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Ann Thorac Surg 2004;77:574-579
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

High risk coronary artery bypass patient: incidence, surgical strategies, and results

^a Department of Cardiac Surgery, Catholic University, Rome, Italy

Accepted for publication August 6, 2003.

^* Address reprint requests to Dr Gaudino, Divisione di Cardiochirurgia, Policlinico Universitario A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy.
e-mail: mgaudino{at}dtiscali.it

	Abstract

Top Abstract Introduction Patient and methods Results Comment References

 
BACKGROUND: To describe our experience in the treatment of high risk coronary artery bypass patients and compare patients assigned to on-pump or off-pump surgery.

METHODS: During a 42-month period 306 high risk (Euroscore > 5) coronary artery bypass patients were consecutively treated at our institution. On the basis of the coronary anatomy and possibility of achieving a complete revascularization, 197 patients were assigned to off-pump and 109 to on-pump operation. Overall mortality was 6.2% (19 of 306 patients).

RESULTS: Although patients treated off-pump had a better cardiac status, no clinical advantages related to the avoidance of cardiopulmonary bypass were found in the overall population. Off-pump patients had more early and late cardiac complications, whereas patients operated on-pump exhibited an higher incidence of postoperative systemic organ dysfunction. Off-pump surgery improved in-hospital outcome only in the subset of patients at highest risk.

CONCLUSIONS: Avoidance of cardiopulmonary bypass does not confer significant clinical advantages in all high risk coronary patients; instead, there are particular subsets of patients in whom beating heart surgery can be particularly indicated and others for whom on-pump revascularization appears a better solution. Adaptation of the operation to the single patient is probably the way to improve outcome.

	Introduction

Top Abstract Introduction Patient and methods Results Comment References

 
The population of patients referred for coronary artery bypass grafting (CABG) has substantially changed in the last years. The progress in medical therapy and interventional cardiology coupled with the increase in life expectancy and the widespread availability of cardiac surgery facilities have shifted toward the high the risk profile of patients proposed for surgical myocardial revascularization, and there is clear evidence that the cardiac and the systemic preoperative status of CABG patients have became progressively more complex, and that high risk patients represent now a substantial proportion of surgical candidates [1–6]. In these high risk patients the standard concepts, criteria, and technique of surgical myocardial revascularization often produce poor results and lead to significant mortality and morbidity rates.

The present study was elicited by the need to improve the clinical outcome of high risk coronary artery bypass patients by applying different surgical approaches to the different patients and to verify if the theoretical benefits of off-pump revascularization (OPCABG) translate to effective clinical benefits in all complex CABG patients or at least in some subset of them.

	Patient and methods

Top Abstract Introduction Patient and methods Results Comment References

 
For the purpose of the present analysis prospective data collection started in January 1999. Since that date all isolated CABG patients have been screened for enrollment.

Inclusion criteria
The operative risk was calculated on the basis of the Euroscore [7]. According to the Euroscore criteria patients with a preoperative score more than 5 were considered high risk patients and included in the study. The only exclusion criteria was severe arteriosclerosis of the ascending aorta. In fact, as we have previously reported how in case of diffuse aortic disease (grade III of Mills and Everson classification) [8] the use of off-pump target vessels revascularization is associated with significant neurologic advantages [9], patients with severely diseased aorta were not included in the present study and always treated by off-pump revascularization.

Surgical strategy
After inclusion in the protocol on the basis of the preoperative characteristics, the coronary anatomy of each patient was carefully evaluated for assignment to OPCABG or on-pump surgery. In every patient complete anatomic revascularization of all diseased vessels with a luminal diameter greater than or equal to 1 mm was considered necessary. If the operating surgeon judged a complete revascularization feasible on the beating heart, OPCABG was scheduled. In patients in whom the location or the quality of the target vessels were considered to make off-pump revascularization technically too challenging, conventional on-pump surgery was performed. All the procedures (either on-pump or off-pump) were performed by the same surgical team and there were no differences in the rate of adoption of OPCABG between the different surgeons.

On-pump group
The operation was performed using moderately hypothermic (nasopharyngeal temperature = 28°C) cardiopulmonary bypass (CPB) and isothermic intermittent antegrade blood cardioplegia. Proximal and distal anastomoses were performed during a single period of aortic clamping.

