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 Table of Contents  
Year : 2018  |  Volume : 46  |  Issue : 2  |  Page : 152-161

Coronary artery bypass grafting surgery in chronic hemodialysis patients

1 Cardiac Surgery Department, Saud AlBabtin Cardiac Center, Dammam; Cardiac Surgery Department, Tanta University Hospitals, Tanta, Saudi Arabia
2 Cardiac Surgery Department, Saud AlBabtin Cardiac Center, Dammam, Saudi Arabia

Date of Submission06-Feb-2018
Date of Acceptance26-Feb-2018
Date of Web Publication31-Oct-2018

Correspondence Address:
Ibrahim M Yassin
Department of Cardiothoracic Surgery, Faculty of Medicine, Tanta University, Tanta 31111
Saudi Arabia
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DOI: 10.4103/tmj.tmj_8_18

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Background and aim Off-pump coronary artery bypass grafting (CABG) can be ideal for revascularization of chronic hemodialysis patients when the targets are easily accessible. Full revascularization usually necessitates the use of cardiopulmonary bypass (CPB) if the targets are not easily accessible. Either conventional CABG with cardioplegic arrest or on-pump beating-heart CABG can be used. The early and long-term outcomes are still controversial. We sought to compare the early and long-term outcomes of the three different methods of revascularization of this patient category.
Patients and methods This was a retrospective analysis of randomized three selected equal groups, with 25 patients each revascularized with a different technique. Patients were operated from January 2008 to June 2016 in our institution. Group I underwent conventional CABG with cardioplegic arrest, group II underwent off-pump CABG, and group III underwent on-pump beating-heart CABG.
Results The postoperative bleeding amount (P<0.001), length of hospital stay (P<0.001), and length of postoperative intensive care unit stay (P<0.001) were significantly lower in the off-pump and on-pump beating-heart CABG groups than in the conventional CABG group. No significant difference was found regarding 30-day mortality and morbidity rates including stroke, pneumonia, arrhythmia, intestinal complication, and low cardiac output syndrome. On-pump beating-heart CABG significantly reduced the duration of CPB compared with conventional CABG. There were no statistical differences in the freedom from cardiac events (P=0.143), but on-pump beating-heart CABG provided better long-term survival than conventional CABG (P≤0.01).
Conclusion Off-pump CABG when safely implemented is the best option for complete revascularization of chronic hemodialysis patients. On-pump beating-heart CABG is a safe procedure that provides optimal operative exposure in chronic hemodialysis patients. The use of CPB and the elimination of cardioplegic arrest may be beneficial for the short-term and long-term survival of chronic hemodialysis patients.

Keywords: coronary artery bypass, end-stage renal disease, hemodialysis, off pump

How to cite this article:
Yassin IM, Oueida FM. Coronary artery bypass grafting surgery in chronic hemodialysis patients. Tanta Med J 2018;46:152-61

How to cite this URL:
Yassin IM, Oueida FM. Coronary artery bypass grafting surgery in chronic hemodialysis patients. Tanta Med J [serial online] 2018 [cited 2019 Oct 21];46:152-61. Available from: http://www.tdj.eg.net/text.asp?2018/46/2/152/244692

