Download PDF
Thorac Cardiovasc Surg 2018; 66(06): 464-469
DOI: 10.1055/s-0038-1636936
Original Cardiovascular
Georg Thieme Verlag KG Stuttgart · New York

Off-Pump Coronary Artery Bypass Grafting and Stroke—Exploratory Analysis of the GOPCABE Trial and Methodological Considerations

Wilko Reents
1   Herzchirurgie, Herz- und Gefäßklinik Bad Neustadt, Bad Neustadt, Germany
,
Michael Zacher
1   Herzchirurgie, Herz- und Gefäßklinik Bad Neustadt, Bad Neustadt, Germany
,
Jochen Boergermann
2   Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Bad Oeynhausen, NRW, Germany
,
Utz Kappert
3   Herzzentrum Dresden, Dresden, Germany
,
Michael Hilker
4   Herz-, Thorax- und herznahe Gefäßchirurgie, Regensburg, Germany
,
Gloria Färber
5   Department of Cardiac and Thoracic Surgery, University of Jena, Jena, Germany
,
Marc Albert
6   Herzchirurgie, Robert-Bosch-Krankenhaus GmbH, Stuttgart, Baden-Württemberg, Germany
,
David Holzhey
7   Herzchirurgie, Herzzentrum Leipzig, Leipzig, Germany
,
Lenard Conradi
8   Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
,
Friedrich Christian Riess
9   Department of Cardiac Surgery, Albertinenkrankenhaus, Hamburg, Germany
,
Philippe Veeckman
10   HELIOS Klinik fur Herzchirurgie Karlsruhe, Karlsruhe, Baden-Württemberg, Germany
,
Justus T. Strauch
11   Department of Cardiothoracic Surgery, Ruhr-University Bochum, Bochum, Germany
,
Anno Diegeler
1   Herzchirurgie, Herz- und Gefäßklinik Bad Neustadt, Bad Neustadt, Germany
,
Andreas Böning
12   Department of Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
› Author Affiliations
Further Information

Publication History

16 October 2017

05 January 2018

Publication Date:
22 March 2018 (online)

    Permissions and Reprints All articles of this category

Abstract

Background Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (off-pump CABG) may reduce severe adverse events including stroke.

Methods In the German Off-Pump Coronary Artery Bypass Grafting in Elderly patients trial, the rate of major adverse cardiovascular events was compared in 2,394 elderly (≥ 75 years) patients undergoing CABG with (on-pump) or without (off-pump) cardiopulmonary bypass. This exploratory post-hoc analysis investigated the impact of surgical aortic manipulation on the rate of stroke.

Results There was no significant difference in the rate of stroke within 30 days after surgery between both groups (off-pump: 2.2%; on-pump: 2.7%; odds ratio [OR]: 0.83 [0.5–1.38]; p = 0.47). Within the off-pump group, different degrees of aortic manipulation did not lead to significant different stroke rates (tangential clamping: 2.3%; OR 0.86 [0.46–1.60]; clampless device: 1.8%; OR 0.67 [0.26–1.75]; no aortic manipulation: 2.4%; OR 0.88 [0.37–2.14]). An aggregate analysis including more than 10,000 patients out of the four recent major trials also yielded comparable stroke rates for on- and off-pump CABG (off-pump: 1.4%; on-pump: 1.7%; OR 0.87 [0.64–1.20]).

Conclusion Within recent prospective randomized multicenter trials off-pump CABG did not result in lower stroke rates. The possible intrinsic benefit of off-pump CABG may be offset by the complexity of the operative therapy as well as the multiple pathomechanisms involved in perioperative stroke.

