Advertisement
Heart, Lung and Circulation

Coronary Artery Bypass Grafting in Patients With High Risk of Bleeding

      Background

      Postoperative bleeding after cardiac surgery is associated with increased morbidity and mortality. We tested the hypothesis that patients with a preoperatively estimated high risk of severe perioperative bleeding may have impaired early outcome after on-pump versus off-pump coronary artery bypass grafting (CABG).

      Method

      Data from 7,352 consecutive patients who underwent isolated CABG from January 2015 to May 2017 were included in the multicentre European Coronary Artery Bypass Grafting registry. The postoperative bleeding risk was estimated using the WILL-BLEED risk score. Of all included patients, 3,548 had an increased risk of severe perioperative bleeding (defined as a WILL-BLEED score ≥4) and were the subjects of this analysis. We compared the early outcomes between patients who underwent on-pump or off-pump CABG using a multivariate mixed model for risk-adjusted analysis.

      Results

      Off-pump surgery was performed in 721 patients (20.3%). On-pump patients received more packed red blood cell units (on-pump: 1.41 [95% confidence interval {CI} 0.99–1.86]; off-pump: 0.86 [95% CI 0.64–1.08]; p<0.001), had a longer stay in the intensive care unit (on-pump: 4.4 [95% CI 3.6–8.1] days; off-pump: 3.2 [95% CI 2.0–4.4] days; p=0.049), and a higher rate of postoperative atrial fibrillation (on-pump: 46.5% [95% CI 34.9–58.1]; off-pump: 31.3% [95% CI 21.7–40.9]; p=0.025). Furthermore, on-pump patients showed a trend towards a higher rate of postoperative stroke (on-pump: 2.4% [95% CI 0.9–4.1]; off-pump: 1.1 [95% CI 0.2–2.7]; p=0.094).

