Coronary artery bypass grafting with and without manipulation of the ascending aorta: a network meta-analysis

Dong Fang Zhao,  James Edelman, Michael Seco, Paul G. Bannon, Michael K. Wilson, Michael J. Byrom, Vinod Thourani, Andre Lamy, David P. Taggart, John D. Puskas, Michael P. Vallely

Background

Coronary artery bypass grafting (CABG) remains the standard of treatment for three-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.

Objectives

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 clamp-less 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 six 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 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 postoperative stroke (-78% vs CABG, 95% CI 0.14 – 0.33; -66% vs OPCABG-PC, 0.22 – 0.52; - 52% vs OPCABG-HS, 0.27 – 0.86), mortality (-50% vs CABG, 0.35 – 0.70; -40% vs OPCABG-HS, 0.38 – 0.94), renal failure (-53% vs CABG, 0.31 – 0.68), bleeding complications (-48% vs OPCABG-HS, 0.31 – 0.87; -36% vs CABG, 0.42 – 0.95), atrial fibrillation (-34% vs OPCABG-HS, 0.49 – 0.89; -29% vs CABG, 0.55 – 0.87; -20% vs OPCABG-PC, 0.68 – 0.97), and shortening the length of ICU stay (-13.3 hours, -19.32 to -7.26, P<0.0001).

Conclusions

Avoidance of aortic manipulation in an OPCABG may decrease the risk of post-operative stroke, especially in patients with higher stroke risk. In addition, the elimination of CPB may reduce the risk of short-term mortality, renal failure, atrial fibrillation, bleeding, and length of ICU stay.