Cardiovascular Outcomes in High-Risk Patients Undergoing OPCAB Surgery Compared to Traditional CABG

<p>The benefit of coronary artery bypass graft (CABG) for coronary artery disease (CAD) with Ejection Fraction (EF) 30% and ischemic burden (IB) 10% is still debatable. The objective of this study is to analyze mortality and morbidity in patients with EF 30% and ischemic burden 10% undergoing OPCAB compared to traditional CABG (TCABG). The retrospective analytic cohort study was performed using data from January 2015–November 2018 at National Cardiovascular Center Harapan Kita Jakarta, Indonesia. 109 patients were included. 35 patients undergoing OPCAB and 74 patients undergoing TCABG. The primary outcomes were mortality rate, morbidity rate, and length of stay. Arrhythmia is statistically lower in OPCAB compared to TCABG (8.6% vs 39.2%; p=0.001). Kidney injury is statistically lower in OPCAB (8.6% vs 27.0 %; p=0.027). Stroke is statistically lower in OPCAB (1.0 % vs 17.6%; p=0,032). There is no significant difference between OPCAB and TCABG in mortality, 5.7% vs 16.2%, (RR=3.20; CI 95%=0.67–15.12; p= 0.126). There was a statistically significant difference in the occurrence of postoperative morbidity in CAD patients with EF &lt;30% and IB&lt;10% who underwent OPCAB surgery compared with patients who underwent TCABG. Mortality that occurred after OPCAB procedure was lower in CAD patients with EF &lt; 30% and IB&lt;10% compared to TCABG although the statistical difference was not significant. Therefore, patients with this condition are more advisable to undergo OPCAB.</p>

Effect of BMI on Postoperative Outcome, after Off-Pump CABG, A Prospective Observational Study

Background: Obesity and its complications are global health concerns with rising interests, and in Bangladesh, the scenario is not different. This study was designed to analyze the effect of BMI on postoperative outcomes in patients who underwent Off-Pump Coronary Artery Bypass (OPCAB)graft surgery. Methods: This prospective observational study was conducted from September 2017 to August 2018 in the department of cardiac surgery, NICVD & 90 patients were divided into two groups. 43 patients in group A, with BMI ≥ 25 kg/m2 and 47 patients in group B, with BMI<25 kg/m2. Results: In between groups, homogenous distribution was noted in terms of age and sex. Pre-operative risk factors, such as hypertension, dyslipidemia, and sternal wound infection, harvest site infection along with post-operative AF, were significantly higher in group A in comparison to group B. Conclusion: Obese patients undergoing OPCAB surgery should undergo maximum care. Meticulous tissue handling during OPCAB surgery in obese patients is needed to avoid or minimize sternal, and harvest site wound infection.

A Comparison of Success Rate in Off-Pump Coronary Artery Bypass Grafting Surgery among Patients with Varying Preoperative Left Ventricular Ejection Fractions: Retrospective Observational Study

Background: Off-pump coronary artery bypass grafting (OPCAB) is an alternative to coronary artery revascularization and avoids the complications of cardiopulmonary bypass (CPB). The procedure’s success, however, depends on intraoperative hemodynamic stability. Preoperative cardiac function can predict the tolerance to compromised hemodynamics during cardiac surgery. Inability to manage hypotension and low cardiac output while manipulating the heart is the most frequent cause of intraoperative conversion to CPB. Objective: The authors investigated the effects of the preoperative left ventricular ejection fraction (LVEF) on the success of OPCAB surgery and the relation of intraoperative factors to the success of OPCAB surgery. Material and Methods: Medical records of 284 patients who underwent OPCAB surgery in Ramathibodi Hospital between January 2015 and December 2017 were retrospectively reviewed. Preoperatively, the patients were classified into groups 1 to 4 based on LVEFs of 50% to 70%, 40% to 49%, 30% to 39%, and <30%, respectively. Preoperative characteristics were collected. Intraoperative success of OPCAB surgery, application of inotropes, vasopressor, fluid, and intra-aortic balloon pump (IABP), and post-operative outcomes were analyzed and compared among the four LVEF groups. Results: No significant differences in success of OPCAB surgery emerged among the four groups (p=0.430). Intraoperative requirements of IABP were significantly higher for LVEF <30% patients (p=0.001). In addition, the time to extubation was significantly delayed (p=0.001) and the LVEF <30% patients stayed longer in intensive care unit (ICU) (p=0.002) when compared with the good LVEF patients. There were no significant differences in the operative time, amount of intravenous fluid, blood transfusion requirement, or blood loss among the groups. There were no significant differences in major postoperative morbidities. Conclusion: OPCAB surgery can be performed successfully in patients with severe cardiac dysfunction (LVEF <30%) without significant differences from LVEF ≥30% patients, although the need for an intraoperative IABP device and inotropic drugs for hemodynamic support were greater and the extubation times and ICU stays were longer. Keywords: Coronary artery bypass graft; Left ventricular ejection fraction; Off-pump CABG; OPCAB; Poor cardiac function

