M. 2000. Off-pump bypass graft operation significantly reduces oxidative stress and inflammation. Ann Thorac Surg 69:785-91.nPetro KR, Dullum MK, Garcia JM, et al. 2000. Minimally invasive coronary revascularization in women: a safe approach for a high-risk group. Heart Surg Forum 3:41-6.nPfister AJ, Zaki MS, Garcia JM, et al. 1992. Coronary artery bypass without cardiopulmonary bypass. Ann Thorac Surg 54:1085-91.nPuskas JD, Williams WH, Duke PG, et al. 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.nPuskas JD, Williams WH, Mahoney EM, et al. 2001. Clinical outcomes, angiographic patency, and resource utilization in 200 consecutive off-pump coronary bypass patients. Ann Thorac Surg 71:1477-84.nPuskas JD, Williams WH, Mahoney EM, et al. 2004. Off-pump vs conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial. JAMA 291:1841-9.nRastan AJ, Bittner HB, Gummert JF, et al. 2005. On-pump beating heart versus off-pump coronary artery bypass surgery-evidence of pump-induced myocardial injury. Eur J Cardiothorac Surg 27:1057-64.nSaba D, Ener S, Bicer M, Kan Aytac II, Senkaya I, Ozkan H. 2004. Off-pump bypass grafting in patients with significant left main coronary artery stenosis. Heart Vessels 19:8-12.nSchulze C, Conrad N, Schutz A, et al. 2000. Reduced expression of systemic proinflammatory cytokines after off-pump versus conventional coronary artery bypass grafting. Thorac Cardiovasc Surg 48:364-9.nSelvanayagam JB, Petersen SE, Francis JM, et al. 2004. Effects of off-pump versus on-pump coronary surgery on reversible and irreversible myocardial injury: a randomized trial using cardiovascular magnetic resonance imaging and biochemical markers. Circulation 109:345-50.nSpencer FC, Galloway AC, SB Colvin. 1995. Surgical management of coronary artery disease. In: Sabiston DC Jr and Spencer FC, eds. Surgery of the Chest. 6th ed. Philadelphia, Penn: Saunders; 1884-5.nSrinivasan AK, Grayson AD, Fabri BM. 2004. On-pump versus off-pump coronary artery bypass grafting in diabetic patients: a propensity score analysis. Ann Thorac Surg 78:1604-9.nStallwood MI, Grayson AD, Mills K, Scawn ND. 2004. Acute renal failure in coronary artery bypass surgery: independent effect of cardiopulmonary bypass. Ann Thorac Surg 77:968-72.nStamou SC, Dangas G, Dullum MK, et al. 2000. Beating heart surgery in octogenarians: perioperative outcome and comparison with younger age groups. Ann Thorac Surg 69:1140-5.nStaton GW, Williams WH, Mahoney EM, et al. 2005. Pulmonary outcomes of off-pump vs on-pump coronary artery bypass surgery in a randomized trial. Chest 127:892-901.nStroobant N, Van Nooten G, Van Belleghem Y, Vingerhoets G. 2005. Relation between neurocognitive impairment, embolic load, and cerebrovascular reactivity following on-and off-pump coronary artery bypass grafting. Chest 127:1967-76.nTrapp WG, Bisarya R. 1975. Placement of coronary artery bypass graft without pump oxygenator. Ann Thorac Surg 19:1-9.nvan Dijk D, Nierich AP, Jansen EW, et al; Octopus Study Group. 2001. Early outcome after off-pump versus on-pump coronary bypass surgery: results from a randomized study. Circulation 104:1761-6.nVarghese D, Yacoub MH, Trimlett R, Amrani M. 2001. Outcome of non-elective coronary artery bypass grafting without cardio-pulmonary bypass. Eur J Cardiothorac Surg 19:245-8.nVlassov GP, Deyneka CS, Travine NO, Timerbaev VH, Ermolov AS. 2001. Acute myocardial infarction: OPCAB is an alternative approach for treatment. Heart Surg Forum 4:147-50.nVirani SS, Lombardi P, Tehrani H, et al. 2005. Off-pump coronary artery grafting in patients with left main coronary artery disease. J Card Surg 20:537-41.nWan S, Izzat MB, Lee TW, et al. 1999. Avoiding cardiopulmonary bypass in multivessel CABG reduces cytokine response and myocardial injury. Ann Thorac Surg 68:52-6.nWandschneider W, Thalmann M, Trampitsch E, Ziervogel G, Kobinia G. 2000. Off-pump coronary bypass operations significantly reduce S100 release: an indicator for less cerebral damage? Ann Thorac Surg 70:1577-9.nWestaby S. 1997. Landmarks in Cardiac Surgery. In: Isis Medical Media Ltd, Oxford.nWidimsky P, Straka Z, Stros P, et al. 2004. One-year coronary bypass graft patency: a randomized comparison between off-pump and on-pump surgery angiographic results of the PRAGUE-4 trial. Circulation 110:3418-23.nWildhirt SM, Schulze C, Conrad N, et al. 2000. Reduced myocardial cellular damage and lipid peroxidation in off-pump versus conventional coronary artery bypass grafting. Eur J Med Res 5:222-8.nYacoub M. 2001. Off-pump coronary bypass surgery: in search of an identity. Circulation 104:1743-5.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.nWestaby S, Benetti FJ. 1996. Less invasive coronary surgery: consensus from the Oxford meeting. Ann Thorac Surg 62:924-31.n
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