  Introduction Top

Patients with end-stage renal disease (ESRD) have a 3–4-fold higher risk of death than other patients after CABG [1]. They have a high prevalence of the known risk factors for atherosclerosis, for example, hypertension, diabetes, dyslipidemia, and advanced age. So, prognosis for those who are undergoing coronary artery bypass grafting surgery (CABG) is significantly worse than those of patients without ESRD [1],[2],[3]. However, CABG for these hemodialysis-dependent patients could potentially improve their life expectancy. These patients can get benefit especially when revascularized using off-pump CABG, which has become an established and feasible procedure [4],[5]. Nevertheless, patients with ESRD are more likely to have three-vessel coronary artery, friable tissues, and severe calcification and the possibility of hemodynamic collapse during off-pump CABG. This affects the technical ability and comfort level of the surgeon, and therefore, full revascularization can be affected. The use of CPB is still the gold standard during revascularization of all ischemic patients including those with ESRD. It gives a good chance for stat hemofiltration during the surgical procedure and provides optimal operative exposure and complete revascularization for these highly fragile, bad atheromatous calcific targets, but the drawbacks of cross-clamping the atheromatous aorta and cardioplegic volume overload and electrolyte disturbances are well known. On-pump beating-heart CABG can offer hemodynamic stability, good exposure, full revascularization, and stat hemofiltration set during the procedure. This technique has been adopted in our institute for hemodialysis-dependent patients and is becoming more preferable for us. We sought to evaluate the early outcome as well as the long-term survival of those hemodialysis-dependent patients after CABG comparing on-pump, on-pump beating heart, and off-pump cardiopulmonary bypass (CPB).

  Patients and methods Top

We started our experience with patients with ESRD in Saud AlBabtin Cardiac Center and Kanoo Kidney Center (KKC) (where an active Nephrology Unit is there, allowing good continuous follow-up of these patients) using the conventional CABG with cardioplegic arrest and off-pump CABG depending on the possibility to revascularize all the targets with no hemodynamic (HD) instability, and later we developed our experience with on-pump beating-heart CABG for those with difficult anatomy originally indicated for cardioplegic arrest and it became our preferred methodology in patients with uremia.

The Institutional Ethical Committee approved this study and waived the requirement for individual consent because of its retrospective manner. Our study is a retrospective randomized analysis of three groups, each comprising 25 patients who were chronically hemodialyzed for at least 6 months before elective surgery and complete follow-up till the time of the study. Group 1 had patients who underwent conventional CABG with cardioplegic arrest, group 2 had patients who underwent off-pump, and group 3 had patients who underwent on-pump beating-heart CABG. They were operated upon from January 2008 to June 2016. Patients who underwent a simultaneous procedure (e.g. valve surgery) or a previous cardiac operation were excluded from this study. Patients with unstable angina but HD stable were included in the study, but all (HD) unstable patients or on intra-aortic balloon pump (IABP) or emergency are excluded for the purpose of the study. The results for primary end point (freedom from cardiac events and survival) and secondary end point (need for continuous renal replacement therapy within 24 h, ventilation time >24 h), arrhythmia, pneumonia, stroke, low cardiac output, need for IAPB, gastrointestinal complications, bleeding amount, re-exploration, prolonged ICU stay, hospital stay, and 30-days mortality are tabulated and analyzed. The long-term outcomes were compared among these three groups. Data were collected retrospectively from patient medical records and presented as the mean and SD value.

Preoperative management

The following were the preoperative management criteria:
  1. Preoperative obstructive pulmonary disease consultation with cardiologist and endocrinologist, with tight control of hypertension with medications and diabetes with intravenous insulin infusion protocol.
  2. Patients are kept on their normal dialysis regimen.
  3. Patients were admitted 48 h before the surgery, and final dialysis is done a day before surgery.

Surgical technique

Anesthesia management was the same for all patients (propafol and diacronium). All patients received an antifibrinolytic (tranexamic acid). All patients received cefuroxime and vancomycin intraoperatively. Procedures were performed using CPB in the conventional CABG and on-pump beating-heart CABG groups. CPB was established through aortic inflow and right atrium outflow cannulation with a single two-stage cannula. Left ventricular (LV) venting was performed only in the conventional CABG group. In the conventional CABG group, all anastomoses were performed under cardiac arrest using tepid blood cardioplegia mostly in an antegrade cannula. The CPB flow was maintained at ∼2.5 l/min/m2 during the cardiac arrest period. In the on-pump beating-heart CABG group, all coronary anastomoses were performed using a commercially available stabilizer and heart positioner and intracoronary shunt. The CPB flow was maintained at 1.5–2.5 l/min/m2 during coronary anastomosis, depending on the hemodynamic status. All aortic-side anastomoses for the free graft in both groups were performed with partial aortic clamping. Patient temperature on bypass was not less than 34°C. All patients had intraoperative hemofiltration by connecting a hemofilter to CPB circuit.