OPCABG group
The operation was performed using mechanical stabilization (Octopus III; Medtronic Inc, Minneapolis, MN) and intravascular shunting of the target coronary arteries. If possible Y or T grafts were used to avoid partial aortic clamping for performance of the proximal anastomoses; a detailed description of the surgical technique used has been published elsewhere [9].

Overall, 197 patients were assigned to OPCABG and 109 to on-pump CABG. The type of revascularization performed is described in Table 1. The number of anastomoses per patient was significantly superior in the on-pump group; patients with diseased obtuse marginal or posterolateral branches were more likely to be assigned to conventional surgery, whereas patients with disease limited to the left anterior descending and right coronary artery were usually submitted to OPCABG.

Each surviving patient was followed up regularly at our institution by clinical examination, surface electrocardiography, stress Tl (201) myocardial scintigraphy, and transthoracic echocardiography 6 months after surgery and every year thereafter. Angiographic control was proposed to the patients in case of scintigraphic evidence of inducible ischemia.

For the purpose of the present study all patients were recalled by phone and resubmitted to clinical examination and all exams repeated at the time of the follow-up. In case of death all available clinical data were collected and reviewed by the authors to establish the cause of the fatality. Death was considered cardiac in origin when it was preceded by objective evidence of myocardial ischemia or arrhythmia, and noncardiac when a clear systemic or accidental cause of death was evident. Follow-up was 100% complete (287 of 287 surviving patients) and mean follow-up time was 16 ± 9 months.

Statistical analysis
Results are expressed as mean value ± 1 standard deviation. At univariate analysis the methods used to compare the two groups included the parametric or nonparametric tests (t test and Mann-Whithney U test, respectively) for continuous variables and the X² or Fisher-exact tests for discrete variables. Nonparametric variables were compared by the Kaplan and Meier method.

Multivariate analysis was performed by using the Cox binary logistic regression model. Statistical significance was assumed for a p value less than 0.05. The statistical analysis package used was the MINITAB release 13 statistical software (MINITAB Inc, State College, PA).

	Results

Top Abstract Introduction Patient and methods Results Comment References

 
In-hospital results
Overall mortality was 19 of 306 patients (6.2%). Seven deaths were due to multiorgan failure, 7 to myocardial infarction, and the remaining 5, respectively, to mesenteric ischemia (1 patient), aortic dissection (1 patient), pulmonary embolism (1 patient), intractable coagulopathy (1 patient), and rupture of an aortic aneurysm (1 patient). Five of the in-hospital deaths occurred among patients with a preoperative Euroscore of 6, five among patient with a score of 7, four among patients with a score of 8, and the remaining five in the highest risk group (score > 8).

The in-hospital outcome of patients in relation to the surgical strategy used is illustrated in Table 4; no difference between the on-pump and OPCABG groups was found with regards to hospital mortality, type or incidence of major complication, intensive care unit, and in-hospital stays. The use of CPB was not a predictor of death or worse in-hospital outcome at multivariate analysis.

Moreover, stratification of difference in outcome between OPCABG and on-pump patients according to preoperative Euroscore revealed a reduced incidence of in-hospital death (1 of 25 OPCABG patients vs 4 of 11 on-pump patients; p = 0.03) and a trend toward reduced incidence of complications and stay in the intensive care unit in the subgroup of patients at highest risk (preoperative score > 8) treated off-pump (10 of 25 patients vs 9 of 11 patients [p = 0.05] and 68.6 ± 3.2 hours OPCABG vs 73.9 ± 5.6 on-pump [p < 0.001]).

Follow-up data
During the follow-up period 35 of 287 patients who survived surgery died (12.1%). Twenty-one of these late deaths were cardiac related (21 of 35 patients = 60.0%), whereas 11 were due to noncardiac pathologies. In 3 patients the etiology of late death could not be established with certainty.

Scintigraphic evidence of ischemia recurrence was evident in 90 patients (31.3%). Seventy of these patients accepted to undergo coronary angiography: in 21 of these patients ischemia was due to progression of the disease in the native coronary circulation, whereas in the remaining 49 patients malfunction of one or more grafts was demonstrated. Twenty-one of 90 patients (23.3%) underwent percutaneous coronary revascularization, whereas none was resubmitted to surgery.

