SHA24/068004

Dr. Huda Ismail , MD Consultant Department of Adult Cardiac Surgery PSCC , Riyadh

OPCAB

was introduced > 30yrs ago, adopted mainly by developing countries then gradually introduced in developed countries where patients are older with comorbidities in an attempt to reduce the risk of CPB The

debate between OPCAB proponents and critics is still unchanged even after 25ys Currently

OPCAB plateaued to 15-20% in the west but still popular in the far-east (70-100% in China)

Circulation.2010;121:498-504

Ann. Thorac surg 2005;80: 2141-7



6665pts & Follow up 4.5yrs

Circulation.2012;121:1800-1808

Conclusion: OPCAB is associated with minimal short term benefits and high long term risk of repeat revascularization and major vascular adverse events specially among high risk pts. OPCAB is less cost effective in the long run

Hu et al.Circulation.2012;121:1800-18

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Observational (8yrs) 297pt ONCAB & 298pt OPCAB Conversion rate 1.1% Acutely converted pts. tended to have higher in hospital mortality & morbidity Acute conversion appeared to lead to an increased risk of death or serious cardiac related events up to 2-3yrs postop

Conclusion: The experience of the surgeon is the main factor

J. Cardiothoracic Surgery,2006 (29).941-947

  

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59 RCT (8961pts) Mean age 63yrs (16% ♀) All cause mortality showed no statistically significant difference OPCAB benefits were thought to be more when more graft were performed

Afilalo et al, Euro Heart Journal, Oct. 2011

Myocardial infarction showed no difference Afilalo et al, Euro Heart Journal, Oct. 2011

Stroke there was a 30% reduction in OPCAB Afilalo et al, Euro Heart Journal, Oct. 2011

 To assess the benefits & harm of OPCAB vs. ONCAB  86 RCT trials (10,716pt) OPCAB vs. ONCAB

Result

All cause mortality

75trial ,OPCAB significantly increased mortality P=0.04

Myocardial infarction

55trials,no difference

Stroke

64trials , a significantly greater risk of stroke in ONCAB however in the trials with low risk of bias no statistically significant differences were observed

Atrial fibrillation

34trials ,significant effect of OPCAB P=0.008

Coronary Revascularization

19trial ,no statistical significant differences

Renal impairment

21 trials ,no significant difference

Number of distal anastomosis

OPCAB resulted in fewer distal anastomosis(p<.00001) Mollar et al. Cochrane review 2012(3)

Conclusion: OPCAB

has no significant benefit regarding mortality ,MI &

stroke OPCAB

may be an acceptable option when ONCAB is contraindicated Based

on current evidence ONCAB is the standard treatment option for CAD

Circulation. 2012;125:2827-2835

NEJM,2012;366:1489-97

NEJM,2012;366:1489-97

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Adopting OPCAB is hindered by long learning curve

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High risk pts. are included in registries that report clinical and statistical benefits in term of mortality and all major postoperative complications



Most OPCAB RCT are conducted on low risk pts.

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No supportive evidence to the superiority of OPCAB

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OPCAB outcome depends on the experience of the surgeon

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OPCAB still shrouded in controversy Need for large RCT mainly in the high risk and elderly patients Limit OPCAB in the hands of experienced centers or surgeons to achieve complete revascularization