ORIGINAL ARTICLE
European Journal of Cardio-Thoracic Surgery 43 (2013) 541–548 doi:10.1093/ejcts/ezs277 Advance Access publication 22 May 2012
Surgical treatment of left main disease and severe carotid stenosis: does the off-pump technique provide a better outcome?† Michael O. Zembalaa,*, Krzysztof Filipiaka, Daniel Cieslab, Jerzy Pacholewicza, Tomasz Hrapkowicza, Piotr Knapikc, Roman Przybylskia and Marian Zembalaa a b c
Department of Cardiac Surgery and Transplantology, Silesian Center for Heart Diseases, Zabrze, Poland Department of Biostatistics, Silesian Center for Heart Diseases, Zabrze, Poland Department of Anesthesiology, Silesian Center for Heart Diseases, Zabrze, Poland
Received 2 September 2011; received in revised form 23 February 2012; accepted 25 March 2012
Abstract OBJECTIVES: Left main disease (LMD), combined with carotid artery stenosis (CAS), constitutes a high-risk patient population. Priority is often given to coronary revascularization, due to the severity of the angina. However, the choice of revascularization strategy [off-pump coronary artery bypass (OPCAB) vs coronary artery bypass grafting (CABG)] remains elusive. METHODS: A total of 1340 patients with LMD were non-randomly assigned to either on-pump (CABG group, n = 680) or off-pump (OPCAB group, n = 634) revascularization between 1 January 2006 and 21 September 2010. Multivariable regression was used to determine the risk-adjusted impact of a revascularization strategy on a composite in-hospital outcome (MACCE), and proportional hazards regression was used to define the variables affecting long-term survival. RESULTS: Significant CAS was found in 130 patients: 84 (13.1%) patients underwent OPCAB, while 46 patients (6.8%) underwent CABG (P < 0.05). Patients with a history of stroke/transient ischaemic attack were also more likely to receive OPCAB (7.1 vs 4.7%; P = 0.08). OPCAB patients were older, in a higher New York Heart Association (NYHA) class, with a lower LVEF and higher EuroSCORE. A calcified aorta was found in 79 patients [OPCAB–CABG: 49 (7.73%) vs 30 (4.41%); P = 0.016] and resulted in a less complex revascularization (OPCAB–CABG: 2.3 ± 0.71 vs 3.19 ± 0.82; P < 0.05), and 30-day mortality was insignificantly higher in the CABG (2.7 vs 2.8%) as well as MACCE (11.2 vs 12.2%; P = NS). This trend reversed when late mortality was evaluated; however, it did not reach significance at 60 months. Preoperative renal impairment requiring dialysis was found to be a technique-independent predictor of MACCE. The number of arterial conduits also influenced MACCE. CONCLUSIONS: Off-pump coronary revascularization may offer risk reduction of neurological complications in patients with a significant carotid artery disease and a history of previous stroke, but a larger study population is needed to support this thesis. The growing discrepancy in long-term survival should draw attention to a more complete revascularization in OPCAB patients. Keywords: Myocardial revascularization • Coronary artery bypass grafting • Carotid diseases • Outcomes • Off-pump coronary artery bypass
INTRODUCTION Significant stenosis of the left main disease (LMD), especially in the presence of multivessel disease, represents the most compound form of coronary atherosclerosis and remains a strong indication for revascularization in both symptomatic and asymptomatic patients [1]. Coronary artery bypass grafting (CABG) is reported to offer a significant survival advantage as well as a reduced need for repeated intervention when compared with percutaneous coronary intervention within the LMD. However, the higher incidence of cerebrovascular accidents in † Presented at the 25th Annual Meeting of the European Association for Cardio-Thoracic Surgery, Lisbon, Portugal, 1–5 October 2011.
surgically treated patients varying from 0.8 to 5.2% casts a shadow on the overall benefit of CABG [2]. With atherosclerosis being a systemic disease affecting multiple arterial beds within the same patient, the coexistence of severe coronary artery disease (CAD) and carotid artery disease (CAS) is not rare. Recent reports reveal that 8–15% of patients undergoing surgical revascularization have an advanced carotid disease, whereas 28–40% of patients undergoing carotid endarterectomy suffer from CAD [3]. ‘Carotid before coronary’, a revascularization strategy, has therefore been widely applied with the good results of both procedures with a minimal risk [4]. The situation differs in the left main disease (LMD), combined with severe CAS. While priority is given to coronary revascularization, the most beneficial surgical technique has not been
© The Author 2012. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ADULT CARDIAC
* Corresponding author. Department of Cardiac Surgery and Transplantology, Silesian Center for Heart Diseases, Sklodowskiej 9 Str., 41-800 Zabrze, Poland. Tel: +48-600-402994; fax: +48-32-3733786; e-mail:
[email protected] (M.O. Zembala).
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M.O. Zembala et al. / European Journal of Cardio-Thoracic Surgery
defined. The off-pump coronary artery bypass (OPCAB) grafting technique was introduced to overcome CABG’s deficiencies such as aortic cross-clamping and cardiopulmonary bypass, thus minimizing the risk of stroke. However, early indications for OPCAB excluded patients with LMD due to the potential for haemodynamic compromise [5]. A growing experience has enabled this type of surgical coronary revascularization to be safe and effective even in the high-risk patient population [6]. The aim of this study was to determine whether off-pump coronary revascularization provides better in-hospital and late outcomes in patients with LMD with concomitant carotid stenosis in comparison with the conventional CABG.
Table 1: Baseline clinical characteristics in left main patients Variable
OPCAB (n = 634)
CABG (n = 680)
P-value
Age (mean ± SD) Female (%) BMI (mean ± SD) CCS (mean ± SD) NYHA NYHA class I NYHA class II NYHA class III NYHA class IV History of MI (>90 days) Recent MI (200 µmol/l Renal failure (on dialysis) COPD on steroids PVD with claudication (100 m) h/o Stroke Transient ischaemic attack NTG (iv) on admission Preoperative IABP EuroSCORE (mean ± SD)
65.6 ± 9.0 25.7% 27.9 ± 4.1 2.82 ± 0.86 1.51 ± 0.61 54.6% 39.1% 4.7% 0.5% 24.9% 33.4% 28.5% 2.2% 31.4% 49.3 ± 9.5 3.9% 0.6% 2.5% 7.6% 6.0% 7.1% 3.2% 4.6% 1.4% 4.69 ± 2.81
63.1 ± 8.8 20.4% 28.3 ± 4.0 2.83 ± 0.81 1.38 ± 0.59 65.9% 27.9% 3.5% 0.7% 27.4% 28.1% 26.0% 2.6% 27.8% 50.6 ± 9.1 2.4% 0.1% 1.9% 8.1% 4.9% 4.7% 2.5% 4.7% 1.2% 4.21 ± 2.68
