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Impact of Aortic Partial Clamping and All-arterial Grafting on Stroke and Death after OPCAB
Emmanuel Moss1, Michael Halkos2, Patrick Kilgo3, Vinod Thourani2, Omar Lattouf2, John D. Puskas2.
1Emory University, Atlanta, GA, USA, 2Emory University Hospital Midtown, Atlanta, GA, USA, 3Emory University, Rollins School of Public Health, Atlanta, GA, USA.

Objective: To assess the impact of aortic partial occlusion clamping and all-arterial grafting on stroke and death after off-pump coronary artery bypass grafting (OPCAB).
Methods: Clinical and demographic data were analyzed from the STS Adult Cardiac Database for all primary, isolated, multi-vessel, OPCAB patients from a large academic hospital system between December 2004 and November 2013. Patients converted to CPB were excluded. The primary variables of interest were 1) whether a partial clamp was used (CLAMP) and, 2) whether all of the grafts were arterial (ART). A propensity scoring approach estimated both 1) a patient’s likelihood of being clamped and, 2) patient’s likelihood of receiving all arterial grafts, based on 37 preoperative variables. Separate multivariable logistic regression models were used to determine the effect of CLAMP and ART on post-operative (30-day) incidence of stroke and other outcomes, adjusted for the propensity score. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated. Also, long-term survival was compared between groups using Cox regression and Kaplan-Meier (KM) curves.
Results: CLAMP patients tended to be younger (62.7 vs. 65.3) with lower preoperative risks of death (1.90% vs. 2.52%) and stroke (1.44% vs. 1.86%). After multivariable regression propensity adjustment, CLAMP was associated with a statistically insignificant 47% increase in odds of stroke (AOR=1.47, 95% CI 0.83-2.61, p=0.19). ART was associated with a statistically insignificant 72% decrease in the odds of stroke (AOR=0.28, 95% CI 0.04-2.04, p=0.21). After multivariable Cox adjustment, long-term survival was similar between CLAMP and No CLAMP groups (AHR=0.87, 95% CI 0.73-1.04, p=0.12).
All Patients
N=6061
At Least One Venous Graft
N=5638
All Arterial Grafts
N=423
No CLAMP
N=1733
CLAMP
N=4328
pNo CLAMP
N=1453
CLAMP
N=4185
pNo CLAMP
N=280
CLAMP
N=143
p
Age65.3±10.962.7±10.7<0.00166.4±10.662.9±10.6<0.00159.4±10.456.9±10.90.02
Stroke19 (1.10)64 (1.48)0.2518 (1.24)64 (1.53)0.431 (0.36)0 (0.0)0.47
PROPS*1.86±1.971.44±1.42<0.0012.01±1.961.45±1.43<0.0011.08±1.840.90±0.790.15
O/E Stroke0.561.03--0.621.06--0.330.00--
Death23 (1.33)51 (1.18)0.6322 (1.51)49 (1.17)0.311 (0.36)2 (1.40)0.23
PROM*2.52±4.181.90±2.93<0.0012.78±4.351.93±2.97<0.0011.20±2.811.01±0.920.31
O/E Death0.530.62--0.540.61--0.301.39--

*Expressed as a percentage; PROPS=Pred. Risk of Permanent Stroke; PROM=Pred. Risk of Mortality
Conclusion: Performing all-arterial grafting and avoiding aortic clamping were associated with statistically insignificant reductions in adjusted risk of stroke and death after OPCAB.


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