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Ann Thorac Surg 2003;75:306-313
© 2003 The Society of Thoracic Surgeons

Review

Off-pump coronary artery bypass grafting: not a flash in the pan

Raimondo Ascione, MDa, Massimo Caputo, MDa, Gianni D. Angelini, FRCSa*

a Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom

* Address reprint requests to Prof Angelini, Bristol Heart Institute, Bristol Royal Infirmary, Bristol BS2 8HW, UK.
e-mail: g.d.angelini{at}bristol.ac.uk


   Abstract
Top
 Abstract
Introduction
 Historical aspects
 Results of large clinical...
 Subsystem organ function
 Off-pump operations in high-risk...
 Midterm clinical outcome
 Conclusions
 References
 
During the past decade, technical improvements have made off-pump coronary artery bypass operations a routine procedure. During this time, off-pump coronary artery bypass has been audited against conventional techniques by many observational, case-matched, and prospective randomized studies. There is evidence in the literature suggesting that off-pump coronary artery bypass operations reduce postoperative morbidity, organ dysfunction, and costs, without compromising midterm outcome compared with conventional coronary operations. The available evidence also supports the view that high-risk patients might benefit the most from revascularization on the beating heart. High quality follow-up data are still needed to assess the impact of off-pump coronary artery bypass operations on long-term clinical outcome.


   Introduction
Top
 Abstract
 Introduction
Historical aspects
 Results of large clinical...
 Subsystem organ function
 Off-pump operations in high-risk...
 Midterm clinical outcome
 Conclusions
 References
 
Increased life expectancy in western countries and a higher incidence of coronary artery disease in the developing world [1] are likely to increase the demand for coronary revascularization; hence any improvements in anesthetic, perfusion, or surgical techniques will have a major effect on the quantity and quality of care available to these patients. This situation has generated a renewed interest in off-pump coronary artery bypass (OPCAB) operations despite the demonstrated safety and efficacy of the conventional technique [2, 3]. Because revascularization is conducted on the beating heart, OPCAB is a potentially more physiologic method to maintain the functional integrity of major organ systems with the possibility of reducing mortality and morbidity rates. In the past few years a large body of evidence has been presented in the literature on the safety and efficacy of OPCAB operations. This review evaluates the available evidence on OPCAB operations on early clinical outcome, subsystem organ function, and midterm follow-up.


   Historical aspects
Top
 Abstract
 Introduction
 Historical aspects
Results of large clinical...
 Subsystem organ function
 Off-pump operations in high-risk...
 Midterm clinical outcome
 Conclusions
 References
 
In the 1950s Murray and Longmire [4] were the first to report the use of the beating heart technique for coronary endarterectomy or segmental excision with saphenous vein or internal mammary artery grafts. The concept of the direct anastomosis of the internal mammary artery to coronary artery was diffused separately by Demikhov and Murray in animal models in the early 50’s [3,5]. The first saphenous vein graft to bypass the right coronary artery on the beating heart was performed by Sabiston in 1962, and to the left anterior descending coronary artery by Garrett in 1964 [6]. The first left internal mammary artery to coronary artery bypass graft on the beating heart in human was performed by Kolesov in 1964 [7]. After the advent of the heart-lung machine, OPCAB operations were virtually abandoned, with a few exceptions [8, 9].

The first two important reports on the new era of OPCAB operations, during the 1980s, came from Benetti and associates [10] and Buffolo and colleagues [11], with most of the grafts placed on the right coronary artery or the left anterior descending coronary artery. In the early 1990s OPCAB operations regained popularity, and two contrasting schools of thought developed. The one in favor of OPCAB was based on the potential of reducing morbidity in the ever-increasing surgical population and allowing underdeveloped countries to have access to a program of coronary operations, at reduced cost [12]. Others expressed concerns about the difficulty of performing coronary operations on the beating heart with the potential for intraoperative myocardial ischemia, suboptimal anastomoses, and a steep learning curve [13].