Keywords

off-pump surgery - coronary artery bypass grafting - CABG - stroke
 

  • References

  • 1 Paparella D, Yau TM, Young E. Cardiopulmonary bypass induced inflammation: pathophysiology and treatment. An update. Eur J Cardiothorac Surg 2002; 21 (02) 232-244
    CrossrefPubMedGoogle Scholar
  • 2 Kirklin JK, Westaby S, Blackstone EH, Kirklin JW, Chenoweth DE, Pacifico AD. Complement and the damaging effects of cardiopulmonary bypass. J Thorac Cardiovasc Surg 1983; 86 (06) 845-857
    CrossrefPubMedGoogle Scholar
  • 3 Whitlock RP, Rubens FD, Young E, Teoh KH. Pro: Steroids should be used for cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2005; 19 (02) 250-254
    CrossrefPubMedGoogle Scholar
  • 4 Diegeler A, Börgermann J, Kappert U. , et al; GOPCABE Study Group. Off-pump versus on-pump coronary-artery bypass grafting in elderly patients. N Engl J Med 2013; 368 (13) 1189-1198
    CrossrefPubMedGoogle Scholar
  • 5 Selnes OA, Gottesman RF, Grega MA, Baumgartner WA, Zeger SL, McKhann GM. Cognitive and neurologic outcomes after coronary-artery bypass surgery. N Engl J Med 2012; 366 (03) 250-257
    CrossrefPubMedGoogle Scholar
  • 6 Likosky DS, Marrin CA, Caplan LR. , et al; Northern New England Cardiovascular Disease Study Group. Determination of etiologic mechanisms of strokes secondary to coronary artery bypass graft surgery. Stroke 2003; 34 (12) 2830-2834
    CrossrefPubMedGoogle Scholar
  • 7 Dashe JF, Pessin MS, Murphy RE, Payne DD. Carotid occlusive disease and stroke risk in coronary artery bypass graft surgery. Neurology 1997; 49 (03) 678-686
    CrossrefPubMedGoogle Scholar
  • 8 Yoon BW, Bae HJ, Kang DW. , et al. Intracranial cerebral artery disease as a risk factor for central nervous system complications of coronary artery bypass graft surgery. Stroke 2001; 32 (01) 94-99
    CrossrefPubMedGoogle Scholar
  • 9 Lee EJ, Choi KH, Ryu JS. , et al. Stroke risk after coronary artery bypass graft surgery and extent of cerebral artery atherosclerosis. J Am Coll Cardiol 2011; 57 (18) 1811-1818
    CrossrefPubMedGoogle Scholar
  • 10 Ricotta JJ, Faggioli GL, Castilone A, Hassett JM. Risk factors for stroke after cardiac surgery: Buffalo Cardiac-Cerebral Study Group. J Vasc Surg 1995; 21 (02) 359-363 , discussion 364
    CrossrefPubMedGoogle Scholar
  • 11 Gottesman RF, Sherman PM, Grega MA. , et al. Watershed strokes after cardiac surgery: diagnosis, etiology, and outcome. Stroke 2006; 37 (09) 2306-2311
    CrossrefPubMedGoogle Scholar
  • 12 Caplan LR, Hennerici M. Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol 1998; 55 (11) 1475-1482
    CrossrefPubMedGoogle Scholar
  • 13 Tarakji KG, Sabik III JF, Bhudia SK, Batizy LH, Blackstone EH. Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA 2011; 305 (04) 381-390
    CrossrefPubMedGoogle Scholar
  • 14 Houlind K, Kjeldsen BJ, Madsen SN. , et al; DOORS Study Group. On-pump versus off-pump coronary artery bypass surgery in elderly patients: results from the Danish on-pump versus off-pump randomization study. Circulation 2012; 125 (20) 2431-2439
    CrossrefPubMedGoogle Scholar
  • 15 Lamy A, Devereaux PJ, Prabhakaran D. , et al; CORONARY Investigators. Off-pump or on-pump coronary-artery bypass grafting at 30 days. N Engl J Med 2012; 366 (16) 1489-1497
    CrossrefPubMedGoogle Scholar
  • 16 Shroyer AL, Grover FL, Hattler B. , et al; Veterans Affairs Randomized On/Off Bypass (ROOBY) Study Group. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med 2009; 361 (19) 1827-1837
    CrossrefPubMedGoogle Scholar
  • 17 Fleiss JL, Tytun A, Ury HK. A simple approximation for calculating sample sizes for comparing independent proportions. Biometrics 1980; 36 (02) 343-346
    CrossrefPubMedGoogle Scholar
  • 18 Sergeant P, Wouters P, Meyns B. , et al. OPCAB versus early mortality and morbidity: an issue between clinical relevance and statistical significance. Eur J Cardiothorac Surg 2004; 25 (05) 779-785
    CrossrefPubMedGoogle Scholar
  • 19 Sellke FW, DiMaio JM, Caplan LR. , et al; American Heart Association. 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 (21) 2858-2864
    CrossrefPubMedGoogle Scholar