Clinic for Cardiovascular Surgery, University of Zurich, Zurich, Switzerland.
J Thorac Cardiovasc Surg. 2011 Dec;142(6):1499-506. doi: 10.1016/j.jtcvs.2011.04.031. Epub 2011 Jun 16.
Both off-pump surgery (OPCAB) and aortic no-touch technique reduce stroke after coronary artery bypass grafting (CABG). We evaluate the impact of partial aortic clamping (PC) versus a no-touch technique using either the HEARTSTRING system (HS) or total arterial revascularization (TAR) on the incidence of stroke.
From 1999 [corrected] to 2009, 4314 patients underwent myocardial revascularization. Patients either underwent OPCAB (n = 2203) or conventional on-pump CABG (n = 2111). The OPCAB cohort was divided into 2 subgroups: patients requiring proximal anastomosis applying PC (n = 567) or a "no-touch" technique with the HS (n = 1365). Patients who received TAR (n = 271) served as a control group (gold-standard). Data collection was performed prospectively using a propensity score (PS)-adjusted regression analysis. End points were stroke, mortality, major adverse cardiac and cerebrovascular events (MACCE), and a noncardiac composite end point including respiratory failure, renal failure, and bleeding.
The mortality rate (1.6% vs 2.4%; propensity-adjusted odds ratio [PAOR] = 0.51; CI 95%, 0.26-0.99; P = .047), MACCE (7.9% vs 17.1%; PAOR = 0.67; CI 95%, 0.52-0.84; P = .001) including myocardial infarction (1.1% vs 2.2%; PAOR = 0.50; CI 95%, 0.26-0.98; P = .044) and stroke (1.1% vs 2.4%; PAOR = 0.35; CI 95%, 0.17-0.72; P = .005) as well as the noncardiac composite (PAOR = 0.46; CI 95%, 0.35-0.91; P < .001) were significantly lower for OPCAB when compared with on-pump CABG. In comparison with PC, OPCAB patients undergoing the HS approach had significantly lower frequencies of stroke (0.7% vs 2.3%; PAOR = 0.39; CI 95%, 0.16-0.90; P = .04) and MACCE (6.7% vs 10.8%; PAOR = 0.55; CI 95%, 0.38-0.79; P = .001), and these results were similar to those of the control group, who underwent no-touch TAR (stroke rate, 0.8%; MACCE, 7.9%).
Our results confirm that OPCAB is superior with regard to risk-adjusted outcomes. There is no difference in the stroke rate when comparing on-pump CABG versus applying partial aortic crossclamping in OPCAB. Whenever a proximal anastomosis is needed, a no-touch technique should be applied, that is, using the HS device.
非体外循环冠状动脉旁路移植术（OPCAB）和主动脉不接触技术均可降低冠状动脉旁路移植术后（CABG）的中风发生率。我们评估了使用 HEARTSTRING 系统（HS）或全动脉血运重建（TAR）的部分主动脉钳夹（PC）与非接触技术对中风发生率的影响。
1999 年至 2009 年，4314 例患者接受了心肌血运重建。患者接受 OPCAB（n=2203）或常规体外循环 CABG（n=2111）。OPCAB 队列分为 2 个亚组：需要近端吻合时应用 PC（n=567）或 HS 的“非接触”技术（n=1365）。接受 TAR（n=271）的患者作为对照组（金标准）。数据采用倾向评分（PS）调整回归分析进行前瞻性收集。终点事件为中风、死亡率、主要心脏和脑血管不良事件（MACCE）以及包括呼吸衰竭、肾衰竭和出血在内的非心脏复合终点。
死亡率（1.6%对 2.4%；调整后的优势比[PAOR]为 0.51；95%CI，0.26-0.99；P=0.047）、MACCE（7.9%对 17.1%；PAOR=0.67；95%CI，0.52-0.84；P=0.001），包括心肌梗死（1.1%对 2.2%；PAOR=0.50；95%CI，0.26-0.98；P=0.044）和中风（1.1%对 2.4%；PAOR=0.35；95%CI，0.17-0.72；P=0.005）以及非心脏复合终点（PAOR=0.46；95%CI，0.35-0.91；P<0.001）在 OPCAB 组明显低于体外循环 CABG 组。与 PC 相比，接受 HS 方法的 OPCAB 患者中风发生率（0.7%对 2.3%；PAOR=0.39；95%CI，0.16-0.90；P=0.04）和 MACCE（6.7%对 10.8%；PAOR=0.55；95%CI，0.38-0.79；P=0.001）明显较低，结果与接受无接触 TAR（中风率 0.8%；MACCE 7.9%）的对照组相似。
我们的结果证实，OPCAB 在风险调整结局方面更具优势。在体外循环 CABG 与 OPCAB 中的部分主动脉钳夹相比，中风发生率没有差异。无论何时需要进行近端吻合，都应采用非接触技术，即使用 HS 装置。
