BACKGROUND: Most recent published meta-analysis of randomized controlled trials (RCTs) showed that off-pump coronary artery bypass graft surgery (CABG) reduces incidence of stroke by 30% compared with on-pump CABG, but showed no difference in other outcomes. New RCTs were published, indicating need of new meta-analysis to investigate pooled results adding these further studies. METHODS: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for RCTs that compared outcomes (30-day mortality for all-cause, myocardial infarction or stroke) between off-pump versus on-pump CABG until May 2012. The principal summary measures were relative risk (RR) with 95% Confidence Interval (CI) and P values (considered statistically significant when <0.05). The RR's were combined across studies using DerSimonian-Laird random effects weighted model. Meta-analysis and meta-regression were completed using the software Comprehensive Meta-Analysis version 2 (Biostat Inc., Englewood, New Jersey, USA). RESULTS: Forty-seven RCTs were identified and included 13,524 patients (6,758 for off-pump and 6,766 for on-pump CABG). There was no significant difference between off-pump and on-pump CABG groups in RR for 30-day mortality or myocardial infarction, but there was difference about stroke in favor to off-pump CABG (RR 0.793, 95% CI 0.660-0.920, P=0.049). It was observed no important heterogeneity of effects about any outcome, but it was observed publication bias about outcome "stroke". Meta-regression did not demonstrate influence of female gender, number of grafts or age in outcomes. CONCLUSION: Off-pump CABG reduces the incidence of post-operative stroke by 20.7% and has no substantial effect on mortality or myocardial infarction in comparison to on-pump CABG. Patient gender, number of grafts performed and age do not seem to explain the effect of off-pump CABG on mortality, myocardial infarction or stroke, respectively.

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Off-pump versus on-pump coronary artery bypass surgery: meta-analysis and meta-regression of 13,524 patients from randomized trials

Objective: To determine the prevalence, risk factors, and the clinical outcome of patients undergone coronary artery bypass grafting who progressed with Acute Renal Failure (ARF). Methods: A prospective study was performed from data of 186 patients undergone surgery from January 2003 through June 2006. The stored data were analyzed using the software STATA 9.0. Results: The prevalence of ARF was of 30.6% (57/186). In 7.0% (4/57) dialysis therapy was needed. The mean age of patients with and without ARF progression was 62.8 % (±9.4) years and 61.3% (±8.8) years respectively (P=NS). CPB time >115 min (p= 0.011) and cross-clamp time >85 min (p=0.044) were related to ARF by the univariate analysis. The need for intra-aortic balloon (P= 0.049), mechanical ventilation >24h (P = 0.006), Intensive Care Unit (ICU) stay > three days (P 3 days showed statistical correlation with ARF by the multivariate analysis (P=0.018). The mortality rate with and without ARF was 8.8% (five cases) and 0.8% (one case) respectively (P=0.016), but it reached 50% (2/4) in dialytic patients. Conclusion: ARF was a frequent and severe postoperative complication associated with higher mortality and longer ICU stay, which presented as risk factors: longer CPB and cross-clamp times, mechanical ventilation > 24h and hemodynamic instability.

http://www.scielo.br/pdf/rbccv/v24n3/en_v24n3a07.pdf

Prevalence and risk factors for acute renal failure in the postoperative of coronary artery bypass grafting.

OBJECTIVE: To analyze the results of isolated on-pump coronary artery bypass graft surgery (CABG) in patients >70 years-old in comparison to patients 70 years-old) and G2 (age 70-year-old was an independent predictive factor for higher in-hospital mortality (P=0.004), reexploration for bleeding (P=0.002), sepsis (P=0.002), respiratory complications (P 70 years-old were at increased risk of death and other complications in the CABG's postoperative period in comparison to younger patients.

