title: Surgical treatment of left main disease and severe carotid stenosis: does the off-pump technique provide a better outcome?
abstract: OBJECTIVE
  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.
authors.affiliation: Department of Cardiac Surgery and Transplantology, Silesian Center for Heart Diseases, Zabrze, Poland. m.zembala.jr@sccs.pl
authors.forename: Michael O
authors.initials: MO
authors.lastname: Zembala
authors.forename: Krzysztof
authors.initials: K
authors.lastname: Filipiak
authors.forename: Daniel
authors.initials: D
authors.lastname: Ciesla
authors.forename: Jerzy
authors.initials: J
authors.lastname: Pacholewicz
authors.forename: Tomasz
authors.initials: T
authors.lastname: Hrapkowicz
authors.forename: Piotr
authors.initials: P
authors.lastname: Knapik
authors.forename: Roman
authors.initials: R
authors.lastname: Przybylski
authors.forename: Marian
authors.initials: M
authors.lastname: Zembala
mesh_terms: D000368:Aged; D016893:Carotid Stenosis / Q000601:surgery*; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000379:methods* / Q000592:standards; D047549:Coronary Artery Bypass, Off-Pump / Q000009:adverse effects / Q000379:methods* / Q000592:standards; D003324:Coronary Artery Disease / Q000601:surgery*; D005260:Female; D006801:Humans; D002546:Ischemic Attack, Transient / Q000503:physiopathology; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D020521:Stroke / Q000503:physiopathology; D016896:Treatment Outcome