Beating-Heart Versus Conventional On-Pump Coronary Artery Bypass Grafting: A Meta-Analysis of Clinical Outcomes

doi:10.1016/j.athoracsur.2015.05.057

The Annals of Thoracic Surgery

Volume 100, Issue 6, December 2015, Pages 2251-2260

https://doi.org/10.1016/j.athoracsur.2015.05.057 Get rights and content

Background

Beating-heart on-pump coronary artery bypass grafting (BH-ONCAB) offers a hybrid coronary revascularization technique that may confer the benefits of an “off-pump” operation while maintaining the hemodynamic stability and mechanical support of conventional on-pump CABG (C-ONCAB). This study aimed to identify whether BH-ONCAB confers a morbidity or mortality benefit over C-ONCAB in the immediate and midterm postoperative period.

Methods

A systematic literature review identified 13 studies incorporating 3,930 patients (937 BH-ONCAB; 2,993 C-ONCAB) fulfilling our inclusion criteria. Outcomes were meta-analyzed using random-effects modelling. Between-study heterogeneity was investigated through quality assessment, subgroup, and risk of bias analysis.

Results

No difference was seen in overall 30-day mortality (13 studies; odds ratio, 0.60; 95% confidence interval, 0.32 to 1.14; p = 0.12), or midterm survival (5 studies; hazard ratio, 0.65; 95% confidence interval, 0.22 to 1.88; p = 0.43) between BH-ONCAB and C-ONCAB. BH-ONCAB was associated with significantly fewer postoperative myocardial infarction events (odds ratio, 0.32; 95% confidence interval, 0.11 to 0.92; p = 0.03); however, no significant difference was observed in other postoperative morbidity outcomes. Intraoperatively, BH-ONCAB resulted in significantly less intraaortic balloon pump use, shorter cardiopulmonary bypass time, and less blood loss. The number of anastomoses and vessels grafted were not significantly different between BH-ONCAB and C-ONCAB.

Conclusions

BH-ONCAB is a safe and comparable alternative to C-ONCAB in terms of early mortality and late survival. Furthermore, BH-ONCAB may confer a particular advantage in preventing perioperative myocardial infarction and reducing overall blood loss. Future work should focus on larger matched studies and multicenter randomized controlled trials that risk-stratify patients according to preoperative ventricular function and renal insufficiency to allow us to optimize our surgical revascularization strategy in these high-risk patients.

Section snippets

Literature Search

A literature search was performed using MEDLINE (PubMed), EMBASE (OVID Interface), Cochrane Central databases, Web of Science, and Google Scholar using the MeSH terms “coronary artery bypass” and “cardiopulmonary bypass,” and the search term “beating-heart.” The last search date was November 15, 2014. The search was limited to human studies but was open to any language. Studies available with an abstract and published after 1990 were selected. Citation review was also performed manually and

Results

Thirteen single-center studies met the selection criteria 4, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 incorporating 3,930 patients (937 BH-ONCAB; 2,993 C-ONCAB). Two were prospective RCTs 15, 16, and the remaining 11 were retrospective observational studies, of which one was propensity matched [14]. A summary of the study characteristics of the 13 included studies is presented in Table 1. Three studies were analyzed by intention-to-treat 15, 16, 20, and three studies provided information

Comment

The results of this meta-analysis demonstrate that early mortality and midterm survival after CABG was similar between BH-ONCAB and C-ONCAB coronary revascularization. This remained true when only higher-quality studies were analyzed. In addition, significant favorability was observed toward BH-ONCAB for a number of morbidity outcomes, including postoperative MI, IABP use, and blood loss.

