Both off-pump surgery (OPCAB) and aortic no-touch technique reduce stroke after coronary artery bypass grafting (CABG). We evaluate the impact of partial aortic clamping (PC) versus a no-touch technique using either the HEARTSTRING system (HS) or total arterial revascularization (TAR) on the incidence of stroke.
Methods
From 2004 to 2009, 4314 patients underwent myocardial revascularization. Patients either underwent OPCAB (n = 2203) or conventional on-pump CABG (n = 2111). The OPCAB cohort was divided into 2 subgroups: patients requiring proximal anastomosis applying PC (n = 567) or a “no-touch” technique with the HS (n = 1365). Patients who received TAR (n = 271) served as a control group (gold-standard). Data collection was performed prospectively using a propensity score (PS)–adjusted regression analysis. End points were stroke, mortality, major adverse cardiac and cerebrovascular events (MACCE), and a noncardiac composite end point including respiratory failure, renal failure, and bleeding.
Results
The mortality rate (1.6% vs 2.4%; propensity-adjusted odds ratio [PAOR] = 0.51; CI 95%, 0.26-0.99; P = .047), MACCE (7.9% vs 17.1%; PAOR = 0.67; CI 95%, 0.52-0.84; P = .001) including myocardial infarction (1.1% vs 2.2%; PAOR = 0.50; CI 95%, 0.26-0.98; P = .044) and stroke (1.1% vs 2.4%; PAOR = 0.35; CI 95%, 0.17-0.72; P = .005) as well as the noncardiac composite (PAOR = 0.46; CI 95%, 0.35-0.91; P < .001) were significantly lower for OPCAB when compared with on-pump CABG. In comparison with PC, OPCAB patients undergoing the HS approach had significantly lower frequencies of stroke (0.7% vs 2.3%; PAOR = 0.39; CI 95%, 0.16-0.90; P = .04) and MACCE (6.7% vs 10.8%; PAOR = 0.55; CI 95%, 0.38-0.79; P = .001), and these results were similar to those of the control group, who underwent no-touch TAR (stroke rate, 0.8%; MACCE, 7.9%).
Conclusions
Our results confirm that OPCAB is superior with regard to risk-adjusted outcomes. There is no difference in the stroke rate when comparing on-pump CABG versus applying partial aortic crossclamping in OPCAB. Whenever a proximal anastomosis is needed, a no-touch technique should be applied, that is, using the HS device.
CTSNet classification
23
Abbreviations and Acronyms
CABG
coronary artery bypass grafting
CI
confidence interval
HS
HEARTSTRING system
MACCE
major adverse cardiac and cerebrovascular events
ONCABG
on-pump coronary artery bypass surgery
OPCAB
off-pump coronary artery bypass surgery
PAOR
propensity-adjusted odds ratio
PC
partial aortic clamping
PS
propensity score
OR
odds ratio
TAR
total arterial revascularization
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Disclosures: Authors have nothing to disclose with regard to commercial support.