      Conclusion

      Our data suggest that in patients with an increased risk of bleeding, the use of cardiopulmonary bypass is associated with higher morbidity. These patients may benefit from off-pump surgery if complete revascularisation can be ensured.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Heart, Lung and Circulation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Houlind K.
        • Kjeldsen B.J.
        • Madsen S.N.
        • Rasmussen B.S.
        • Holme S.J.
        • Nielsen P.H.
        • et al.
        On-pump versus off-pump coronary artery bypass surgery in elderly patients: results from the danish on-pump versus off-pump randomization study.
        Circulation. 2012; 125: 2431-2439
        • Shroyer A.L.
        • Grover F.L.
        • Hattler B.
        • Collins J.F.
        • McDonald G.O.
        • Kozora E.
        • et al.
        On-pump versus off-pump coronary-artery bypass surgery.
        N Engl J Med. 2009; 361: 1827-1837
        • Shroyer A.L.
        • Hattler B.
        • Wagner T.H.
        • Collins J.F.
        • Baltz J.H.
        • Quin J.A.
        • et al.
        Five-year outcomes after on-pump and off-pump coronary-artery bypass.
        N Engl J Med. 2017; 377: 623-632
        • Chikwe J.
        • Lee T.
        • Itagaki S.
        • Adams D.H.
        • Egorova N.N.
        Long-term outcomes after off-pump versus on-pump coronary artery bypass grafting by experienced surgeons.
        J Am Coll Cardiol. 2018; 72: 1478-1486
        • Benedetto U.
        • Lau C.
        • Caputo M.
        • Kim L.
        • Feldman D.N.
        • Ohmes L.B.
        • et al.
        Comparison of outcomes for off-pump versus on-pump coronary artery bypass grafting in low-volume and high-volume centers and by low-volume and high-volume surgeons.
        Am J Cardiol. 2018; 121: 552-557
        • Kowalewski M.
        • Pawliszak W.
        • Malvindi P.G.
        • Bokszanski M.P.
        • Perlinski D.
        • Raffa G.M.
        • et al.
        Off-pump coronary artery bypass grafting improves short-term outcomes in high-risk patients compared with on-pump coronary artery bypass grafting: meta-analysis.
        J Thorac Cardiovasc Surg. 2016; 151: 60-77
        • Lamy A.
        • Devereaux P.J.
        • Prabhakaran D.
        • Taggart D.P.
        • Hu S.
        • Paolasso E.
        • et al.
        Off-pump or on-pump coronary-artery bypass grafting at 30 days.
        N Engl J Med. 2012; 366: 1489-1497
        • Deppe A.-C.
        • Arbash W.
        • Kuhn E.W.
        • Slottosch I.
        • Scherner M.
        • Liakopoulos O.J.
        • et al.
        Current evidence of coronary artery bypass grafting off-pump versus on-pump: a systematic review with meta-analysis of over 16 900 patients investigated in randomized controlled trials.
        Eur J Cardiothoracic Surg. 2016; 49: 1031-1041
        • Jarral O.A.
        • Saso S.
        • Harling L.
        • Casula R.
        • Athanasiou T.
        Atrial fibrillation, blood loss, and transfusion in patients with left ventricular dysfunction: what is the effect of cardiopulmonary bypass?.
        ASAIO J. 2012; 58: 311-319
        • Koch C.G.
        • Li L.
        • Van Wagoner D.R.
        • Duncan A.I.
        • Gillinov A.M.
        • Blackstone E.H.
        Red cell transfusion is associated with an increased risk for postoperative atrial fibrillation.
        Ann Thorac Surg. 2006; 82: 1747-1756
        • Gurbuz O.
        • Kumtepe G.
        • Yolgosteren A.
        • Ozkan H.
        • Karal I.
        • Ercan A.
        • et al.
        A comparison of off- and on-pump beating-heart coronary artery bypass surgery on long-term cardiovascular events.
        Cardiovasc J Afr. 2017; 28: 30-35
        • Bhaskar B.
        • Dulhunty J.
        • Mullany D.V.
        • Fraser J.F.
        Impact of blood product transfusion on short and long-term survival after cardiac surgery: more evidence.
        Ann Thorac Surg. 2012; 94: 460-467
        • Biancari F.
        • Ruggieri V.G.
        • Perrotti A.
        • Svenarud P.
        • Dalén M.
        • Onorati F.
        • et al.
        European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG registry): study protocol for a prospective clinical registry and proposal of classification of postoperative complications.
        J Cardiothorac Surg. 2015; 10: 90
        • Biancari F.
        • Brascia D.
        • Onorati F.
        • Reichart D.
        • Perrotti A.
        • Ruggieri V.G.
        • et al.
        Prediction of severe bleeding after coronary surgery: the WILL-BLEED Risk Score.
        Thromb Haemost. 2017; 117: 445-456
        • R Core Team. R
        A language and environment for statistical computing.
        R Foundation for Statistical Computing, Vienna2014
        • Paparella D.
        • Brister S.J.
        • Buchanan M.R.
        Coagulation disorders of cardiopulmonary bypass: a review.
        Intensive Care Med. 2004; 30: 1873-1881
        • de Haan J.
        • Boonstra P.W.
        • Monnink S.H.J.
        • Ebels T.
        • van Oeveren W.
        Retransfusion of suctioned blood during cardiopulmonary bypass impairs hemostasis.
        Ann Thorac Surg. 1995; 59: 901-907
        • Hartmann M.
        • Boehm O.
        • Koch A.
        • Loer S.
        • Zacharowski K.
        Das Gerinnungssystem während extrakorporaler Zirkulation.
        Kardiotechnik. 2005; 2: 32-43
        • Dieberg G.
        • Smart N.A.
        • King N.
        On- vs. off-pump coronary artery bypass grafting: a systematic review and meta-analysis.
        Int J Cardiol. 2016; 223: 201-211
        • Cheng D.C.
        • Bainbridge D.
        • Martin J.E.
        • Novick R.J.
        Does off-pump coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with conventional coronary artery bypass? A meta-analysis of randomized trials.
        Anesthesiology. 2005; 102: 188-203
        • Almassi G.H.
        • Schowalter T.
        • Nicolosi A.C.
        • Aggarwal A.
        • Moritz T.E.
        • Henderson W.G.
        • et al.
        Atrial fibrillation after cardiac surgery.
        Ann Surg. 1997; 226: 501-513
        • Afilalo J.
        • Rasti M.
        • Ohayon S.M.
        • Shimony A.
        • Eisenberg M.J.
        Off-pump vs. on-pump coronary artery bypass surgery: an updated meta-analysis and meta-regression of randomized trials.
        Eur Heart J. 2012; 33: 1257-1267
        • Kuss O.
        • von Salviati B.
        • Börgermann J.
        Off-pump versus on-pump coronary artery bypass grafting: a systematic review and meta-analysis of propensity score analyses.
        J Thorac Cardiovasc Surg. 2010; 140: 829-835
        • Brascia D.
        • Garcia-Medina N.
        • Kinnunen E.-M.
        • Tauriainen T.
        • Airaksinen J.
        • Biancari F.
        Impact of transfusion on stroke after cardiovascular interventions: meta-analysis of comparative studies.
        J Crit Care. 2017; 38: 157-163
        • Biancari F.
        • Tauriainen T.
        • Kinnunen E.-M.
        • Airaksinen J.
        External validation of the WILL-BLEED risk score.
        Thromb Haemost. 2018; 118: 433-434
        • Gunertem E.
        • Urcun S.
        • Pala A.A.
        • Budak A.B.
        • Ercisli M.A.
        • Gunaydin S.
        Predictiveness of different preoperative risk assessments for postoperative bleeding after coronary artery bypass grafting surgery.
        Perfusion. 2021; 36: 277-284
        • Salsano A.
        • Dominici C.
        • Nenna A.
        • Olivieri G.M.
        • Miette A.
        • Barbato R.
        • et al.
        Predictive scores for major bleeding after coronary artery bypass surgery in low operative risk patients.
        J Cardiovasc Surg (Torino). 2020; 61: 234-242
        • Kereiakes D.J.
        Reassessing the importance of complete versus incomplete coronary revascularization.
        Rev Cardiovasc Med. 2014; 15: 24-30