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OPCABG vs ONCABG

On Pump Vs. Off Pump CABG NEW ORLEANS Conference Debate 2014 Chance Dewitt m.d lacvt Alexandria, La. OPCABG vs ONCABG. Patients that benefit most from OPCABG Calcified aorta Significant comorbidities Recent stroke Severe carotid dz Renal dysfunction Severe chronic lung dz

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OPCABG vs ONCABG

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  1. On Pump Vs. Off Pump CABG NEW ORLEANS Conference Debate 2014Chance Dewitt m.dlacvtAlexandria, La

  2. OPCABG vs ONCABG Patients that benefit most from OPCABG • Calcified aorta • Significant comorbidities • Recent stroke • Severe carotid dz • Renal dysfunction • Severe chronic lung dz • Jehovah’s Witness

  3. OPCABG vs ONCABG Patients that benefit least from OPCABG • Cardiogenic shock • Unable to maintain hemodynamic instability • ST changes or VT • Redo surgery • Poor EF, ischemic mitral reguritation • Poor coronary target • Small, intramyocardial, and/or calcified coronary artery • Young healthy patient

  4. OPCABG vs ONCABG • CABG volume – 416,000/yr • 80yr • 1% - 1990 • 6% - 2005 • OPCABG 19% cases current • Down from 25% cases 2004

  5. On Pump Vs. Off Pump • Off pump CABG has been shown to benefit many patients and when a practiced surgeon uses this technique on selected patients, outcomes can be improved and major resource utilization decreased. • Yet it remains a controversial and hotly debated topic.

  6. OPCAB ASSOCIATED WITH SIGNIFICANT CLINICAL BENEFITS • Decrease vent times • Reduced transfusions and bleeding1,3 • Reduced inotropes1,3 • Reduced arrhythmias1-3 • Reduced sternal wound infection1-3 • Reduced cerebral emboli and cognitive dysfunction2 • Reduced postoperative hospital length of stay1 • Ascione R, Angelini GD. OPCAB surgery: a voyage of discovery back to the future. Eur Heart J. 2003;24:121-124. • Puskas JD, Williams WH, Duke PG, et al. 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 ThoracCardiovasc Surg. 2003;125:797-808. • Angelini GD, Taylor FC, Reeves BC, Ascione R. Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomized controlled trials. Lancet. 2002;359:1194-1199.

  7. STS NATIONAL CARDIAC DATABASE REVIEWNOVEMBER 2007 • 42,477 consecutive, non-emergency, isolated primary CABG cases reviewed • Data collected from 63 centers across North America • OPCAB also reduced the gender disparity in clinical outcomes commonly associated with conventional CABG Source: Puskas JD, Edwards FH, Pappas PA, et al. Off-pump techniques benefit men and women and narrow the disparity in mortality after coronary bypass grafting. Annals of Thoracic Surgery. 2003;84:1447-1456.

  8. SHORT-TERM BENEFITS WITHOUT SACRIFICING LONG-TERM RESULTS • 12,812 consecutive isolated CABG patients treated from 1997 to 2006 Short-term Survival: • OPCAB associated with a significant reduction in operative mortality and in-hospital major adverse cardiac events • When treated with traditional CABG, women experienced twice as much operative mortality and in-hospital major adverse cardiac events when compared to men • Women disproportionately benefited from OPCAB in terms of operative mortality and in-hospital major adverse cardiac events Long-term Survival: • 10-year follow-up showed similar survival between the two surgery types regardless of gender Source: Puskas JD, Kilgo PD, Lattouf OM, et al. Off-pump coronary artery bypass grafting is associated with significantly reduced operative mortality and in-hospital adverse events and is equivalent to on-pump CABG in 10-year survival. Abstract presented at Annual Meeting of The Society of Thoracic Surgeons. January 28, 2008.

  9. POTENTIAL LIMITATIONS OF OPCAB • Patient outcome depends greatly on surgical experience • Significant learning curve associated with OPCABG • Higher likelihood of conversion to on-pump surgery, coupled with evidence that conversion sometimes fails to rescue the adverse situation • Possibility of less complete revascularization • After all it is more difficult operating on a beating bleeding heart Source: Sedrakyan A, Wu AW, Parashar A, Bass EB, Treasure T. Off-pump surgery is associated with reduced occurrence of stroke and other morbidity as compared with traditional coronary artery bypass grafting: a meta-analysis of systematically reviewed trials. Stroke. 2006;37:2759-2769.