Early adopters of BH-ONCAB used the technique for high-risk patients, considering it to be an acceptable

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In the two largest trials, the CORONARY study142 and the German GOPCABE trial,143 off-pump surgery was associated with lower transfusion rates. In addition, a meta-analysis reports off-pump surgery to have reduced blood loss.144 In summary, off-pump surgery may be associated with reduced blood loss and fewer transfusion requirements in comparison to on-pump surgery.
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On-Pump Beating Heart Versus Conventional Coronary Artery Bypass Grafting Early After Myocardial Infarction: A Propensity-Score Matched Analysis From the ANZSCTS Database
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These include patients with AMI and requiring prompt surgical revascularisation [9,11]. Other studies have reported non-superior outcomes [15,16], or possible disadvantage [17]. Thus, whether ONBEAT constitutes clinical benefit over ONSTOP remains unclear.
Coronary artery bypass grafting (CABG) performed early after acute myocardial infarction (AMI) carries a high risk of mortality. By avoiding cardioplegic arrest and aortic cross-clamping, on-pump beating heart CABG (ONBEAT) may benefit patients requiring urgent or emergency revascularisation in the setting of AMI. We evaluated the early and long-term outcomes of ONBEAT versus conventional CABG (ONSTOP) utilising the ANZSCTS National Cardiac Surgery Database.
Between 2001 and 2015, 5,851 patients underwent non-elective on-pump CABG within 7 days of AMI. Of these, 77 patients (1.3%) underwent ONBEAT and 5774 (98.7%) underwent ONSTOP surgery. Propensity-score matching (with a 1:2 matching ratio) was performed for risk adjustment. Survival data were obtained from the National Death Index.
Before matching, the unadjusted 30-day mortality was ONBEAT: 9/77 (11.7%) vs. ONSTOP: 256/5,774 (4.4%), p < 0.001. Preoperative factors independently associated with the ONBEAT were: septuagenarian age, peripheral vascular disease, redo surgery, cardiogenic shock, emergency surgery and single-vessel disease. After propensity-score matching, 30-day mortality was similar (ONBEAT: 9/77 (11.7%) vs. ONSTOP: 16/154 (10.4%), p = 0.85), as was the rate of major adverse cardiac and cerebrovascular events (ONBEAT: 17/77 (22.1%) vs. ONSTOP: 38/154 (24.7%), p = 0.84). ONBEAT patients received fewer distal anastomoses and were more likely to have incomplete revascularisation (ONBEAT: 15/77 (19.5%) vs. ONSTOP: 15/154, (9.7%), p = 0.03). Despite this, 12-year survival was comparable (ONBEAT: 64.8% (95% CI 39.4-82.4%) vs. ONSTOP: 63.6% (95% CI 50.5, 74.3%), p = 0.89).
ONBEAT can be performed safely in high-risk patients requiring CABG early after AMI with similar short and long-term survival compared to ONSTOP.
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This technique permits continuous coronary perfusion, thereby minimizing myocardial ischemia and reperfusion injury.66 In a recent meta-analysis in patients undergoing on-pump coronary artery bypass grafting (n = 3,930 [13 trials]), the beating-heart technique significantly reduced CPB time, blood loss, low-cardiac-output syndrome, and perioperative myocardial infarction.67 A second similar meta-analysis (n = 2,040 [14 trials]) confirmed these outcome benefits, including significantly lower rates of renal failure (odds ratio 0.362; 95% confidence interval 0.209-0.626; p < 0.001) compared with CPB with aortic clamping and cardioplegic arrest.68
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Original articleAdult cardiacBeating-Heart Versus Conventional On-Pump Coronary Artery Bypass Grafting: A Meta-Analysis of Clinical Outcomes

Background

Methods

Results

Conclusions

Section snippets

Literature Search

Results

Comment

Ann Thorac Surg

Control Clin Trials

Ann Thorac Surg

Ann Thorac Surg

Cardiovasc Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year

N Engl J Med

[Effects of on-pump beating-heart coronary artery bypass grafting for left-main patients]

Zhonghua Yi Xue Za Zhi

Original article
Adult cardiac
Beating-Heart Versus Conventional On-Pump Coronary Artery Bypass Grafting: A Meta-Analysis of Clinical Outcomes