1. Lund – Malmö, SWEDEN

2. Is the Era of Off-pump Surgery over? ARASH MOKHTARI, MD, PHD

3. Introduction CABG, around 600,000 worldwide Extracorporeal circulation (ECC) in the 1950s –Disadvantages: »SIRS  multi-organ dysfunction / failure »Microemboli  end organ damage »Aortic manipulation, hemodilution, renal injury etc

4. Avoidance of CPB Kolesov: 1st CABG on the beating heart (1967) Off-pump: early 1990s (South America) Off-pump CABG geographical discrepancy: –Asia, > 60% of CABG –Western world, around 15%

5. Rationale for Off-pump CPB: –aortic manipulation, hemodilution, inflammation, renal injury etc OPCAB must not compromise revascularization in terms of either completeness or patency Reduction in systemic inflammation / end-organ dysfunction

6. Evidence (meta-analyses) equivalent outcomesImproved or equivalent outcomes with Off-pump compared to On-pump: –Stroke, postop mortality, myocardial injury, atrial fibrillation, transfusion, hospital stay »Highly selected low risk patients (mortality & morbidity are already low)

7. Ref. Bainbridge D, et al., Does off-pump or minimally invasive coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with percutaneous coronary intervention? J Thorac Cardiovasc Surg 2007;133:623—31. Parolari A, et al., Meta-analysis of randomized trials comparing off-pump with on-pump coronary artery bypass graft patency. Ann Thorac Surg 2005;80:2121—5. Cheng DC, et al., Does off-pump coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with conventional coronary artery bypass? A meta- analysis of randomized trials. Anesthesiology 2005;102:188—203. van der Heijden GJ, et al., Meta-analysis on the effect of off-pump coronary bypass surgery. Eur J Cardiothorac Surg 2004;26:81—4. Reston JT, et al., Meta-analysis of short-term and midterm outcomes following off-pump coronary artery bypass grafting. Ann Thorac Surg 2003;76:1510—5

8. Observational study Greater benefits of Off-pump: »Less blod loss »Less myocardial enzyme release »Less neurological dysfunction »Less renal insufficiency Fewer grafts with Off-pump Mortality rate, length of hospital stay, long-term neurological function and cardiac outcome – similar in Off-pump and On-pump

9. Ref. Cleveland Jr JC, et al., Off-pump coronary artery bypass grafting decreases risk-adjusted mortality and morbidity. Ann Thorac Surg 2001;72:1282—8 [Discussion 1288—89. Magee MJ, et al., Elimination of cardiopulmonary bypass improves early survival for multivessel coronary artery bypass patients. Ann Thorac Surg 2002;73:1196—202. Plomondon ME, et al., Off-pump coronary artery bypass is associated with improved risk- adjusted outcomes. Ann Thorac Surg 2001;72:114—9. Sabik JF, et al., Does off-pump coronary surgery reduce morbidity and mortality? J Thorac Cardiovasc Surg 2002;124:698—707. Sellke FW, et al., Comparing on-pump and off-pump coronary artery bypass grafting: numerous studies but few conclusions: a scientific statement from the American Heart Association council on cardiovascular surgery and anesthesia in collaboration with the interdisciplinary working group on quality of care and outcomes research. Circulation 2005;111:2858—64.

10. Randomised Controlled Trial (RCT) – studies (short- & mid-term outcomes) I No significant differences for 30-day: –Storke, death, MI, renal dysfunction, wound infection, re-exploration, re-intervention, IABP use Off-pump: significant reduction in: –Atrial fibrilation, transfusion, inotorope requirements, respiratory infections, ventilation time, ICU & hospital stay Graft patency & neurocongnitive function – Inconclusive Cheng DC, et al., Does off-pump coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with conventional coronary artery bypass? A meta-analysis of randomized trials. Anesthesiology 2005;102:188—203.

11. Ref. Cheng DC, et al., Does off-pump coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with conventional coronary artery bypass? A meta-analysis of randomized trials. Anesthesiology 2005;102:188—203 Wijeysundera DN, et al.,. Off-pump coronary artery surgery for reducing mortality and morbidity: meta-analysis of randomized and observational studies. J Am Coll Cardiol 2005;46:872—82.

12. Randomised Controlled Trial (RCT) – studies (short- & mid-term outcomes) II No benefit of Off-pump vs On-pump: –Mortality –MI –Stroke –“Redo” coronary revascularisation Moller CH, et al., Clinical outcomes in randomized trials of off- vs on-pump coronary artery bypass surgery: systematic review with meta-analyses and trial sequential analyses. Eur Heart J 2008;29:2601—16.

13. Completeness of Revascularization and Graft patency Reduced completeness of revascularization for Off-pump vs On-pump? Inferior patency rates with Off-pump CABG ? –Due to: »Surgeons experience »Antiplatelet effect of CPB

14. Long-term Survival after on- & off- pump coronary surgery, (1989-2012) Study Endpoint: All-caus mortality

15. Long-term Survival …(I) 5203 patients: elective isolated CABG –(off-pump, n=2333; on-pump, n=2870) On-pump CABG: higher number of distal anastomoses than off-pump P<0.001 FU: 5167 patients (99.3%) with a median follow-up duration of 6.4 years 1181 patients (22.7%) died. Similar risk of death at 30- day and up to one year.

19. Long-term Survival …(II) Off-pump CABG significantly higher risk of death P<0.0001) compared with on-pump CABG On-pump CABG survival benefits in most demographic, clinical and anatomic subgroups compared with off-pump CABG

20. Take Home Message “On-pump” CABG: Long-term survival advantage “Off-pump” and “no-touch aortic” CABG: Elderly, high-risk patients ascending aortic atherosclerosis risk of stroke is high Elderly, high-risk patients with significant ascending aortic atherosclerosis where the risk of stroke is high

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