Aortic no-touch technique makes the difference in off-pump coronary artery bypass grafting

Objectives: 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 1999 [corrected] 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.