Cirugía Cardiovascular

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Editorial
Is there still a role for off-pump CABG in 2015? Certainly yes
¿Hay todavía un lugar para la cirugía coronaria sin circulación extracorpórea en 2015?
Ciertamente sí
David P. Taggart
University of Oxford, Dept Cardiac Surgery, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, United Kingdom
Conventional coronary artery bypass grafting using cardiopul-
monary bypass (CPB) and cardioplegic arrest of the heart has been
the gold standard technique for coronary artery bypass grafting
(CABG) since the mid 1960s. The major rationale for this approach
is to provide a still, bloodless operating field that optimizes the abil-
ity to do a technically perfect operation. Crucially, this technique
also enables the surgeon to perform a very low risk operation and
several countries currently report electivemortality rates of around
1% for CABG despite the advancing age and comorbidities of the
surgical population.
In the 1980s surgeons from South Americ tarted repor-
ting their experience with off-pump CABG (OPCABG). While their
work was motivated at least in part by economic considerations, by
performing CABG without the costs of CPB the operation became
accessible to a much wider population, it also became evident
that this approach also had the potential to minimize the dam-
aging affects of CPB. Three decades ago CPB was associated with a
potent systemic inflammatory response syndrome, due to activa-
tion of a myriad of cellular and humoral inflammatory mediators
as blood circulated through the extracorporeal circuit and was
strongly linked to multi-organ dysfunction and/or failure ur-
thermore, CPB also generated a large amount of gaseous and
particulate microemboli that was implicated in adverse neurolog-
ical sequelae
These reports of OPCABG encouraged a widespread adoption of
this new technique until evidence began to emerge that its pro-
posed benefits did not materialize in randomized trials against
on-pump CABG (ONCABG). Indeed evidence began to accumulate
that OPCABG could result in significantly inferior outcomes when
compared to ONCABG. Two particular pieces of evidence ques-
tioned the safety and efficacy of OPCAB nd, with the exception
of the Far East, initiated a decline in the numbers of OPCABGworld-
wide.
Short term outcomes
The ROOBY trial randomized 2203 patients to ONCABG
and OPCABG hile there was no significant difference between
OPCABG and ONCABG in the 30-day composite outcome (7.0%
and 5.6%, respectively; P = 0.19), the 1-year composite outcome
was higher for OPCABG (9.9% vs. 7.4%, P = 0.04) and accompanied
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by fewer grafts completed per patient than originally planned
(17.8% vs. 11.1%, P< 0.001) and lower angiographic graft patency
(82.6% vs. 87.8%, P< 0.01). The trial was, however, subsequently crit-
icized due to the relative inexperience of the participating surgeons
and large numbers of cross-overs
In 2012 Moller and colleagues reported a Cochrane Database
systematic reviewof 86 trials of OPCABGandONCABG that included
10,716 patients pooled analysis showed that OPCABG increased
all-cause mortality (3.7% vs. 3.1%; P = 0.04) and resulted in fewer
distal anastomoses (−0.28; 95% CI −0.40 to −0.16, P < .00001) with
no significant differences in myocardial infarction, stroke, renal
insufficiency, or coronary re-intervention but a reduced incidence
of post-operative atrial fibrillation. The authors concluded ‘Based
on the current evidence, on-pump CABG should continue to be
the standard surgical treatment. However, off-pump CABG may
be acceptable when there are contraindications for cannulation of
the aorta and cardiopulmonary bypass’.
The existing literature has, until recently, consisted of trials
of ONCABG and OPCABG that were individually underpowered to
assess their relative effects on mortality. Two larger trials have
provided greater insights and, crucially so, because the participat-
ing surgeons were, unlike in ROOBY, highly experienced in both
techniques having performed at least 100 OPCABG cases. Lamy and
colleague andomized 4752 patients to ONCABG or OPCABG. At
30 days therewas no significant difference in the rate of the primary
composite outcome of death, myocardial infarction, stroke, or new
renal failure requiring dialysis between ONCABG and OPCABG. At
1 year, there was again no significant difference in the hazard ratio
(HR) rate of the primary composite outcome (12.1% OPCABG and
13.3% ONCABG: HR with OPCABG 0.91; 95% CI: 0.77–1.07; P = 0.24).
At 1-year repeat coronary revascularization was 1.4% for OPCABG
and 0.8% for ONCABG (HR 1.66; 95% CI, 0.95–2.89; P= 0.07) with
no significant differences between the two groups quality of life
measures or neurocognitive function.
In the German Off-Pump CABG trial in the Elderly (GOPCABE)
2539 patients, aged over 75 years, were randomized to OPCABG
or ONCABG t 30 days there was no significant difference in
the respective composite outcome of death, stroke, myocardial
infarction, or new renal-replacement therapy (7.8% vs. 8.2%; HR,
0.95; 95% CI: 0.71–1.28; P = 0.74) or of its individual components.
As for CORONARY repeat revascularization occurred more fre-
quently after OPCABG than ONCABG (1.3% vs. 0.4%; HR, 2.42; 95%
CI, 1.03–5.72; P = 0.04). At 12 months, there was no significant dif-
ference between the groups in the composite end point (13.1% vs.
14.0%; HR, 0.93; 95% CI, 0.76–1.16; P = 0.48) or in any of the indi-
vidual components.
1134-0096/© 2015 Sociedad Espa˜nola de Cirugía Torácica-Cardiovascular. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license
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