Follow-up data in relation to the surgical strategy used are depicted in Table 5. At a follow-up of 16 ± 9 months OPCABG patients had an higher incidence of ischemia recurrence (71 of 184 patients vs 19 of 103 patients; p < 0.0001) and cardiac-related death (19 of 184 patients vs 2 of 103 patients; p = 0.001). OPCABG patients had a significantly higher need for percutaneous coronary revascularization (18 OPCABG patients vs 3 on-pump patients; p = 0.05). OPCABG was a significant predictor of cardiac death and angina recurrence at multivariate analysis.

	Comment

Top Abstract Introduction Patient and methods Results Comment References

 
Data from both European and US institutions are concordant in demonstrating that patients submitted to CABG are becoming progressively older and have a worse cardiac status and an higher incidence of systemic comorbidities, and it seems highly likely that this trend will be even enhanced in the near future and that high risk patients will represent an increasing proportion of patients treated by cardiac surgeons [1–6].

The 306 patients described in the present experience represent 20% of the total number of CABG procedures performed at our institution during the study period and almost the 30% of those performed in the last 18 months, with an evident annual increase from the beginning of the study protocol (see Fig 1); this finding replicates what has been already described by several other authors and is a testament to how the preoperative risk profile of coronary artery bypass patients is progressively worsening [1–6]. Of note, the extension of the indication to surgery to categories of patients previously judged not operable led to an impressive increase of systemic comorbidities in CABG patients so that noncardiac causes account for a greater part of postoperative complications and deaths [1, 2, 5, 7].

View larger version (30K): [in this window] [in a new window]   Fig 1. Annual incidence of high risk patients in the entire population of cases submitted to isolated coronary artery bypass grafting (numbers are percentages). ( = Euroscore < 5; = Euroscore > 5.)

The search for new technical solutions and strategies able to improve the postoperative outcome has become a primary objective for both surgeons and researchers, and the task of identifying the best operative strategy (the one that can assure the maximum clinical benefit at the lowest surgical risk) is one of the more challenging and frequent problem of modern coronary artery surgery.

Since its recent reintroduction in clinical practice, off-pump revascularization seemed to have the conceptual premises to play a major role in the treatment of high risk coronary patients. In fact, one of the main theoretical argument in support of OPCABG is the assumption that the avoidance of cardiopulmonary bypass and cardioplegic arrest can minimize the systemic reaction that usually follows on-pump CABG, significantly reducing the intraoperative damage of organs known to be particularly vulnerable to the post-CPB inflammatory response (such as the myocardium, the kidneys, the liver, and the lungs [10–13]) and, thus, improving postoperative outcome in patients with preoperative organ dysfunction.

However, to date few reports have focused on the results of off-pump versus conventional surgery in high risk patients, and no published report comparison between the two techniques has been carried out prospectively. Moreover, methodological issues and the heterogeneity of the reported results have, until now, precluded any definitive conclusion on the possibility that off-pump surgery can reduce the operative risk of complex CABG patients [14–18].

The present series prospectively describes our experience in the treatment of high risk CABG patients and compares patients assigned to on-pump or off-pump revascularization. Overall mortality (19 of 306 patients, 6.2%) was one of the lowest reported in patients of this type, although still far from what would be desirable. Notably, despite the fact that the patients assigned to OPCABG or on-pump surgery were not strictly comparable and that patients treated off-pump had a better coronary artery status, we could find no clear clinical advantages related to the simple avoidance of cardiopulmonary bypass in the overall population. Only in the small subgroup of patients at extreme preoperative risk (Euroscore 8) the adoption of beating heart surgery resulted in a moderate reduction of in-hospital mortality and morbidity.

A more detailed analysis of the cause of postoperative deaths revealed that, although overall in-hospital mortality in the two patients series was similar, patients operated on-pump died for systemic causes, whereas among OPCABG patients most of the deaths were cardiac in origin. Moreover, despite the fact that on-pump patients had a more severe and diffuse coronary disease, at short-term follow-up patients treated off-pump had an higher incidence of ischemia recurrence, cardiac death, and need for percutaneous revascularization.

