Coronary artery bypass grafting with and without manipulation of the ascending aorta

A Network Meta-Analysis

Dong Fang Zhao, J. James Edelman, Michael Seco, Paul G. Bannon, Michael K. Wilson, Michael J. Byrom, Vinod Thourani, Andre Lamy, David P. Taggart, John D. Puskas, Michael P. Vallely*

*Corresponding author for this work

Research output: Contribution to journalArticle

89 Citations (Scopus)

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.

Original languageEnglish
Pages (from-to)924-936
Number of pages13
JournalJournal of the American College of Cardiology
Volume69
Issue number8
DOIs
Publication statusPublished - 28 Feb 2017
Externally publishedYes

Keywords

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

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