title: Coronary Artery Bypass Grafting With and Without Manipulation of the Ascending Aorta: A Network Meta-Analysis.
abstract: BACKGROUND
  Coronary artery bypass grafting (CABG) remains the standard of treatment for 3-vessel and left main coronary disease, but is associated with an increased risk of post-operative stroke compared to percutaneous coronary intervention. It has been suggested that CABG techniques that eliminate cardiopulmonary bypass and reduce aortic manipulation may reduce the incidence of post-operative stroke.
  
  
  OBJECTIVE
  A network meta-analysis was performed to compare post-operative outcomes between all CABG techniques, including anaortic off-pump CABG (anOPCABG), off-pump with the clampless Heartstring device (OPCABG-HS), off-pump with a partial clamp (OPCABG-PC), and traditional on-pump CABG with aortic cross-clamping.
  
  
  METHODS
  A systematic search of 6 electronic databases was performed to identify all publications reporting the outcomes of the included operations. Studies reporting the primary endpoint, 30-day post-operative stroke rate, were included in a Bayesian network meta-analysis.
  
  
  RESULTS
  There were 13 included studies with 37,720 patients. At baseline, anOPCABG patients had higher previous stroke than did the OPCABG-PC (7.4% vs. 6.5%; p = 0.02) and CABG (7.4% vs. 3.2%; p = 0.001) patients. AnOPCABG was the most effective treatment for decreasing the risk of post-operative stroke (-78% vs. CABG, 95% confidence interval [CI]: 0.14 to 0.33; -66% vs. OPCABG-PC, 95% CI: 0.22 to 0.52; -52% vs. OPCABG-HS, 95% CI: 0.27 to 0.86), mortality (-50% vs. CABG, 95% CI: 0.35 to 0.70; -40% vs. OPCABG-HS, 95% CI: 0.38 to 0.94), renal failure (-53% vs. CABG, 95% CI: 0.31 to 0.68), bleeding complications (-48% vs. OPCABG-HS, 95% CI: 0.31 to 0.87; -36% vs. CABG, 95% CI: 0.42 to 0.95), atrial fibrillation (-34% vs. OPCABG-HS, 95% CI: 0.49 to 0.89; -29% vs. CABG, 95% CI: 0.55 to 0.87; -20% vs. OPCABG-PC, 95% CI: 0.68 to 0.97), and shortening the length of intensive care unit stay (-13.3 h; 95% CI: -19.32 to -7.26; p < 0.0001).
  
  
  CONCLUSIONS
  Avoidance of aortic manipulation in anOPCABG may decrease the risk of post-operative stroke, especially in patients with higher stroke risk. In addition, the elimination of cardiopulmonary bypass may reduce the risk of short-term mortality, renal failure, atrial fibrillation, bleeding, and length of intensive care unit stay.
authors.affiliation: Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Baird Institute of Applied Heart and Lung Surgical Research, Sydney, New South Wales, Australia.
authors.forename: Dong Fang
authors.initials: DF
authors.lastname: Zhao
authors.affiliation: Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Baird Institute of Applied Heart and Lung Surgical Research, Sydney, New South Wales, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
authors.forename: J James
authors.initials: JJ
authors.lastname: Edelman
authors.affiliation: Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Baird Institute of Applied Heart and Lung Surgical Research, Sydney, New South Wales, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
authors.forename: Michael
authors.initials: M
authors.lastname: Seco
authors.affiliation: Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Baird Institute of Applied Heart and Lung Surgical Research, Sydney, New South Wales, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Sydney Heart and Lung Surgeons, Sydney, New South Wales, Australia.
authors.forename: Paul G
authors.initials: PG
authors.lastname: Bannon
authors.affiliation: Baird Institute of Applied Heart and Lung Surgical Research, Sydney, New South Wales, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Sydney Heart and Lung Surgeons, Sydney, New South Wales, Australia.
authors.forename: Michael K
authors.initials: MK
authors.lastname: Wilson
authors.affiliation: Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Baird Institute of Applied Heart and Lung Surgical Research, Sydney, New South Wales, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Sydney Heart and Lung Surgeons, Sydney, New South Wales, Australia.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Byrom
authors.affiliation: Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Vinod
authors.initials: V
authors.lastname: Thourani
authors.affiliation: Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Andre
authors.initials: A
authors.lastname: Lamy
authors.affiliation: Department of Cardiovascular Surgery, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom.
authors.forename: David P
authors.initials: DP
authors.lastname: Taggart
authors.affiliation: Department of Cardiac Surgery, Mt. Sinai Hospital, New York, New York.
authors.forename: John D
authors.initials: JD
authors.lastname: Puskas
authors.affiliation: Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Baird Institute of Applied Heart and Lung Surgical Research, Sydney, New South Wales, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Sydney Heart and Lung Surgeons, Sydney, New South Wales, Australia. Electronic address: michael.vallely@sydneyheartandlung.com.au.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Vallely
mesh_terms: D000328:Adult; D000368:Aged; D001011:Aorta; D001026:Coronary Artery Bypass / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control*; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*
keywords: aorta; cardiopulmonary bypass; coronary artery bypass grafting; no-touch; off-pump; stroke