These findings reflect the intuitive limitations of the two described techniques: increased risk of systemic organ dysfunction related to the systemic inflammatory reaction and probably to microembolism in the CPB group and lower efficacy of myocardial revascularization in patients operated off-pump. On-pump and off-pump surgery seem then to offer to the surgeon two different benefits: better preservation of systemic organ function at the expense of higher risk of postoperative cardiac complications for OPCABG, and higher systemic organ damage but more effective revascularization and reduced rate of postoperative cardiac morbidity for patients operated on the arrested heart.

Careful individualization of the surgical act to the anatomic and physiologic determinants of the operative risk of the single patient seems to be the only key to improve postoperative outcome. Off-pump surgery should probably be adopted in patients at high risk due to preoperative systemic organs impairment and at the highest extreme of the spectrum of complexity, conventional on-pump surgery should instead be adopted when the risk is related to the cardiac, not systemic, preoperative status.

The role of additional strategies, such as incomplete off-pump revascularization of the culprit vessel eventually completed by percutaneous interventions, should be further explored and it is possible that even the dogma of the completeness of myocardial revascularization should be revised in particular patients subgroups at very high operative risk.

From a methodologic standpoint our study is far from ideal: assignment to OPCABG or on-pump surgery was not randomized but based on the operating surgeon judgment on the possibility of achieving a complete revascularization and, in fact, patients submitted to conventional CABG were those whose coronary anatomy was more complex and less favorable to surgical revascularization. Moreover the detrimental effects of the learning curve on OPCABG results should be always kept in mind. Although these are obvious methodologic bias, they probably mirror what occur in every real clinical setting. It seems unlikely that a prospective randomized trial could ever be realized on this subject: OPCABG is an operator-dependent technique and the surgeons skill and experience play a major role while operating on the beating heart, so that the standardization and reproducibility of the surgical results needed to realize large prospective randomized trials will probably be impossible to obtain. Moreover, the fact that, despite the preoperative differences in favor of patients operated without pump, no in-hospital advantages could be demonstrated for OPCABG patients further highlights the finding that avoidance of cardiopulmonary bypass per se is not able to improve the hospital outcome of all high risk coronary patients.

Another point in favor of the reliability of our findings is the fact that all procedures (either on-pump or off-pump) were performed by the same surgeons, thereby reducing the possibility that, as suggested for other series [19], the different experience of surgeons performing off-pump and on-pump operations can have influenced the observed results.

In conclusion, our data furnish substantial evidence that the adoption of OPCABG does not confer significant clinical advantages in all high risk CABG patients. Avoidance of cardiopulmonary bypass is not a panacea for all patients; instead, there are particular subsets of patients in whom beating heart surgery can be indicated and others for whom on-pump revascularization is probably a better solution. Adaptation of the operation to the determinants of the operative risk of the single patient is likely to be the way to improve outcome.

	Appendix

 
Definitions
For the purpose of this report the following definitions were used:

Carotid disease
Mono- or bilateral carotid stenosis 70% demonstrated by preoperative echo-Doppler and carotid angiography.

Myocardial infarction
Diagnosed on the basis of echocardiographical evidence of regional hypoor dyskinesia, MB fraction more than 4% of the total hematic level of creatine kinase concentration, and appearance of new Q waves on the electrocardiogram.

Renal insufficiency
Defined as a postoperative increase of the serum creatinine level 2 mg/dL with respect to the preoperative level.

Respiratory insufficiency
Defined as a PaO₂ less than 60 mm Hg in current air.

Intraoperative stroke
Defined as a new focal neurologic deficit or coma associated with computed tomography demonstration of recent ischemic cerebral lesion, which became evident at the moment of the awakening of the patient from the anesthesia and lasted more than 24 hours.

Postoperative stroke
Defined as a new focal neurologic deficit or coma associated with computed tomography demonstration of recent ischemic cerebral lesion and lasting more than 24 hours, which became evident after a normal awakening of the patient from the anesthesia and a normal postoperative neurologic status.

Major postoperative complications
Included death, stroke, shock, sepsis, myocardial infarction, and reoperation.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mario Gaudino Franco Glieca Francesco Alessandrini Giuseppe Nasso Claudio Pragliola Nicola Luciani Mauro Morelli Gianfederico Possati Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gaudino, M. Articles by Possati, G. Search for Related Content PubMed PubMed Citation Articles by Gaudino, M. Articles by Possati, G. Related Collections Coronary disease