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J Am Coll Cardiol. 2017 Feb 28;69(8):924-936. doi: 10.1016/j.jacc.2016.11.071.

Coronary Artery Bypass Grafting With and Without Manipulation of the Ascending Aorta: A Network Meta-Analysis.

Author information

1
Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Baird Institute of Applied Heart and Lung Surgical Research, Sydney, New South Wales, Australia.
2
Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Baird Institute of Applied Heart and Lung Surgical Research, Sydney, New South Wales, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
3
Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Baird Institute of Applied Heart and Lung Surgical Research, Sydney, New South Wales, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Sydney Heart and Lung Surgeons, Sydney, New South Wales, Australia.
4
Baird Institute of Applied Heart and Lung Surgical Research, Sydney, New South Wales, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Sydney Heart and Lung Surgeons, Sydney, New South Wales, Australia.
5
Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
6
Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
7
Department of Cardiovascular Surgery, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom.
8
Department of Cardiac Surgery, Mt. Sinai Hospital, New York, New York.
9
Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Baird Institute of Applied Heart and Lung Surgical Research, Sydney, New South Wales, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Sydney Heart and Lung Surgeons, Sydney, New South Wales, Australia. Electronic address: michael.vallely@sydneyheartandlung.com.au.

Abstract

BACKGROUND:

Coronary artery bypass grafting (CABG) remains the standard of treatment for 3-vessel and left main coronary disease, but is associated with an increased risk of post-operative stroke compared to percutaneous coronary intervention. It has been suggested that CABG techniques that eliminate cardiopulmonary bypass and reduce aortic manipulation may reduce the incidence of post-operative stroke.

OBJECTIVES:

A network meta-analysis was performed to compare post-operative outcomes between all CABG techniques, including anaortic off-pump CABG (anOPCABG), off-pump with the clampless Heartstring device (OPCABG-HS), off-pump with a partial clamp (OPCABG-PC), and traditional on-pump CABG with aortic cross-clamping.

METHODS:

A systematic search of 6 electronic databases was performed to identify all publications reporting the outcomes of the included operations. Studies reporting the primary endpoint, 30-day post-operative stroke rate, were included in a Bayesian network meta-analysis.

RESULTS:

There were 13 included studies with 37,720 patients. At baseline, anOPCABG patients had higher previous stroke than did the OPCABG-PC (7.4% vs. 6.5%; p = 0.02) and CABG (7.4% vs. 3.2%; p = 0.001) patients. AnOPCABG was the most effective treatment for decreasing the risk of post-operative stroke (-78% vs. CABG, 95% confidence interval [CI]: 0.14 to 0.33; -66% vs. OPCABG-PC, 95% CI: 0.22 to 0.52; -52% vs. OPCABG-HS, 95% CI: 0.27 to 0.86), mortality (-50% vs. CABG, 95% CI: 0.35 to 0.70; -40% vs. OPCABG-HS, 95% CI: 0.38 to 0.94), renal failure (-53% vs. CABG, 95% CI: 0.31 to 0.68), bleeding complications (-48% vs. OPCABG-HS, 95% CI: 0.31 to 0.87; -36% vs. CABG, 95% CI: 0.42 to 0.95), atrial fibrillation (-34% vs. OPCABG-HS, 95% CI: 0.49 to 0.89; -29% vs. CABG, 95% CI: 0.55 to 0.87; -20% vs. OPCABG-PC, 95% CI: 0.68 to 0.97), and shortening the length of intensive care unit stay (-13.3 h; 95% CI: -19.32 to -7.26; p < 0.0001).

CONCLUSIONS:

Avoidance of aortic manipulation in anOPCABG may decrease the risk of post-operative stroke, especially in patients with higher stroke risk. In addition, the elimination of cardiopulmonary bypass may reduce the risk of short-term mortality, renal failure, atrial fibrillation, bleeding, and length of intensive care unit stay.

KEYWORDS:

aorta; cardiopulmonary bypass; coronary artery bypass grafting; no-touch; off-pump; stroke

PMID:
28231944
DOI:
10.1016/j.jacc.2016.11.071
[Indexed for MEDLINE]
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