Does avoidance of cardiopulmonary bypass decrease the incidence of stroke in diabetics undergoing coronary surgery?

R. Abraham, H. L. Karamanoukian, M. R. Jajkowski, K. von Fricken, G. D'Ancona, J. Bergsland, Tomas Salerno

Research output: Contribution to journalArticle

17 Citations (Scopus)

Abstract

Background: The adverse effects of diabetes mellitus on the coronary circulation and the higher incidence of cardiovascular events in diabetic patients are well documented [Johnson 1982]. Improvements in myocardial protection, revascularization techniques, and anesthetic management have had favorable impacts on coronary artery bypass grafting (CABG) outcome in diabetic patients. Despite that, diabetic patients are significantly more likely to have a prior history of myocardial infarction, congestive heart failure, peripheral vascular disease, and hypertension, as well as having a significantly greater baseline serum creatinine. The aim of our study was to record, compare, and analyze the stroke rate among patients with a history of preoperative diabetes undergoing "off-pump" CABG (OPCAB) with conventional cardiopulmonary bypass (CPB) CABG to determine whether the stroke rate in this higher risk population could be decreased by off-pump techniques. Methods: The records of 1,227 patients with a pre-operative history of diabetes undergoing conventional CABG (973 patients, 79.3%) using cardiopulmonary bypass and off-pump CABG 254 (20.7%) were analyzed from 1995 through 1999. There were no differences in age, sex, or elective/urgent status of patients. Preoperative risk factors (gender distribution, carotid disease, ejection fraction, CHF, hypertension, previous MI) were identical in both groups. The goal of the operations were complete revascularization, which was achieved via median sternotomy in both groups. Results: Our reported series reveals a stroke rate of 3.6% in the CPB group and 1.2% in the off-pump group. This evidence alone was not statistically significant, but two other high-risk criteria for stroke, re-do CABG and calcified aortas, revealed that the off-pump series had a higher percentage of each (26.4% redos in off-pump vs. 8.7% CPB redos, p < 0.005; 7.1% calcified aorta cases in the off-pump group vs. 2.9% in the CPB group, p < 0.004). The threefold reduction in stroke may be clinically significant in light of the higher-risk profile of the off-pump group. The limitations of this study are that it was retrospective, there were a small number of events, and different surgeons were involved in the two different approaches to these patients. Conclusions: Improvements in myocardial protection, revascularization techniques, and anesthetic management have made significant, favorable impacts on CABG outcome in diabetic patients. New diagnostic and therapeutic strategies must be developed to lessen the medical and economic implications of stroke. A larger series or a more effective way of analyzing preoperative risk may well have shown a statistically significant difference in the stroke incidence given the differences in preoperative risk factors/stroke predictors. Until such advances occur, a three-fold reduction of stroke incidence using OPCAB certainly makes this technique a favorable one for high-risk diabetics requiring coronary revascularization.

Original languageEnglish
Pages (from-to)135-140
Number of pages6
JournalHeart Surgery Forum
Volume4
Issue number2
StatePublished - Jul 18 2001
Externally publishedYes

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Cardiopulmonary Bypass
Coronary Artery Bypass
Stroke
Incidence
Off-Pump Coronary Artery Bypass
Myocardial Revascularization
Aorta
Anesthetics
Hypertension
Medical Economics
Coronary Circulation
Sternotomy
Peripheral Vascular Diseases
Creatinine
Diabetes Mellitus
Heart Failure
Myocardial Infarction
Serum
Population

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Abraham, R., Karamanoukian, H. L., Jajkowski, M. R., von Fricken, K., D'Ancona, G., Bergsland, J., & Salerno, T. (2001). Does avoidance of cardiopulmonary bypass decrease the incidence of stroke in diabetics undergoing coronary surgery? Heart Surgery Forum, 4(2), 135-140.