Factors such as patient selection, type of surgical technique used, and degree of expertise of the surgeon may all be important factors to consider when attempting to compare mortality and morbidity associated with OPCAB versus conventional operations. Conversely, surgical techniques for exposure and stabilization have evolved continuously, making the treatment of multivessel coronary disease a routine procedure, although patient selection still largely depends on the surgeon’s expertise, as suggested by the variation in the proportion of OPCAB procedures (0% to 90%) between centers [14].


   Results of large clinical series of off-pump coronary artery bypass operations
Top
 Abstract
 Introduction
 Historical aspects
 Results of large clinical...
Subsystem organ function
 Off-pump operations in high-risk...
 Midterm clinical outcome
 Conclusions
 References
 
With the revival of OPCAB operations in the middle 1990s, several other retrospective series appeared in the literature. Cartier and colleagues [15] reviewed their 300 OPCAB procedures compared with 1870 conventional CABG. The number and distribution of grafts was similar between groups, with 93% complete revascularization in the beating heart operations. Perioperative mortality and myocardial infarction (MI) rates were comparable for the two groups, but in the OPCAB group a reduction of transfusion, use of intraaortic balloon pump, and release of creatine kinase MB isoenzyme was observed. Tasdemir and colleagues [16] reviewed 2052 OPCAB cases and reported an operative mortality rate of 1.9% and a perioperative MI rate of 2.9%. The authors stressed the importance of achieving complete coronary revascularization because ungrafted circumflex coronary artery disease was significantly associated with higher a hospital mortality rate, perioperative MI, and low cardiac output.

Major postoperative complications, in particular death, are rare events, and large cohorts would therefore be required to identify statistical differences between groups. Recently, Cleveland and coworkers [17], in a multicenter retrospective analysis, reported the outcome of 118,140 coronary artery bypass grafting (CABG)-only procedures of the Society for Thoracic Surgery (STS) National Adult Cardiac Surgery Database. Of these, 11,717 (9.9%) were off-pump procedures. When compared with conventional on-pump CABG, OPCAB operations were associated with a significant decrease in the risk-adjusted operative mortality rate (from 2.9% to 2.3%) and in the risk-adjusted major complication rate (from 14.1% to 10.6%). Similar results were reported by Plomondon and associates [18] in a large prospective cohort study from the Veterans’ Administration Continuous Improvement in Cardiac Surgery Program. Calafiore and associates [19] in 1,843 consecutive patients (919 off-pump, 49.9%) also reported a significantly lower rates of in-hospital mortality, perioperative MI, cardiovascular accidents, and early major complications in the off-pump group compared with the on-pump group. In a similar retrospective comparison by Hernandez and coworkers [20], of 6,126 conventional CABG versus 1,741 OPCAB procedures, in-hospital mortality rates and major complications, such as mediastinitis, stroke, and reopening for bleeding, were similar between groups, but OPCAB operations resulted in a statistically significant reduction in need for intraaortic balloon pump and incidence of postoperative atrial fibrillation. Recently, Magee and colleagues [21] in 8,449 CABG procedures (1,983 OPCAB) found cardiopulmonary bypass (CPB) to be an independent predictor of mortality by multivariate logistic regression analysis.

Recently the results of two prospective randomized studies were published. The Beating Heart Against Cardioplegic Arrest Studies 1 and 2 were randomized trials carried out at our institution on a total population of 401 (200 off pump) patients who had elective operations [22]. Completeness of revascularization was similar in both groups. In-hospital mortality rates were 1% and 0% in the on- and off-pump groups, respectively, and did not differ between groups. Postoperative morbidity (chest infection, inotropic requirement, incidence of arrhythmias, total chest tube drainage, and consequent transfusion requirement, intubation time, intensive care unit stay, and hospital length of stay) were significantly lower in the off-pump group compared with the conventional on-pump group.

Van Dijk and associates [23] reported the outcome of a multicenter randomized trial in a cohort of 281 patients (142 off-pump). There was no in-hospital death in either group, and there were no differences in postoperative complications, although the off-pump patients had a shorter ventilation time, were discharged 1 day earlier, and had a 41% reduction of release of creatine kinase-MB compared with the on-pump patients.


