On PUMP Versus Off PUMP Coronary Bypass Grafting Post-Operative Clinical and Laboratory Focus on Neurological Outcome

Conventional bypass grafting using cardioplegic arrest continues to be associated with some complications that may negate an otherwise successful procedure. Interest in off-pump bypass grafting (OPCABG) in the mid-1990s presented surgeons with the option of revascularization without the potential complications of extracorporeal support if CPB can be avoided; a reduction in peri-operative morbidity and mortality is anticipated. The Aim of our Study: Is to compare both techniques regarding mortality, morbidity, complications and brain injury in both groups of patients with ischemic heart disease. Patients and Methods: Eighty patients (pts) were subjected to CABGs, 40 with off pump (group I- gpI) and the other 40 pts with on pump (group II-gpII) techniques. Patients in both groups were matching as regards age, sex, risk factors, and number of bypassed coronaries. Pre-operatively and postop-eratively all patients were subjected to clinical examination, ECG, chest X-ray, transthoracic echocardiography, routine laboratory tests and serum S 100 B protein as well as Neuron Serum Enolase (NSE). Brain injury will be evaluated by using Glasgow Coma Scale and the neuromediators. Results: Intra-operatively, group I pts had statistically significant shorter operative time (3.6±0.6 Vs. 4.1±0.7 hours in group II, p 0.001), less intra-operative bleeding-of medical causes-with lower intra-operative use of blood products (55% of pts in group I Vs. 100% of group II) and lower incidence of arrhythmias (25% Vs. 60% of group II). Post-operatively, group I showed statistically significant shorter stay in intensive care unit (2.8±0.7 Vs. 3.8±1.3 days in group II; p 0.001), earlier extubation (9.4±4 Vs. 15.5±11.6 hours in group II; p 0.002), lower pulmonary complications as regard atelectasis, chest infection (5% Vs. 22.5% in group II; p 0.02), lower cardiac complications as regard atrial fibrillation, low cardiac output and need for use of inotropic support (55% Vs. 82.5% in group II; p 0.007), less hypothermia with lower incidence of postoperative bleeding with less need for use of blood products and reopening. Group I showed significantly less renal (22.5% Vs. 52.5% in group II; p 0.05) and less hepatic impairment than in pts of group II (20% Vs. 55% in group II, p 0.05). No statistically difference between both groups as regards cardiac ischemia, cardiac arrest, ECG changes, trans-thoracic echocardiographic findings, hematemesis, and sternal wound infection. Finally, group I showed lower incidence of neurological deficits (whether reversible or permanent) (5% Vs. 27.5% in group II; p 0.006). Despite the latter, postoper-ative values of neuromediators S 100B protein and NSE showed a significant increase in both groups compared to preoperative serum level denoting some brain ischemia (as regard S 100B protein, 60 Vs. 20pg/ml preoperatively in group I; p 0.05 and 100 Vs. 35pg/ml preoperatively in group II; p 0.05), (NSE, 22 Vs. 6ug/L preoperatively in group I; p 0.05 and 20 Vs. 7ug/L preoperatively in group II; p 0.05). However; there is no statistically significant difference between both groups regarding the percent of increase of both mediators postoper-atively (1.88% in group I Vs. 1.7% in group II; p-value: Non significant). Conclusions: 1-In the view of S 100B and NSE serum levels in both groups, no significant difference between both groups regarding cerebral ischemia. 2-Off-pump Coronary artery bypass grafting is effective with success rate comparable to On-pump CABGs. 3-Off-pump technique is safer in patients with preoperative bleeding disorders, renal/hepatic impairment, pulmonary disorders, or high risk for stroke e.g. calcific aortic roots. 4-Off-pump technique saves expenses due to fewer compli-cations and less postoperative stay in intensive care unit.