  10. TODAY’S SURGICAL PATIENTS ARE FREQUENTLY HIGH RISK High-Risk Patients: • Have extensive coronary disease • Experience abnormal ventricular function • Present with multiple co-morbidities • Are elderly (>65 years) • 1. Ferguson TB Jr, Hammill BG, Peterson ED, DeLong ER, Grover FL. A decade of change—risk profiles and outcomes for isolated coronary artery bypass grafting procedures, 1990-1999: a report from the STS National Database Committee and the Duke Clinical Research Institute. Ann Thorac Surg. 2002;73:480-490.

  11. OPCAB ASSOCIATED WITH BETTER OUTCOMES FOR HIGH-RISK PATIENTS • OPCAB offers hope for better outcomes in high-risk patients whose prognosis may have been poor with conventional bypass surgery, including1 • Women • Patients with renal dysfunction 1. Puskas J, Cheng D, Knight J, et al. Off-pump versus conventional coronary artery bypass grafting: a meta-analysis and consensus statement from the 2004 ISMICS Consensus Conference. Innovations. 2005;1:3-27.

  12. WOMEN SHOWN TO BENEFIT FROM OPCAB • Women have higher morbidity and mortality rates than men after conventional CABG1 • Female gender is an independent risk factor for mortality in conventional CABG2 • In a large study of 7,376 women, OPCAB procedures resulted in a lower mortality rate compared with on-pump procedures3 • Mack MJ, Brown P, Houser F, et al. On-pump versus off-pump coronary artery bypass surgery in a matched sample of women. Circulation. 2004;110(suppl II):II-1-II-6. • Athanasiou T, Al-Ruzzeh S, Del Stanbridge R, Casula RP, Glenville BE, Amrani M. Is the female gender an independent predictor of adverse outcome after off-pump coronary artery bypass grafting? Ann Thorac Surg. 2003;75:1153-1160. 3. Mack M, Brown P, Kugelmass A, et al. Outcomes differences in women undergoing off-pump and on-pump CABG surgery: a matched sample of 7,376 women from the HCA database. Paper presented at: American Heart Association Scientific Sessions; November 9-12, 2003; Orlando, Fla.

  13. OPCAB SHOWN TO BENEFIT PATIENTS WITH RENAL DYSFUNCTION • 78% of patients about to undergo CABG surgery have at least some form of renal dysfunction preoperatively1 OPCAB Benefits: • Reduce postoperative morbidity and risk of acute renal failure2 • Significantly lower serum creatanine and urea at 12 hours post-op2 • Cooper WA, O’Brien SM, Thourani VH, et al. Impact of renal dysfunction on outcomes from coronary artery bypass grafting. Circulation. 2006;113:1063-1070. • Ascione R, Nason G, Al-Ruzzeh S, et al. Coronary revascularization with or without cardiopulmonary bypass in patients with preoperative nondialysis dependent renal insufficiency. Ann Thorac Surg. 2001;72:2020-2025.

  14. AHA Scientific Guidelines Off pump vs. On pump CABG surgery There appear to be trends in most studies, however. These trendsinclude less blood loss and need for transfusion after OPCAB,less myocardial enzyme release after OPCAB up to 24 hours, lessearly neurocognitive dysfunction after OPCAB, and less renalinsufficiency after OPCAB. Of note, patients who require urgentor emergent conversion from off-pump to on-pump revascularizationhave a much greater risk of mortality, postoperative cardiacarrest, and multisystem organ failure than do patients initiallyundergoing on-pump CABG.28,29 In addition, fewer grafts tendto be performed with OPCAB than with standard CABG in many studies,and no study in the literature reports more grafts being placedwith OPCAB. Length of hospital stay, mortality, and long-termneurological function and cardiac outcome appear to be similarin the 2 groups. A recent report from a prospective study suggestedthat graft patency may be significantly lower with OPCAB thanwith standard CABG,10 but this needs to be verified or dismissedby additional prospective randomized studies. The greatest utilityfor OPCAB is probably the severely calcified or diseased aortain which manipulation or clamping of the aorta can be associatedwith dire neurological consequences. To definitively answerwhether either strategy is superior and in which patients, alarge-scale prospective randomized trial will be required inwhich the surgeons and other physicians caring for the patientdo not have prior knowledge of the operation the patient isto undergo. Also, optimally, the surgeon should not know therevascularization strategy until just before entering the operatingroom, and subsequent caregivers in the ICU should remain blindedafter surgery. Finally, the surgeons should be equally skilledwith either type of procedure. Surgeons who perform either OPCABor standard CABG almost exclusively should not be part of sucha study. Criticism has been aimed at Khan et al with regardto the relative inexperience of the surgeons in their studyin performing off-pump surgery.10 On the other side, there isthe question of a randomized study performed by a single surgeonwhose referral pattern may reflect those cases more easily amenableto OPCAB. Such a trial will be difficult to design and execute.The need for such a large prospective trial was suggested ata recent NIH working group composed of cardiac surgeons andother clinicians. The Department of Veterans Affairs currentlyis enrolling patients into a large prospective trial. Ultimately,whether a patient benefits more from standard on-pump CABG orOPCAB may depend more on the familiarity, comfort, and skillof the individual surgeon with either procedure than on an intrinsicbenefit. Both the OPCAB and standard CABG procedures usuallyresult in excellent outcomes, and neither should be judged tobe inferior to the other.

