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CABG With and Without Manipulation of the Ascending Aorta
Study Questions:
What are the postoperative outcomes between all coronary artery bypass grafting (CABG) techniques, including an aortic off-pump CABG (anOPCABG), off-pump with the clamp-less 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 six electronic databases was performed to identify all publications reporting the outcomes of the different CABG techniques. Studies reporting the primary endpoint, 30-day postoperative stroke rate, were included in a Bayesian network meta-analysis. A hierarchical Bayesian network was used for its greater flexibility, more natural interpretation, and ability to rank treatments according to their comparative effectiveness.
Results:
Thirteen studies were included with 37,720 patients. At baseline, anOPCABG patients had higher previous stroke than the OPCABG-PC (7.4% vs . 6.5%, p = 0.02) and CABG (7.4% vs. 3.2%, p = 0.001) patients. An OPCABG was the most effective treatment for decreasing the risk of postoperative stroke (-78% vs. CABG, 95% confidence interval [CI], 0.14-0.33; -66% vs. OPCABG-PC, 0.22-0.52; -52% vs. OPCABG-HS, 0.27-0.86), mortality (-50% vs. CABG, 0.35-0.70; -40% vs. OPCABG-HS, 0.38-0.94), renal failure (-53% vs. CABG, 0.31-0.68), bleeding complications (-48% vs. OPCABG-HS, 0.31-0.87; -36% vs. CABG, 0.42-0.95), atrial fibrillation (-34% vs. OPCABG-HS, 0.49-0.89; -29% vs. CABG, 0.55-0.87; -20% vs. OPCABG-PC, 0.68-0.97), and shortening the length of intensive care unit (ICU) stay (-13.3 hours, -19.32 to -7.26; p < 0.0001).
Conclusions:
The authors concluded that avoidance of aortic manipulation in anOPCABG may decrease the risk of postoperative stroke, especially in patients with higher stroke risk.
Perspective:
This network meta-analysis suggests that the risk of postoperative stroke, mortality, renal failure, atrial fibrillation, bleeding, and length of ICU stay was the lowest using an anOPCABG technique, which avoids manipulation and clamping of the ascending aorta. The superiority of the anOPCABG technique over OPCABG-PC and OPCABG-HS techniques may explain why prior studies have failed to show a benefit in neurological outcomes between OPCABG and on-pump CABG since they eliminate cardiopulmonary bypass, but not aortic manipulation. Additional randomized trials are needed to better evaluate the relative efficacy, safety, and long-term outcomes associated with anOPCABG compared to conventional and hybrid procedures, and to better understand the mechanisms responsible for these effects.
Keywords: Aorta, Atrial Fibrillation, Cardiac Surgical Procedures, Cardiopulmonary Bypass, Coronary Artery Bypass, Coronary Artery Bypass, Off-Pump, Hemorrhage, Intensive Care Units, Renal Insufficiency, Risk, Secondary Prevention, Stroke, Vascular Diseases
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