   Subsystem organ function
Top
 Abstract
 Introduction
 Historical aspects
 Results of large clinical...
 Subsystem organ function
Off-pump operations in high-risk...
 Midterm clinical outcome
 Conclusions
 References
 
The development of beating heart coronary operations provides for the first time a true control group to evaluate critically the large body of evidence suggesting detrimental effects of CPB and cardioplegic arrest on organ function.

Inflammatory response
Contact of blood components with the artificial surfaces of the bypass circuit, aortic cross-clamping, and reperfusion injury are considered the main causes of inflammatory response after cardiac operations [24–28]. Several humoral and cellular responses involving complement, coagulation, fibrinolytic and kallikrein cascades, neutrophils, platelets, and endothelial cells contribute to this postperfusion syndrome. This syndrome, in the most extreme form, is characterized by leukocytosis, increased capillary permeability, accumulation of interstitial fluid, organ dysfunction, and hemodynamic instability [25–29].

Biochemical markers have been used predominantly to identify the mechanisms mediating the inflammatory response and to compare groups of patients who had CABG with or without CPB. A recent study by Wan and associates [30] of 44 consecutive patients who had on- or off-pump operations found that the release of interleukin (IL)-8 and IL-10 was significantly lower in the off-pump group. This finding was also reported by Brasil and colleagues [31]. However, they did not find any significant differences in the release of tumor necrosis factor-{alpha} (TNF-{alpha}). In a similar study of 30 patients who had either conventional CABG, OPCAB, or limited left anterior thoracotomy, Diegeler and associates [32] found a significantly increased release of activated complement factors C5a, C3a, IL-8, IL-10, and TNF-{alpha} receptors p55 and p75 at different postoperative times in the CPB group. Matata and colleagues [33] showed a significant increase of lipid hydroperoxides, protein carbonyls, and nitrotyrosine (markers of oxidative stress) in the on-pump group but not in the off-pump group. C3a and elastase levels increased rapidly upon institution of CPB, and this was followed by increases in IL-8, TNF-{alpha}, and sE-selectin, whereas the increase in these markers was minimal in the off-pump group. In a randomized study we showed higher values in the on-pump group compared with the off-pump group for most of the markers investigated, which included IL-8 neutrophil elastase, C3a, and C5a [34]. White blood cell, neutrophil, and monocyte counts were also significantly higher in the on-pump group. This is in accordance with the findings of Vertrees and colleagues [35] who demonstrated that activation of the complement cascade and the increase of inflammatory immune regulators such as IL-6, IL-8, and TNF-{alpha} caused a release of neutrophil leukocytes from the bone marrow as part of the acute-phase reaction.

Leukocyte activation causes release of oxygen-derived free radicals, proteases, leukotrienes, and other arachidonic acid metabolites, as well as neutrophil clumping with obstruction to capillary blood flow and release of elastase into the pulmonary circulation [1]. We used alveolar-arterial oxygen tension to assess pulmonary function after conventional CABG and off-pump coronary operations [36]. We found that alveolar-arterial oxygen tension gradients increased during the perioperative period, but this deterioration occurred equally in both groups, suggesting that CPB was not associated with significant lung dysfunction other than that caused by the operative and anesthetic techniques themselves. Similar results were reported by Taggart [37] in a retrospective study of 175 patients (25 off-pump) who also had assessment of respiratory function with alveolar-arterial oxygen tension gradients. In both groups maximum respiratory dysfunction occurred at 48 hours with partial recovery by 5 days postoperatively.