The goal is to achieve patients’ balanced fluid load and attenuate the increase in serum potassium, so that we can avoid the need for initiation of dialysis on the day of surgery owing to overhydration or hyperkalemia.

Postoperative management

No hemodialysis is used in the ICU the day of the surgery to avoid hemodynamic instability and risk of heparin-associated bleeding.

Increase of serum potassium is treated by dextrose insulin cocktail.

Any metabolic acidosis is treated aggressively.

The patients’ crystalloid intake was restricted to 1.5–2 l/24 h. Volume replacement in the form of blood or hestril was given as needed based on direct measurement of filling pressures.

Continuous Veno-Venous Hemofiltration (CVVH) was achieved via femoral vein or through subclavian vein on first or second postoperative day when indicated regarding electrolytes and fluid balance.

Once patients are transferred to floor, they get switched back to their regular preoperative dialysis regimen.

Statistical analysis

Continuous data were expressed as mean±SD and categorical variables as percentages. Statistical comparisons between groups and survival rates were computed using Student’s t-test, the χ2-test, or log rank test, according to the type of data. For all statistical evaluations regarding differences in data, P values of less than 0.05 were considered statistically significant. SPSS (SPSS Inc., Chicago, Illinois, USA) was used in the analysis.

  Results Top

Preoperative characteristics

The preoperative characteristics of the three groups are listed in [Table 1] and were similar regarding sex, BMI values, diabetes mellitus, hypertension, and hyperlipidemia.
Table 1 Patients characteristics

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Moreover, there was no significant difference between the three groups regarding the presence of previous myocardial infarction, those with left main coronary artery disease more than 50%, and those with unstable angina. The mean preoperative duration of hemodialysis also showed no significant difference (P=0.77).

The on-pump beating-heart CABG patients were significantly older than the patients in the other two groups (mean age: conventional CABG, 60.6±11.4 years; off-pump CABG, 61.3±11.0 years; and on-pump beating-heart CABG, 66.3±8.7 years; P=0.04).

The incidence of smoking (%) was significantly higher in the conventional group, with 18 (72%) patients, than in the other two groups, with 15 (60%) patients in both, P=0.02. Meanwhile, the incidence of chronic obstructive pulmonary disease and chronic obstructive pulmonary disease (%) was significantly less in the same group, with four (16.0%) patients, rather than in the other two groups [eight (32.0%) patients in the off-pump group and nine (36.0%) patients in the on-pump beating, P=0.03].

The incidence of peripheral arterial disease and cerebrovascular disease was significantly higher in group III and group II than group I. For the preoperative cerebrovascular disease, there were five (20.0%) patients in the conventional group whereas nine (36.0%) patients in the off-pump group and 12 (48.0%) patients in the on-pump beating group, with P=0.03. Peripheral arterial disease was seen in seven (28.0%) patients in group I and 11 (44.0%) patients each in groups II and III, P=0.02.

Number of diseased vessels was significantly higher in group I and III (2.8±0.5 and 2.8±0.4, respectively) than group II (2.2±0.8), P=0.04. Groups II and III included significantly more patients with aortic calcification (%) [conventional CABG, nine (36.0%) patients and in off-pump and on-pump beating 19 (76.0%) patients each, P<0.001].

Groups I and III included significantly more patients designated as New York Heart Association classification III or IV [conventional CABG, 20 patients (80.0%); off-pump CABG, 11 (44.0%) patients; and on-pump beating-heart CABG, 21 (84.0%) patients; P=0.01].

Those diagnosed with impaired LV function (mean ejection fraction) were as follows: group I, 45.1±13.7%; group II, 55.2±12.6%; and group III, 40.9±9.9%; P<0.001.

