Clampless off-pump surgery reduces stroke in patients with left main disease.
BACKGROUND
Surgical revascularization is the most appropriate therapy for patients with significant left main coronary-artery disease (LMD). An incidence of perioperative stroke remains an issue when compared to the early outcomes to percutaneous coronary intervention (PCI). This study evaluates the safety and impact of standardized "clampless" OPCAB techniques, composed of either complete in situ grafting or "clampless" device enabled techniques for stroke reduction in patients undergoing surgical revascularization for LMD.


METHODS
Between 1999 and 2009, 1031 patients with LMD underwent myocardial-revascularization at our institution. Of these, 507 patients underwent "clampless" OPCAB and 524 patients underwent conventional on-pump CABG (ONCABG). Data-collection was performed prospectively and a propensity-adjusted regression-analysis was applied to balance patient characteristics. LMD was defined as a stenosis >50% and endpoints were mortality, stroke, a cardiac-composite (including death, stroke and myocardial-infarction); a non-cardiac composite and complete-revascularization.


RESULTS
In OPCAB patients, the cardiac composite (3.0% vs. 7.8%; propensity-adjusted (PA)OR=0.27; CI95% 0.12-0.65; p=0.003) as well as the occurrence of stroke (0.4% vs. 2.9%; PAOR=0.04; CI95% 0.003-0.48; p=0.012) were significantly lower while the mortality-rate was well comparable between groups (1.8% vs. 2.5%; PAOR=0.44; CI95% 0.11-1.71; p=0.24). The non-cardiac composite was also significantly decreased after OPCAB (8.9% vs. 19.7%; PAOR=0.55; CI95% 0.34-0.89; p=0.014) and complete revascularization was achieved for similar proportions in both groups (95.1% vs. 93.7%; p=0.35).


CONCLUSIONS
This study shows the superiority of OPCAB for patients with LMD with regards to risk-adjusted outcomes other than mortality. A "clampless OPCAB strategy", effectively reduces stroke yielding similar early outcomes as PCI.
Dept of Cardiac and Vascular Surgery, University Hospital Zurich, Switzerland. maximilian.emmert@usz.ch
Maximilian Y
MY
Emmert
Sacha P
SP
Salzberg
Burkhardt
B
Seifert
Jacques
J
Scherman
Andre
A
Plass
Christoph T
CT
Starck
Oliver
O
Theusinger
Simon P
SP
Hoerstrup
Jürg
J
Grünenfelder
Stephan
S
Jacobs
Volkmar
V
Falk
D000368:Aged; D047549:Coronary Artery Bypass, Off-Pump / Q000009:adverse effects / Q000379:methods*; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000453:epidemiology / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis* / Q000453:epidemiology; D016896:Treatment Outcome