The contact activation with the extracorporeal circuit, shear forces, activation of the complement system, fibrinolysis, and extrinsic factors such as medications all contribute to hemostasis dysfunction, which can result in increased postoperative bleeding and the need for blood transfusion [38–40]. Several large retrospective studies and randomized trials have recently been published. Cleveland and colleagues [17], in a multicenter retrospective analysis (CABG-only procedures of the STS National Adult Cardiac Surgery Database) found that significantly fewer reexplorations for bleeding in the off-pump group were needed compared with the on-pump group. Hernandez and associates [20] in a similar study design comparing 6,126 CABG with 1,741 OPCAB procedures, and Calafiore and coworkers [19] in a single-center retrospective analysis reported a lower blood loss and transfusion requirement when the beating heart was operated on. The multicenter randomized study by van Dijk and associates [23] showed a significantly lower incidence of intraoperative blood transfusion in the off-pump group (3% versus 13%) and a significant reduction in postoperative blood loss in the on-pump group. In our randomized study, total blood loss and transfusion requirements were significantly higher in the on-pump group compared with the off-pump group [41]. The transfusion requirements of the two groups were significantly different when measured by the criteria "required" and "did not require." In the off-pump group less than 5% of patients required fresh frozen plasma and platelet units, whereas 30% and 25% required fresh frozen plasma and platelets, respectively, in the on-pump group.

Myocardial function
Conventional CABG with cardioplegic arrest can result in myocardial dysfunction [42–44] and in some cases myocardial stunning [45]. The need for temporary coronary occlusion during OPCAB operations can result in regional ischemia and myocardial injury. Because the incidence of MI during CABG is rare, cardiac troponin I has been used as a highly specific marker for the detection of myocardial injury [46–49].

In a randomized study of patients who had on- or off-pump coronary operations, we found levels of troponin I release consistently higher in the on-pump group early after the operations, and it was still elevated 24 hours postoperatively [50]. Similarly, Wan and coworkers [30] found a significantly higher release of troponin I which correlated with the release of IL-8, and Van Dijk and associates [23] found a higher release of creatine kinase-MB in patients who had conventional CABG compared with OPCAB operations. There is, indeed, evidence that the myocardium is a major source of IL-8 after ischemic arrest or after acute MI [51, 52].

It could be argued that, although the release of markers such as troponin I or creatine kinase-MB was higher in the on-pump than the off-pump group, this did not reach the defined level of MI [47] in most cases. Recent evidence, however, suggests that small to moderate release of troponin I is a predictor of early and late morbidity and mortality after percutaneous transluminal coronary angioplasty [53, 54].

Renal function
Nonpulsatile flow, renal hypoperfusion, hypothermia, and duration of CPB are known to have adverse effects on renal function [55–57]. In a consecutive series of 40 patients who had coronary operations with or without CPB, oxidative stress and renal function were investigated by Gerritsen and associates [58]. Renal function, assessed as mean urinary creatinine excretion, decreased significantly during operations in the on-pump group, whereas no changes occurred in the off-pump group. Oxidative stress, assessed as mean urinary concentrations of hypoxanthine, xanthine, and malondialdehyde expressed as creatinine ratios, was significantly more elevated in operations done with CPB and cardioplegic arrest than those done on the beating heart. That finding contrasted with the results reported by Gamoso and colleagues [59] who, in a retrospective analysis of 690 patients (55 off-pump), found no benefit with OPCAB operations with regard to renal function.

In a randomized study [60] in the on-pump group, we found significantly lower creatinine clearance values at 24 and 48 hours postoperatively compared with preoperative levels. The potentially deleterious effect of CPB on renal function was confirmed by marked increases in urinary albumin:creatinine ratio and urinary N-acetyl-ß-glucosaminidase activity levels. These changes were minimal and not significant in the off-pump group. Similar results were obtained by Loef and coworkers [61] in a prospective study in which they found a greater increase in several markers of glomerular and tubular damage after on-pump versus off-pump operations.

The benefit of OPCAB operations on renal function seems to be even more evident in the presence of factors predisposing to renal failure, such as elevated preoperative level of serum creatinine and diabetes mellitus, as recently shown by our group [62] and by Magee and associates [63].