  15. AHA Scientific Guidelines Off pump vs. On pump CABG Surgery Findings favoring OPCAB    Probably less bleeding     Probably less renal dysfunction     Probably less short-term neurocognitive dysfunction, especially if aorta is calcified      Possibly shorter overall length of hospital stay Trends favoring on-pump CABG More technically demanding      Shorter "learning curve"      Possibly better long-term graft patency      Easier to graft posterior (circumflex) bypass targets      Probably more bypass grafts constructed

  16. OPCABG vs. On Pump CABG Off-Pump and On-Pump Coronary Revascularization in Patients With Low Ejection Fraction: A Report From The Society of Thoracic Surgeons National Database 2013 • Method Quieried STS EF<30% - 25,667 • ON CABG – 20,509 OPCABG – 5,158 • Result : OPCABG associated with lower • Adjusted risk of death • Major adverse cardiac events • Prolong intubation • Post op transfusions Presented at the Forty-ninth Annual Meeting of The Society of Thoracic Surgeons, Los Angeles, CA, Jan 26–30, 2013. W. Brent Keeling, MDa, , , Matthew L. Williams, MDb, Mark S. Slaughter, MDb, Yue Zhao, PhDc, John D. Puskas, Mda The Annals of Thoracic Surgery volume 96, Issue 1, July 2013, Pages 83–89

  17. OPCABG vs. ONCABG • ROOBY trial • 2230 Low risk pts randomized OPCABG vs ONCABG • Conclusion: • Lower rate of graft patency in OPCABG • 82.6% vs 87.8% at 1 yr • Criticism of trial • Study surgeons (included housestaff) • Surgeons performed min of 20 OPCABG cases Shroyer AL, Grover FL, Hattler B, et al; Veterans Affairs Randomized On/Off Bypass (ROOBY) Study Group On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med. 2009;361(19):1827-1837.

  18. OPCABG vs. ONCABG • Coronary trial • 4752 high risk pt randomized • Conclusions • At 30 days there was no difference in the primary outcome between Off pump CABG and On pump CABG. • No difference in composite end point of death, stoke, MI, renal failure • Implications • Off-pump was associated with: • Less transfusions and re-operation for bleeding • Less acute kidney injury • Less respiratory infections/failure • Trend toward more early revascularizations (1.4% vs 0.8%) Lemma MG, Coscioni E, Tritto FP, et al. On-pump versus off-pump coronary artery bypass surgery in high-risk patients: operative results of a prospective randomized trial (on-off study). J ThoracCardiovasc Surg. 2012;143(3):625-631.

  19. OPCABG vs. ONCABG • GOPCABE trial • 2539 pts age > 75 randomized • Conclusion • No difference in incidence of • Death • MI • Stroke • Renal failure • Increase revascularization at 30 days but not 1yr • Trends toward benefit of OPCABG • MI • Stroke • Blood transfusions (56% vs 65%) • Problem • Emergency conversions to OPCABG 3.5% with 10% mortality Diegeler A, Borgermann J, Kappert U, et al; GOPCABE Study Grou Off-pump versus on-pump coronary-artery bypass grafting in elderly patients. N Engl J Med. 2013;368(13):1189-1198.

  20. OPCABG vs. ONCABG • What Study Do You Believe • You believe none of them • You believe all of them • Truth probably lies somewhere in between

  21. OPCABG vs. ONCABG • Study problems • Non randomized studies seem • Favor OPCABG • Randomized studies seem • Favor ONCABG • Conclusion • These 2 surgical techniques should be customized toward pt • ONCABG • Small calcified vessels • Hypertrophied heart • Healthy pt? • OPCABG • Women • Anteriorly located vessels • Renal Dysfuction • Low EF? • Calcified Asc Aorta

  22. OPCABG vs. ONCABG Two Different Operation ONCABG Place on artificial life support Loss of pulsatile flow Ischemic risk Embolization risk Quiet / bloodless field OPCABG Continuous pulsatile Minimal embolization Lack of a blood membrane interface Hemodynamic instability Moving / bloody field

  23. OPCABG vs. ONCABG One thing for certain The debate will rage on

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