Does avoidance of cardiopulmonary bypass decrease the incidence of stroke in diabetics undergoing coronary surgery? / Abraham, R.; Karamanoukian, H. L.; Jajkowski, M. R.; von Fricken, K.; D'Ancona, G.; Bergsland, J.; Salerno, Tomas.

In: Heart Surgery Forum, Vol. 4, No. 2, 18.07.2001, p. 135-140.

Research output: Contribution to journalArticle

Abraham, R, Karamanoukian, HL, Jajkowski, MR, von Fricken, K, D'Ancona, G, Bergsland, J & Salerno, T 2001, 'Does avoidance of cardiopulmonary bypass decrease the incidence of stroke in diabetics undergoing coronary surgery?', Heart Surgery Forum, vol. 4, no. 2, pp. 135-140.
Abraham R, Karamanoukian HL, Jajkowski MR, von Fricken K, D'Ancona G, Bergsland J et al. Does avoidance of cardiopulmonary bypass decrease the incidence of stroke in diabetics undergoing coronary surgery? Heart Surgery Forum. 2001 Jul 18;4(2):135-140.
Abraham, R. ; Karamanoukian, H. L. ; Jajkowski, M. R. ; von Fricken, K. ; D'Ancona, G. ; Bergsland, J. ; Salerno, Tomas. / Does avoidance of cardiopulmonary bypass decrease the incidence of stroke in diabetics undergoing coronary surgery?. In: Heart Surgery Forum. 2001 ; Vol. 4, No. 2. pp. 135-140.
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N2 - Background: The adverse effects of diabetes mellitus on the coronary circulation and the higher incidence of cardiovascular events in diabetic patients are well documented [Johnson 1982]. Improvements in myocardial protection, revascularization techniques, and anesthetic management have had favorable impacts on coronary artery bypass grafting (CABG) outcome in diabetic patients. Despite that, diabetic patients are significantly more likely to have a prior history of myocardial infarction, congestive heart failure, peripheral vascular disease, and hypertension, as well as having a significantly greater baseline serum creatinine. The aim of our study was to record, compare, and analyze the stroke rate among patients with a history of preoperative diabetes undergoing "off-pump" CABG (OPCAB) with conventional cardiopulmonary bypass (CPB) CABG to determine whether the stroke rate in this higher risk population could be decreased by off-pump techniques. Methods: The records of 1,227 patients with a pre-operative history of diabetes undergoing conventional CABG (973 patients, 79.3%) using cardiopulmonary bypass and off-pump CABG 254 (20.7%) were analyzed from 1995 through 1999. There were no differences in age, sex, or elective/urgent status of patients. Preoperative risk factors (gender distribution, carotid disease, ejection fraction, CHF, hypertension, previous MI) were identical in both groups. The goal of the operations were complete revascularization, which was achieved via median sternotomy in both groups. Results: Our reported series reveals a stroke rate of 3.6% in the CPB group and 1.2% in the off-pump group. This evidence alone was not statistically significant, but two other high-risk criteria for stroke, re-do CABG and calcified aortas, revealed that the off-pump series had a higher percentage of each (26.4% redos in off-pump vs. 8.7% CPB redos, p < 0.005; 7.1% calcified aorta cases in the off-pump group vs. 2.9% in the CPB group, p < 0.004). The threefold reduction in stroke may be clinically significant in light of the higher-risk profile of the off-pump group. The limitations of this study are that it was retrospective, there were a small number of events, and different surgeons were involved in the two different approaches to these patients. Conclusions: Improvements in myocardial protection, revascularization techniques, and anesthetic management have made significant, favorable impacts on CABG outcome in diabetic patients. New diagnostic and therapeutic strategies must be developed to lessen the medical and economic implications of stroke. A larger series or a more effective way of analyzing preoperative risk may well have shown a statistically significant difference in the stroke incidence given the differences in preoperative risk factors/stroke predictors. Until such advances occur, a three-fold reduction of stroke incidence using OPCAB certainly makes this technique a favorable one for high-risk diabetics requiring coronary revascularization.

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