Neurologic function
Major neurologic complications are reported to occur in 3.1% of patients, are responsible for 21% of the postcoronary artery bypass mortality rate, and prolong intensive care unit and in-hospital stay. They can increase, on average 5 to 10 times, the in-hospital charge for rehabilitation and outpatient support [2]. Minor neurologic and neuropsychologic complications are reported to occur in up to 60% of patients in the first week after a cardiac operation and persist in one third of patients 6 months later [2]. Hypoperfusion during CPB [64], microemboli of gaseous or particulate nature [65], or inflammatory changes that lead to increase in permeability across the blood-brain barrier with resultant cerebral edema [66] have been identified as common causes of the deleterious effects on the central nervous system.

In a randomized study [67] we assessed neurologic injury by a serial sampling of S100 protein release and cognitive function by a battery of core tests that covered memory, language, psychomotor speed, attention, and concentration [68]. Immediately postoperatively S100 protein release was significantly higher in the on-pump group than in the off-pump group. However, this difference did not persist much after the initial 30 minutes and, in accordance with other studies [65, 69, 70], returned to normal 24 hours postoperatively. Westaby and colleagues [69] speculated that this finding might result from diffuse microembolic cerebral injury together with increased permeability of the blood-brain barrier but not from irreversible cerebral damage through neuronal ischemia.

Our study showed no significant difference in neuropsychologic outcome between the on- and off-pump groups in terms of postoperative deterioration of cognitive function at 12 weeks. Similarly, in a study in which 25 patients who had OPCAB operations were matched with 50 patients who had conventional CABG, Taggart and associates [71] found no differences between groups in the pattern of early decline and late recovery of cognitive function. This contrasts with the findings of Diegeler and coworkers [72] who, in a randomized study of on- and off-pump operations (120 patients in each group), found significant postoperative impairment of cognitive function in 90% of the patients in the on-pump group versus no impairment in the off-pump group. They also found a higher release of S100 in the on-pump group and a higher median value of high intensive transient signals as assessed by transcranial Doppler ultrasound. In a recent prospective randomized study of 281 patients, van Dijk and associates [73] showed improved cognitive outcome associated with OPCAB operations compared with conventional CABG at 3 months after operations, but this effect was negligible at 12 months.


   Off-pump operations in high-risk patients
Top
 Abstract
 Introduction
 Historical aspects
 Results of large clinical...
 Subsystem organ function
 Off-pump operations in high-risk...
Midterm clinical outcome
 Conclusions
 References
 
During the past few years, there has been an increased demand for longer life expectancy, together with a profile of greater comorbidity in patients presenting for coronary artery bypass operations [75]. These high-risk patients might, in fact, benefit the most from OPCAB operations. Recently, Mohr and colleagues [75] demonstrated good early and long-term results in 57 patients who had OPCAB within 1 week of an acute MI, with a 1.7% operative mortality rate and 5-year actuarial survival of 82%. Tugtekin and associates [76] reported in-hospital and 6-month outcome of 31 patients with severe left ventricular dysfunction who had OPCAB operations. The hospital survival was 93.5%. Intraaortic balloon pump was used in 1 patient, and no additional events of perioperative MI or stroke were observed. The 6-month survival was 90%. In a similar study of 48 patients with severe left ventricular dysfunction, Eryilmaz and colleagues [77] reported an in-hospital mortality rate of 6.25%. Of 45 survivors, 41 had improved New York Heart Association functional status, left ventricular fractional shortening, and improved ejection fraction at 1 year.

We recently investigated the incidence of early mortality and morbidity in 1570 consecutive high-risk CABG-only patients (332 [21.1%] who had OPCAB operations) selected by age more than 75 years, ejection fraction less than 30%, recent MI (< 1 month), current congestive cardiac failure, previous cardiovascular accident, serum creatinine more than 130 µmol, respiratory impairment, peripheral vascular disease, redo operations, and intraoperative endarterectomy. After adjustment for known prognostic factors, most of the variables investigated showed benefits associated with OPCAB operations, which were highly statistically significant for blood loss, transfusion requirement, and intensive care unit and hospital stays [78]. In a subsequent study [62], 253 patients with preoperative serum creatinine higher than 150 mol/L were identified, and they included 51 patients who had OPCAB operations. A multiple logistic regression analysis showed CPB inclusive of cardioplegic arrest to be an independent predictor of acute renal failure. Magee and associates [63], in a retrospective study on the influence of diabetes mellitus on mortality and morbidity, found that diabetic patients who had OPCAB operations had a significantly lower incidence of postoperative acute renal failure compared with patients who had conventional operations.