/pdf/age-influences-outcomes-in-70-year-or-older-patients-1ezsn19zbk.pdf

Age influences outcomes in 70-year or older patients undergoing isolated coronary artery bypass graft surgery

INTRODUCAO: Transfusoes de uma ou mais unidades de concentrado de hemacias e estrategia amplamente utilizada em cirurgia cardiaca, mesmo apos varias evidencias de aumento de morbimortalidade. A escassez de sangue no mundo tambem ja e evidente. OBJETIVO: Avaliar se o risco de mortalidade e dose-dependente do numero de unidades de concentrado de hemacias transfundidas apos cirurgia de revascularizacao miocardica. METODOS: Entre junho 2009 e julho 2010, foram analisados 3010 pacientes: transfundidos e nao transfundidos. Pacientes hemotransfundidos foram divididos em seis grupos conforme receberam uma, duas, tres, quatro, cinco e seis ou mais unidades concentrado de hemacias e, apos um ano da cirurgia de revascularizacao miocardica, avaliamos o risco de mortalidade em cada grupo. Para obtencao do odds ratio foi utilizado modelo de regressao logistica multivariado. RESULTADOS: Transfusao crescente de unidades de concentrado de hemacias resulta em risco tambem crescente de mortalidade, evidenciando uma relacao dose-reposta. Os valores do odds ratio aumentam com o acrescimo do numero de unidades de hemacias alogenicas transfundidas. O risco de ocorrencia de obitos pelo odds ratio bruto foi 1,42 (P=0,165); 1,94 (P=0,005); 4,17; 4,22; 8,70, 33,33 (P<0,001) e o risco de mortalidade pelo odds ratio ajustado foi 1,22 (P=0,43); 1,52 (P=0,08); 2,85; 2,86; 4,91 e 17,61 (P<0,001), conforme receberam transfusao de uma, duas, tres, quatro, cinco, seis ou mais unidades concentrado de hemacias, respectivamente. CONCLUSAO: O risco de mortalidade e diretamente proporcional ao numero de unidades de concentrado de hemacias transfundidas em cirurgia de revascularizacao miocardica. Quanto mais sangue alogenico transfundido, maior o risco de mortalidade. A pratica transfusional atual precisa ser reavaliada.

Mortality risk is dose-dependent on the number of packed red blood cell transfused after coronary artery bypass graft

Objective: To analyze the in-hospital outcome of elderly patients aged 70 years and older who were operated on, using the beating heart coronary artery bypass grafting with an intraluminal shunt, in urgent, emergent and elective coronary revascularizations. Methods: From July 1989 to July 2005, prospectively, we analyzed 87 patients aged 70 to 92 years old. In the whole group, 50 (57.5%) patients had unstable angina, with three (3.4%) acute myocardial infarction. Thirty-one (35.6%) patients underwent urgent and emergent surgery. Thirteen (14.9%) patients had myocardial infarction in less than 30 days and 34 (39.1%) in more than 30 days. Results: The main postoperative complications were: atrial fibrillation (32.2%), heart failure (12.6%), pneumonia (10.3%), septicemia (3.4%), acute myocardial infarction (2.3%), mediastinitis (1.1%) transient ischemic attack (1.1%) and pneumothorax (1.1%). The mean extubation time was 18.50±19.09 hours, the intensive care unit stay was 2.92±2.03 days, and hospital stay was 10.55±7.16 days. Nine (10.34%) patients received blood transfusion with no reoperation for bleeding. The in-hospital mortality was 4.6%. Conclusions: In 70 years old and over patients, elective and non-elective off-pump coronary artery bypass grafting with intracoronary shunt showed to be safe and effective, associated with low rates of postoperative complications and mortality in relation to the studied population.

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Off-pump myocardial revascularization in the elderly: analysis of morbidity and mortality

