Louis-Mathieu Stevens1, Nicolas Noiseux1, Alvaro Avezum2, Dharma Rakshak Ayapati3, Xin Chen4, Fernando Antonio Lucchese5, Horacio Cacheda6, Sirish Parvathaneni7, Yongning Ou8, André Lamy8. 1. Department of Surgery, Division of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal and Research Center, Montreal, QC, Canada. 2. Research Division, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil. 3. Department of Cardiothoracic Surgery, India Global Hospitals, Hyderabad, India. 4. Department of Cardiothoracic Surgery, Nanjing First Hospital, Nanjing, China. 5. Department of Cardiovascular Surgery, São Francisco Hospital, Porto Alegre, Brazil. 6. Department of Cardiothoracic Surgery, Institute of Cardiology of Corrientes, Corrientes, Argentina. 7. Department of Cardiothoracic Surgery, Mercy Medical Research Institute, St-Louis, MO, United States. 8. Department of Surgery, Division of Cardiac Surgery McMaster University and Population Health Research Institute, Hamilton, ON, Canada.
Abstract
Objectives: Emergent and late conversions form OFF-to-ON pump coronary artery bypass grafting (CABG) have been associated with worse outcomes, however, it remains unclear as to which risk factors are associated with conversion and how to prevent them. Methods: Among 4718 patients who randomly underwent off- or on-pump CABG, the incidence of off-pump to on-pump cross-over, or 'OFF-to-ON conversion', was 7.9% (186/2356). The primary outcome was a composite of death, stroke, myocardial infarction, or new renal failure requiring dialysis. We assessed the risk factors and outcomes of converted patients. Results: Emergent OFF-to-ON conversions, defined as conversions for hypotension or ischaemia, were required for 3.2% of patients ( n = 75), while most elective conversions were due to small or intramuscular coronaries ( n = 83). OFF-to-ON converted patients required increased surgery time, blood transfusions, intensive care unit stay, and presented a higher incidence at 1 year of the composite outcome compared with non-converted off-pump patients (all P < 0.01), especially if the conversion was emergent. Conversely, elective conversions outcomes were no different compared with non-converted off-pump patients ( P = 0.35). Independent predictors of emergent conversions included higher heart rate or chronic atrial fibrillation, urgent surgery, more grafts planned and surgeon experience with off-pump CABG. Conclusions: Emergent OFF-to-ON conversion is associated with worse outcomes compared with elective conversion or no conversion. In the presence of risk factors for emergent conversion, an early and elective conversion approach is a judicious strategy.
RCT Entities:
Objectives: Emergent and late conversions form OFF-to-ON pump coronary artery bypass grafting (CABG) have been associated with worse outcomes, however, it remains unclear as to which risk factors are associated with conversion and how to prevent them. Methods: Among 4718 patients who randomly underwent off- or on-pump CABG, the incidence of off-pump to on-pump cross-over, or 'OFF-to-ON conversion', was 7.9% (186/2356). The primary outcome was a composite of death, stroke, myocardial infarction, or new renal failure requiring dialysis. We assessed the risk factors and outcomes of converted patients. Results: Emergent OFF-to-ON conversions, defined as conversions for hypotension or ischaemia, were required for 3.2% of patients ( n = 75), while most elective conversions were due to small or intramuscular coronaries ( n = 83). OFF-to-ON converted patients required increased surgery time, blood transfusions, intensive care unit stay, and presented a higher incidence at 1 year of the composite outcome compared with non-converted off-pump patients (all P < 0.01), especially if the conversion was emergent. Conversely, elective conversions outcomes were no different compared with non-converted off-pump patients ( P = 0.35). Independent predictors of emergent conversions included higher heart rate or chronic atrial fibrillation, urgent surgery, more grafts planned and surgeon experience with off-pump CABG. Conclusions: Emergent OFF-to-ON conversion is associated with worse outcomes compared with elective conversion or no conversion. In the presence of risk factors for emergent conversion, an early and elective conversion approach is a judicious strategy.
Authors: Mario Gaudino; Gianni D Angelini; Charalambos Antoniades; Faisal Bakaeen; Umberto Benedetto; Antonio M Calafiore; Antonino Di Franco; Michele Di Mauro; Stephen E Fremes; Leonard N Girardi; David Glineur; Juan Grau; Guo-Wei He; Carlo Patrono; John D Puskas; Marc Ruel; Thomas A Schwann; Derrick Y Tam; James Tatoulis; Robert Tranbaugh; Michael Vallely; Marco A Zenati; Michael Mack; David P Taggart Journal: J Am Heart Assoc Date: 2018-08-21 Impact factor: 5.501