Obesity has been considered a major risk for coronary artery disease and is often associated with other risk factors, including diabetes, hypertension, and impaired respiratory function [79, 80]. Recently those associations have been questioned by the findings of other patient-cohort studies [82, 83]. A recent retrospective analysis of data collected prospectively at our institution on overweight and obese patients showed significant benefits from off-pump operations, after adjustment for known prognostic factors; intraoperative arrhythmias and use of inotropic agents; and postoperative blood loss, transfusion requirement, chest infections, low cardiac output, use of intraaortic balloon pump, arrhythmias, pulmonary complications, and neurologic complications, including stroke, intubation time, and intensive care unit and hospital length of stay (Ascione R, Reeves BC, Rees K, Angelini GD, unpublished data).

The elderly population is increasing the risk profile of cardiac patients, with an incidence of nonfatal complications ranging from 30% to 73% and in-hospital mortality rate of 5% to 24% [84]. Two recent retrospective reports [85, 86] provided evidence supporting the use of OPCAB operations in elderly patients who had myocardial revascularization, with a decreasing rate of major postoperative complications, including low-output syndrome, atrial fibrillation, blood usage, and prolonged intensive care unit and hospital stays.


   Midterm clinical outcome
Top
 Abstract
 Introduction
 Historical aspects
 Results of large clinical...
 Subsystem organ function
 Off-pump operations in high-risk...
 Midterm clinical outcome
Conclusions
 References
 
There is concern among cardiac surgeons about the quality of the distal coronary anastomoses performed on the beating heart [13]. Several studies have reported midterm clinical outcomes of OPCAB operations. Puskas and associates [87] in a retrospective matched study reported the early angiographic results of 26 of 51 patients operated on without CPB. Forty-one of 43 grafts were patent, one was totally occluded, and one was narrowed by more than 50%. All internal mammary artery grafts were patent. Calafiore and colleagues [19] in a retrospective study reported the angiographic results of 67 of 122 patients who had OPCAB revascularization at a mean follow-up of 33 days. The patency rate was 98.9% (98.2% for the marginal branches). Cartier and coworkers [15] reported similar early angiographic results.

The evolution of the surgical strategy, positioning, and mechanical stabilization of the target coronary vessel have had a major role in improving the quality of the anastomoses. Poirier and associates [88] designed a study to assess, by means of early quantitative angiographic evaluation (4 ± 2 days after the operation), coronary anastomoses performed with or without a myocardial wall stabilizer during CABG on the beating heart. The study included 34 patients. The left internal thoracic artery was anastomosed to the left anterior descending coronary artery in all patients. Eight of the 20 patients in whom the anastomoses were performed without stabilization (40%) had stenoses of more than 50%, whereas there was only one stenosis of more than 50% among the 14 patients in whom the operation was performed with a stabilizer. This finding may help to explain the disappointing results reported by Gundry and coworkers [89] in an early series of OPCAB operations; the operations were performed with no stabilization. At 7-year follow-up, 86 of 107 (80%) patients who had OPCAB were alive versus 88 of 112 (79%) in the conventional CABG group. However, 32 of 107 patients operated on using OPCAB (30%) needed catheterization for their symptoms versus 18 of 112 (16%) patients in the on-pump group (p = 0.01). This resulted in 21 of 107 (20%) patients in the off-pump group needing angioplasty (15 of 21, 71%) or a second coronary bypass procedure (6 of 21, 29%) versus only 8 of 112 (7%) in the on-pump group.

