On-Pump versus Off-Pump Coronary Artery Bypass Grafting in The Surgical Management of High-Risk Patients, A Clinical Randomized Study

Background: Surgical treatment modalities of coronary artery diseases (CAD) include on-pump or off-pump coronary artery bypass grafting (CABG). CABG performed on the beating heart can avoid complications that might occur on cardiopulmonary bypass. Our objective was to compare the effectiveness of on-pump versus off-pump CABG in high-risk patients stratified according to the EuroSCORE scoring system.  Methods: This randomized clinical study included 80 high-risk patients who underwent CABG and assigned into two groups; each contains 40 patients. Patients with valvular affection, ischemic ventricular septal defect or left ventricle and aortic aneurysms, and/or those exhibiting significant neurological pathology were excluded from the study. Study outcomes were blood loss, length of ICU and hospital stay, inotropic use, re-exploration rate, and operative mortality. Results: The study showed significant higher use of inotropic drugs intra and post-operatively (57.5% vs 40%, p = 0.021), more low cardiac output (12.5% vs 2.5%, p = 0.031), lower blood loss (337±67 vs 498±68 ml, p = 0.01), lower blood transfusion (1.1±0.2 vs 1.2±0.4 unit, p = 0.024), more prolonged ICU stay (4.0±1.6 vs 3.0±0.9 day, p = 0.001) and the higher re-exploration rate (17.5% vs 7.5%, p = 0.035) in the on-pump group. Hospital stay (8.7±2 vs 8.1±1, p = 0.121) and early mortality (7.5% vs 2.5%, p = 0.451) did not differ significantly between the two groups. Conclusion: Management of coronary artery disease is still challenging, and there is still a place for off-pump CABG in CAD in high-risk patients due to its advantages in the early complications while has the same total hospital stay when compared with on-pump CABG

Effect of Body Mass Index on Morbidity and Mortality in Patients Undergoing Coronary Artery Bypass Grafting

Background: Obesity affects cardiovascular morbidity and mortality, and it increases the risk of coronary artery disease. Despite that, several cardiac surgery risk stratification scores do not consider the effect of obesity on the outcomes. The objective of this research is to study the impact of body mass index (BMI) on morbidity and mortality after coronary artery bypass grafting (CABG) in Egyptian patients. Methods: This prospective cohort study included 200 patients who underwent CABG for atherosclerotic coronary artery disease. Patients were divided into two groups, group A: patients with BMI ≥ 25 Kg/m2 and group B: patients with BMI < 25 Kg/m2. The mean age in group A was 56± 4.95 years vs. 54± 5.5 years in group B (p= 0.102). Male patients presented 58% of the population in group A vs 74% in group B (p= 0.017). 60% of patients were hypertensive in group A compared to 63% in group B (p= 0.66) and 62%, and 48% were diabetics in group A and B respectively (p= 0.04). Results: Postoperatively, there was a significant increase in wound infection (40% vs 8%; p< 0.001), chest infection (47% vs. 10% p< 0.001), surgical re-exploration (28% vs. 1%; p< 0.001), prolonged ICU stays (5.3 ± 2.88 vs. 3.93 ± 1.71 days; p< 0.001), ward stay (11.28 ±8.9 vs. 5.48 ± 2.45 days; p< 0.001), mediastinitis (34% vs. 6%; p< 0.001), the occurrence of sternal wound sinus within 8 months (26% vs. 7%; p< 0.001), in group A more compared to group B. There was no difference in ejection fraction (54.2 ±7.38 vs. 54.7 ± 9.1%; p= 0.69) and mortality (4% vs. 2%; p= 0.68) between groups. Conclusions: BMI 25 Kg/m2 or higher is associated with increased infectious complications and prolonged stay after CABG; however, it did not affect mortality. Optimizing body weight is recommended before elective surgery

Chordae Tendineae Sparing during Mitral Valve Replacement: A Comparative Study

Background: Mitral valve replacement (MVR) with chordal sparing could improve ventricular function in patients with mitral regurgitation. This study aimed to compare the outcomes of prosthetic MVR with and without chordae tendineae sparing. Methods: This prospective, single-blinded, randomized study was executed on 60 patients undergoing prosthetic MVR with or without chordae tendineae sparing. Patients were divided into two equal groups: Group A (n= 30) included patients who underwent MVR with complete chordae tendineae sparing, and Group B (n= 30) included patients who underwent mitral valve replacement without chordae tendineae sparing. Results: Patients who underwent chordae tendineae sparing demonstrated significantly lower total bypass time (median = 67 vs. 110 min, P < 0.001), total cross-clamp time (median = 40 vs. 80 min, P < 0.001), inotropic support (30% vs. 96.7%, P < 0.001), and arrhythmia (6.7% vs. 86.7%, P < 0.001) than those who did not undergo chordal sparing. Additionally, patients who underwent sparing demonstrated a significantly lower 6-month left ventricle end-systolic diameter (3 ±0.8 vs. 3.9 ±0.5 cm, P < 0.001), 6-month left ventricle end-diastolic diameter (4.4 ±0.7 vs. 5.3 ±0.5 cm, P < 0.001), 3-month left atrium diameter (4.5 ±0.8 vs. 5.1 ±0.6 cm, P < 0.001), and 6-month left atrium diameter (4.3 ±0.8 vs. 5.4 ±0.6 cm, P < 0.001). Conclusion: This technique of MVR might enhance cardiac function and structural parameters and lower the end-diastolic and systolic diameters and the end-systolic and diastolic volumes up to the sixth month of follow-up