Surgical treatment of left main disease and severe carotid stenosis: does the off-pump technique provide a better outcome?

Michael O Zembala, Krzysztof Filipiak, Daniel Ciesla, Jerzy Pacholewicz, Tomasz Hrapkowicz, Piotr Knapik, Roman Przybylski, Marian Zembala
European Journal of Cardio-thoracic Surgery 2013, 43 (3): 541-8; discussion 548

OBJECTIVES: Left main disease (LMD), combined with carotid artery stenosis (CAS), constitutes a high-risk patient population. Priority is often given to coronary revascularization, due to the severity of the angina. However, the choice of revascularization strategy [off-pump coronary artery bypass (OPCAB) vs coronary artery bypass grafting (CABG)] remains elusive.

METHODS: A total of 1340 patients with LMD were non-randomly assigned to either on-pump (CABG group, n = 680) or off-pump (OPCAB group, n = 634) revascularization between 1 January 2006 and 21 September 2010. Multivariable regression was used to determine the risk-adjusted impact of a revascularization strategy on a composite in-hospital outcome (MACCE), and proportional hazards regression was used to define the variables affecting long-term survival.

RESULTS: Significant CAS was found in 130 patients: 84 (13.1%) patients underwent OPCAB, while 46 patients (6.8%) underwent CABG (P < 0.05). Patients with a history of stroke/transient ischaemic attack were also more likely to receive OPCAB (7.1 vs 4.7%; P = 0.08). OPCAB patients were older, in a higher New York Heart Association (NYHA) class, with a lower LVEF and higher EuroSCORE. A calcified aorta was found in 79 patients [OPCAB-CABG: 49 (7.73%) vs 30 (4.41%); P = 0.016] and resulted in a less complex revascularization (OPCAB-CABG: 2.3 ± 0.71 vs 3.19 ± 0.82; P < 0.05), and 30-day mortality was insignificantly higher in the CABG (2.7 vs 2.8%) as well as MACCE (11.2 vs 12.2%; P = NS). This trend reversed when late mortality was evaluated; however, it did not reach significance at 60 months. Preoperative renal impairment requiring dialysis was found to be a technique-independent predictor of MACCE. The number of arterial conduits also influenced MACCE.

CONCLUSIONS: Off-pump coronary revascularization may offer risk reduction of neurological complications in patients with a significant carotid artery disease and a history of previous stroke, but a larger study population is needed to support this thesis. The growing discrepancy in long-term survival should draw attention to a more complete revascularization in OPCAB patients.

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