Safer alternatives to conventional coronary artery bypass (CCAB)

Adverse clinical consequences associated with conventional coronary artery bypass graft

surgery have largely been attributed to cardiopulmonary bypass circuit (CPB), hypothermic cardiac arrest, aortic cannulation and cross-clamping. Since the introduction of OPCAB for coronary artery disease, numerous studies have been published to evaluate the impact of OPCAB surgery compared with conventional coronary artery bypass graft surgery. However, subsequent prospective randomised studies and meta-analyses comparing OPCAB and CCAB surgery were performed on low-risk patients or mixed-risk populations. Due to underpowered design for infrequent complications, they usually failed to demonstrate a significant benefit of OPCAB surgery on early mortality and peri-operative major cardiac and cerebrovascular events. In recent years, further efforts have been made to elucidate the meaning of beating-heart concepts for patients with specific extra-cardiac and cardiac risk factors for extracorporeal circulation and cardioplegic arrest.

Several mono- and multicentre studies are currently available for patients with specific cardiac or extra-cardiac co-morbidities. Even if most of them were non-randomised and thus failed to reach American Heart Association (AHA)/American College of Cardiology (ACC) evidence level A, they still allow analysis of interim results for each specific peri-operative risk factor and help to shed light on these cardiology specialties. Particularly multi-risk patients and patients with severely reduced left ventricular function seem to benefit in terms of peri-operative mortality and major morbidity by avoiding cardiopulmonary bypass and cardioplegic arrest. Moreover, for most patients with significant extra-cardiac risk factors the incidence of peri-operative stroke was reduced. Further insight into these cardiology specialties and risk factors are evident in European Cardiology Review, 2007;3(1):126-128.

For those looking for information on electrophysiology, sister electrophysiology journal Arrhythmia & Electrophysiology Review (AER) is a good source of information. The lastest volume 3, Issue one, includes current recommendations for cardiac resynchronisation therapy to the ablation of arrhythmias in adult congenital heart disease. This electrophysiology journal is tri-annual, helping time-pressured general and specialist cardiologists to stay abreast of key advances and opinion in the arrhythmia and electrophysiology sphere.