Early Outcomes Following off-Pump Coronary Artery Bypass Surgery under General Anaesthesia with and without High Thoracic Epidural Analgesia: A Comparative Study

Introduction: Reduction of postoperative morbidity by providing optimal pain relief and improving overall quality of care is an important goal of modern anaesthesia practice. The aim of this prospective, randomized, open, controlled study is to investigate the impact of high thoracic epidural analgesia on early clinical outcomes in patients undergoing off-pump coronary artery bypass (OPCAB) surgery. Methodology: After obtaining the institutional ethics committee approval and written informed consent from all patients, 80 patients of either sex, aged 40 – 70 years, scheduled for elective primary OPCAB surgery were randomized into two groups. Group I received 4 mL of an epidural bolus of 1% ropivacaine and fentanyl 100 µg followed by ropivacaine 1% and fentanyl 5 µg/mL infusion for 72 h at 3–5 mL/h postoperatively. Analgesia in the Group II was provided with a continuous IV fentanyl infusion. Patients were given rescue analgesic (inj Tramadol intravenous) when VAS score is >40 in the postoperative period. Results: VAS score, need for rescue analgesics and incidence of postoperative arrythmia were significantly lower in Group I specially for first twenty four hours postoperatively. Time for extubation and length of postoperative ICU stay were found similar in both the groups. Incidence of other outcomes found to be not significant. Conclusion: The pain scores, analgesic requirements and incidence perioperative arryrhmias were significantly less in Group I compared to Group II, but we could not be able to find any significant difference in time for extubation and length of ICU stay, neither in incidence of postoperative MI, CVA, renal failure, blood transfusion and death.

Dexmedetomidine as a Heart Rate Control for Off-Pump Coronary Artery Bypass Surgery

Introduction: The traditional surgical approach is performed under cardiac arrest with cardiopulmonary bypass (CPB), which has the potential to result in myocardial injuries. In 1990s, when researchers developed efficient mechanical stabilizer devices, Off-pump coronary artery bypass (OPCAB) gained more widespread interest, as it’s associated with many significant benefits. Avoidance of tachycardia is a goal for anesthetic management during OPCAB surgery. A short-acting Beta-blocker is needed for lowering excessive increases in heart rate. However, in some hospitals these drugs were not available. Case: A 53-yr-old, 73 kg man with a three-vessel coronary arterial disease with left main disease was scheduled for elective OPCAB surgery. Patient has a medical history of heart attack and hypertension. Preoperative echocardiography shows reduced LV systolic function, diastolic dysfunction grade I, with LVEF 47%. Throughout the hour after induction, HR increased in a constant manner to a persistent of 85-90 bpm despite additional fentanyl given. We didn’t have any intravenous beta blocker drug and therefore we started dexmedetomidine. HR decreased to 55-60 bpm and remained at that value throughout the surgical procedure. Patient extubated in OR and transferred to ICU. After 6 days, he was discharged from the hospital without any complications. Conclusion: Perioperative administration of Dexmedetomidine is an effective adjuvant to general anaesthesia, attenuates the stress response to intubation, provides minimal heart rate variations, enabling smooth extubation, also provides adequate sedation in the post-operative period.