OBJECTIVE: The purpose of the present study is to compare and analyze the benefits of this operation with and without cardiopulmonary bypass in octogenarian patients. METHOD: Retrospective data of the patients aged eighty years or more from December 1995 to December 2003 were analyzed. During this period 73 patients were submitted to coronary artery bypass grafting (CABG), 26 (35.6%) on-pump and 47 (64.4%) off-pump. A comparison was made of the demographic data, preoperative risks, concurrent morbid conditions, types of angina, postoperative complications and surgical outcomes between the on-pump and off-pump groups. The Student t-test was used to compare the groups and the level of significance was set at p-value < 0.05. RESULTS: Both groups showed a high preoperative risk, although the off-pump group presented less surgical mortality (11.5% vs 2.1%, p < 0.05). No strokes were observed in the patients operated on off-pump (11.5% vs 0.0%, p < 0.005). Atrial fibrillation (AF) in the immediate postoperative period was present less often in the off-pump group (30.8% vs 12.8%, p < 0.005). The postoperative mechanical ventilation time and the presence of respiratory failure were less in the off-pump group (p < 0.005). The presence of acute renal insufficiency (ARI) was 19.2% in the on-pump group and 0% in the off-pump group (p < 0.05). There was less need for transfusion of blood or blood derivatives in the off-pump group (69.2% vs 31.9%, p < 0.005). The mean sojourn in the intensive care unit (ICU) was shorter in the off-pump group (p < 0.05). The percentage of patients with no postoperative complications was higher in the off-pump group than in the on-pump group (89.4% vs 61.5%, p <0.001). CONCLUSIONS: The present study suggests that patients aged eighty years and over benefit when submitted to off-pump CABG and that this procedure is associated with low rates of postoperative complications such as stroke, AF, ARI and respiratory insufficiency, and with less time in the ICU, a shorter hospital sojourn, less use of blood derivatives and lower mortality. In octogenarian patients off-pump CABG surgery is a safe and effective technique, and may be the operation of choice when correctly indicated.

/pdf/revascularizacao-miocardica-em-pacientes-octogenarios-estudo-5gfofctp2z.pdf

Revascularização miocárdica em pacientes octogenários: estudo retrospectivo e comparativo entre pacientes operados com e sem circulação extracorpórea

/pdf/land-use-intensification-promotes-non-native-species-in-a-znwclyh0z6.pdf

Land-use intensification promotes non-native species in a tropical island bird assemblage

Objective: The purpose of the present study is to compare and analyze the benefits of this operation with and without cardiopulmonary bypass in octogenarian patients. Method: Retrospective data of patients aged eighty years or more from December 1995 to December 2003 were analyzed. During this period 73 patients were submitted to coronary artery bypass grafting (CABG), 26 (35.6%) on-pump and 47 (64.4%) off-pump. A comparison was made of the demographic data, preoperative risks, concurrent morbid conditions, types of angina, postoperative complications and surgical outcomes between the on-pump and off-pump groups. The Student t-test was used to compare the groups and the level of significance was set at p-value < 0.05. Results: Both groups showed a high preoperative risk, although the off-pump group presented less surgical mortality (11.5% vs. 2.1%, p < 0.05). No strokes were observed in the patients operated on off-pump (11.5% vs. 0.0%, p < 0.005). Atrial fibrillation (AF) in the immediate postoperative period was present less often in the off-pump group (30.8% vs. 12.8%, p < 0.005). The postoperative mechanical ventilation time and the presence of respiratory failure were less in the offpump group (p < 0.005). The presence of acute renal insufficiency (ARI) was 19.2% in the on-pump group and 0% in the off-pump group (p < 0.05). There was less need for transfusion of blood or blood derivatives in the off-pump group (69.2% vs. 31.9%, p < 0.005). The mean sojourn in the intensive care unit (ICU) was shorter in the off-pump group (p < 0.05). The percentage of patients with no postoperative complications was higher in the off-pump group than in the on-pump group (89.4% vs. 61.5%, p <0.001). Conclusions: The present study suggests that patients aged eighty years and over benefit when submitted to off-pump CABG and that this procedure is associated with low rates of postoperative complications such as strokes, AF, ARI and respiratory insufficiency, and with less time in the ICU, a shorter hospital sojourn, less use of blood derivatives and lower mortality. In octogenarian patients off-pump CABG is a safe and effective technique, and may be the operation of choice when correctly indicated.

Revascularização miocárdica em pacientes octogenários: estudo retrospectivo e comparativo entre pacientes operados com e sem circulação extracorpórea Myocardial revascularization in octogenarian patients: retrospective and comparative study between patients operated on pump and off pump

Hermano Sampaio

Papers

Revascularização miocárdica em pacientes octogenários: estudo retrospectivo e comparativo entre pacientes operados com e sem circulação extracorpórea

Land-use intensification promotes non-native species in a tropical island bird assemblage

Revascularização miocárdica em pacientes octogenários: estudo retrospectivo e comparativo entre pacientes operados com e sem circulação extracorpórea Myocardial revascularization in octogenarian patients: retrospective and comparative study between patients operated on pump and off pump