Is the evidence from first time off-pump coronary artery bypass graft surgery transferable to re-operative off-pump surgery?

Abstract

On-pump coronary artery surgery remains the gold standard treatment for multi-vessel disease. The technique of off-pump surgery has evolved since its first use; however, currently less than 20% of all cases worldwide are performed this way. This poor uptake has been both the cause and the effect of widespread scepticism regarding the validity of the data on the technique, as well as criticism regarding the conversion-related adverse outcomes, graft patency and completeness of revascularisation. Consequently, there has been focus on patient selection from subgroups most likely to benefit from the technique. Re-operative patients, by virtue of their advanced age, complex co-morbidities and the technical challenges of re-operation, fall into this category. In this review, the authors will discuss the outcomes of off-pump surgery in comparison to on-pump, explore the potential beneficial effects of off-pump in re-operative surgery and formulate a decision-making strategy in patients undergoing reoperative coronary artery surgery.

Keywords::

• cardio-pulmonary bypass
• coronary artery bypass graft surgery
• off-pump surgery
• on-pump surgery
• outcomes
• re-operative surgery

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Coronary artery bypass surgery is the gold standard for multi-vessel coronary artery disease.

• The use of off-pump surgery has evolved and fluctuated, and currently remains relatively low, due to many conflicting opinions regarding its efficacy.

• Patients undergoing reoperative coronary artery surgery constitute a high-risk group with significant co-morbidities and one that is growing in size.

• Most randomized trials performed to date have failed to demonstrate any benefit with the use of off-pump surgery in terms of survival and major adverse events. They have also demonstrated incomplete revascularization after using the technique. These results have been heavily criticized.

• Observational data, which has been described as being more representative of everyday practice, has demonstrated benefits with the use of off-pump surgery.

• Conversion to on-pump surgery is a significant contributor to mortality and morbidity. Reoperative surgery is a significant predictor for the possibility of conversion.

• Very significant benefits have been demonstrated in terms of survival and adverse events in patients undergoing reoperative coronary artery surgery whilst using the off-pump technique.

Notes