Early and midterm clinical outcomes were reported recently as part of two prospective randomized trials. Van Dijk and associates [23] reported 1-month survival, cardiac-related events, and quality of life of their population of 281 patients. No late deaths occurred. In both groups, 4% of the patients had recurrent angina, and the proportions of patients surviving free of cardiac-related events were 94.2% and 93% in the on- and off-pump groups, respectively.

The midterm clinical outcomes of the Beating Heart Against Cardioplegic Arrest Studies 1 and 2 (mean follow-up was 29.3 ± 7.4 and 15.7 ± 5.5 months for studies 1 and 2, respectively) also showed no differences in terms of late mortality rate, cardiac-related events, and need for further coronary revascularization procedures in patients who had off-pump or conventional coronary revascularization [22].


   Conclusions
Top
 Abstract
 Introduction
 Historical aspects
 Results of large clinical...
 Subsystem organ function
 Off-pump operations in high-risk...
 Midterm clinical outcome
 Conclusions
References
 
There seems to be evidence that OPCAB operations reduce postoperative morbidity and organ dysfunction compared with conventional CABG with CPB and cardioplegic arrest.

The lower release of troponin I in the OPCAB group [23, 30, 50] suggested limited myocardial injury, and this could explain the reduced incidence of postoperative arrhythmias and need for inotropic support found by several groups [19, 20, 90]. These observations alone might represent the most important advantage of performing coronary operations on the beating heart, because of the increasing number of patients presenting with recent history of MI and poor left ventricular function.

There is consensus that OPCAB operations result in significant attenuation of the inflammatory response normally seen when CPB is used. However, OPCAB operations do not seem to prevent the postoperative deterioration in pulmonary function previously ascribed to the use of CPB, although a higher incidence of postoperative chest infection has been observed in patients who had conventional on-pump operations [36, 37]. This absence of correlation between alveolar-arterial oxygen tension gradients and chest infection might be explained by the timing of the alveolar-arterial oxygen tension gradient measurements, which was confined to the very early postoperative period, whereas chest infections were observed between 2 and 7 days postoperatively.

One of the constant benefits associated with off-pump operations seems to be reduced blood loss and transfusion requirements, highlighting the detrimental effects of CPB on coagulation mechanisms [17–20, 41].

Although a lower release of S100 protein was reported soon after OPCAB operations in two studies [67, 72], no consistent differences in early and late cognitive dysfunction were observed. The benefits of OPCAB operations on neurologic function seem to be lower than the benefits for other organs. Although this surgical technique avoids aortic cannulation and cross-clamping, it does not allow us to avoid aortic side bite clamping, which is a recognized risk factor for neurologic injury. It should be noted that there is currently a lack of effective methodology for assessing neurologic injury and cognitive dysfunction after cardiac operations.

The protective effect of OPCAB operations on renal function seems to be well established, both by biochemical evaluation in elective patients [58–60] and by the analysis of clinical outcome in patients at higher risk of postoperative renal dysfunction because they present with diabetes [63] or preoperative nondialysis-dependent renal insufficiency [62].

The increase in the number of risk factors in patients with coronary artery disease has fuelled attempts to provide maximum organ protection during CABG. The available evidence in the literature supports the view that these are the patients who might benefit the most from off-pump coronary revascularisation, however, to date no data are available as part of a prospective randomized study in high-risk patients.

Finally, little has been published on midterm clinical outcome of OPCAB operations. However, the results of the Beating Heart Against Cardioplegic Arrest Studies and the trials of van Dijk and associates [23, 73] suggest that the midterm outcomes of beating heart operations are as good as those using conventional CABG with CPB and cardioplegic arrest. Nevertheless, to assess the long-term impact of OPCAB operations, high quality follow-up data are still needed.

On the basis of the available evidence, we conclude that OPCAB operations are safe and effective. They have gained a valuable place among the available techniques to treat coronary artery disease [74, 81].


   References
Top
 Abstract
 Introduction
 Historical aspects
 Results of large clinical...
 Subsystem organ function
 Off-pump operations in high-risk...
 Midterm clinical outcome
 Conclusions
 References
 

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