Off-pump versus on-pump surgery - Advantages only in high-risk patients [Off-pump- versus on-pump-chirurgie - Vorteile nur für hochrisikopatienten?]

摘要

Adverse clinical consequences associated with conventional coronary artery bypass surgery (CCAB) have largely been attributed to cardiopulmonary bypass circuit (CPB), hypothermic cardiac arrest, aortic cannulation, and cross-damping. Consequently, there has been a growing interest in safer alternatives to CCAB including off-pump beating heart bypass surgery (OPCAB). Since its introduction fifteen years ago, early prospective randomized studies and meta-analyses comparing OPCAB and CCAB in mixed patient populations failed to demonstrate a significant benefit of OPCAB surgery on early mortality or perioperative major cardiac and cerebrovascular events. In recent years efforts were made to analyze the impact of OPCAB surgery for patients with specific cardiac and extracardiac risks. For these subsets of patients several mono- and multicenter studies are available today. Even if most of them were non-randomized and thus failed to reach evidence level A according to the AHA/ACC definition, they still allow analyzing interim results for each specific perioperative risk factor. Particularly multi-risk patients and patients with severely reduced left ventricular function seem to benefit in terms of perioperative mortality and major morbidity. Moreover, for most subsets of patients with significant extracardiac risk factors the incidence or perioperative stroke was reduced. In patients with preoperative renal and pulmonary dysfunction a decrease of corresponding organ failure was found for OPCAB strategy. For most risk populations transfusion requirements were significantly lower in OPCAB surgery. In none of the patients an unfavourable outcome of OPCAB compared to CCAB was evident.