Dexmedetomidine as a Heart Rate Control for Off-Pump Coronary Artery Bypass Surgery

Introduction: The traditional surgical approach is performed under cardiac arrest with cardiopulmonary bypass (CPB), which has the potential to result in myocardial injuries. In 1990s, when researchers developed efficient mechanical stabilizer devices, Off-pump coronary artery bypass (OPCAB) gained more widespread interest, as it’s associated with many significant benefits. Avoidance of tachycardia is a goal for anesthetic management during OPCAB surgery. A short-acting Beta-blocker is needed for lowering excessive increases in heart rate. However, in some hospitals these drugs were not available. Case: A 53-yr-old, 73 kg man with a three-vessel coronary arterial disease with left main disease was scheduled for elective OPCAB surgery. Patient has a medical history of heart attack and hypertension. Preoperative echocardiography shows reduced LV systolic function, diastolic dysfunction grade I, with LVEF 47%. Throughout the hour after induction, HR increased in a constant manner to a persistent of 85-90 bpm despite additional fentanyl given. We didn’t have any intravenous beta blocker drug and therefore we started dexmedetomidine. HR decreased to 55-60 bpm and remained at that value throughout the surgical procedure. Patient extubated in OR and transferred to ICU. After 6 days, he was discharged from the hospital without any complications. Conclusion: Perioperative administration of Dexmedetomidine is an effective adjuvant to general anaesthesia, attenuates the stress response to intubation, provides minimal heart rate variations, enabling smooth extubation, also provides adequate sedation in the post-operative period.

Establishing the Safety of Training in Off-Pump Coronary Artery Bypass Surgery: A Retrospective Comparison of Outcomes between Trainees and a Consultant Surgeon

Background The safety of training in off-pump coronary artery bypass (OPCAB) surgery and the stage at which trainees should be exposed to this technique remain controversial. This single-center retrospective study aimed to compare outcomes of OPCAB surgery in consultant and trainee cases. Methods Between 2014 and 2018, all isolated OPCAB operations performed under the care of a consultant surgeon (G.A.) were analyzed. Cases where a surgeon below consultant grade performed at least 70% of the distal anastomoses were designated as “trainee cases” with the remaining cases designated as “consultant cases.” The baseline characteristics of patients, perioperative data, and short-term outcomes were prospectively collated and analyzed. Results During the study period, 245 OPCAB cases were identified: 142 (58%) consultant and 103 (42%) trainee cases. The trainee cases were performed exclusively by trainees in the final 2 years of the UK National Cardiothoracic Training Program. Both trainee and consultant groups had low mortality with two perioperative deaths occurring in either group. The rates of serious postoperative complications including stroke (n = 1 vs. 2, p = 0.759), resternotomy for bleeding (n = 3 vs. 7, p = 0.431), and mediastinal infection (n = 2 vs. 3, p = 0.926) were low and not significantly different between the two groups. Patients operated on by trainees had a slightly longer hospital stay than those operated on by the consultant surgeon, although this did not reach statistical significance (9.9 vs. 7.9 days). Conclusions These results demonstrate comparable outcomes in OPCAB surgery between a consultant surgeon and trainees. This study supports the conclusion that training surgeons in OPCAB is appropriate for trainees in the final years of cardiac surgery training.

Auto-antibodies to protein Z in patients undergoing off-pump coronary artery bypass surgery – preliminary results

Background: Considerable attention has been focused over the past several years on the protein Z (PZ) system. However, little is known about the role of auto-antibodies to PZ (anti-PZ) in cardiac surgery patients.<br>Aim: In the present pilot study, we investigated plasma levels of anti-PZ in patients undergoing off-pump coronary artery bypass (OPCAB) surgery.<br>Material and methods: Thirty patients with coronary artery disease scheduled for OPCAB surgery were enrolled in this study. Plasma levels of anti-PZ IgM and anti-PZ IgG were measured before surgery and one week after surgery using enzyme-linked immunosorbent assay.<br>Results: None of the subjects were shown to have positive results for anti-PZ IgM and anti-PZ IgG either before and one week after OPCAB surgery.<br>Conclusions: These results suggest that anti-PZ autoantibodies are not an effective component of the PZ system in OPCAB patients.

Anesthesia for Off Pump Coronary Artery Bypass Surgery in a Patient with Brain Tumor

The outcome after off pump coronary artery bypass grafting (OPCAB) surgery has been promising. These good outcomes relate to the benefits of avoiding extra corporeal circulation. Some of the reported advantages include a lower incidence of renal complications, pulmonary complication, adverse neurological event, reduced transfusions requirement and attenuation of the systemic inflammatory response. If the patient has associated preoperative complicated neurological issues, then perioperative management will be more challenging and requires extensive care and precautions.We present a case with symptomatic meningioma and unstable angina who underwent successful urgent OPCAB surgery without further neurological deterioration.