Those with moderate to severe LV dilatation defined as LV end-diastolic dimension 60 mm were as follows: group I, 10 (40.0%) patients; group II, six (24.0%) patients; and group III, 15 (60.0%) patients; P=0.04.

The European System for Cardiac Operative Risk Evaluation, known as Euro-SCORE, was calculated for every preoperative patient and used as a predictor of perioperative mortality. The on-pump beating-heart CABG group had the highest Euro-SCORE among the three groups (conventional CABG, 9.9±5.6; off-pump CABG, 8.4±5.0; and on-pump beating-heart CABG, 11.4±5.0; P=0.01).

Perioperative surgical characteristics

Perioperative and postoperative patient characteristics are shown in [Table 2]. The on-pump beating-heart CABG group experienced a shorter CPB duration than the conventional group (conventional CABG, 155.3±43.6, and on-pump beating-heart CABG, 116.5±23.2 min; P<0.001).
Table 2 Operative results

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Except for that the patients in the conventional CABG and on-pump beating-heart CABG groups had significantly more diseased coronary arteries and mean distal anastomoses (conventional CABG, 3.2±0.8; off-pump CABG, 2.2±0.7; and on-pump beating heart CABG, 3.2±0.7; P<0.001), there was no actual significant difference among the three groups regarding the surgical details. There was no significant difference between the number of patients who needed left internal mammary artery (P=0.54, 0.34, 0.94, and 0.34), number of patients who needed bilateral mammary arteries (P=0.34, 0.54, 0.83, and 0.54), or the number of patients who needed left anterior descending artery endarterectomy (P=0.28, 0.43, 0.43, and 0.98). All of the patients in the conventional and on-pump beating groups [25 (100%) patients], and 23 (92%) patients in the off-pump beating heart group achieved complete revascularization (P=0.58, 0.33, 0.92, and 0.33).

Incidence of complications including intraoperative or postoperative IABP initiation, arrhythmia, low cardiac output syndrome, pneumonia, stroke, intestinal complications, and sepsis did not differ among the three groups.

Arrhythmia was identified by cardiac monitoring and confirmed by 12-lead ECG. Gastrointestinal complication included gastric ulcer bleeding, cholecystitis, or intestinal ischemia. Regarding the diagnosis of postoperative low cardiac output syndrome, it was made if a patient required either intra-aortic balloon counter-pulsation and/or dopamine support more than 5 μg/kg/min for more than 24 h in the ICU to obtain a systolic blood pressure more than 90 mmHg and a cardiac index more than 2.0 l/min/m2 despite an adequate preload.

The postoperative bleeding amount was significantly lower in the off-pump CABG and on-pump beating heart CABG groups (conventional CABG, 940.7±311.4; off-pump CABG, 764.3±193; on-pump beating heart CABG, 752.3±165; P<0.001), but the incidence of re-exploration for bleeding was not significant among all groups (P=0.64).

Prolonged ventilation for more than 24 h was significantly less common in the off-pump and on-pump beating CABG groups than conventional group (conventional CABG, n=6, 24%; off-pump CABG, n=2, 8%; on-pump beating-heart CABG, n=2, 8%; P=0.01).

There was a statistically significant difference in the number of patients in need for postoperative continuous renal replacement therapy among the three groups [group I, seven (28%), whereas no patients (0%) in groups II and III; P<0.001].

The duration of ICU stay was shorter and statistically significant in groups II and III than conventional group (group I, 7.0±4.9 days; group II, 3.8±1.6 days; and group III, 3.3±1.4 days; P<0.001).

The duration of postoperative hospital stay was shorter and statistically significant in group II and III than conventional group (group I, 17.5±8.5 days; group II, 14.1±3.6 days; group III, 12.1±4.2 days; P<0.001).

The 30-day mortality rate was lower in groups II and III than conventional group, but no statistically significant difference was observed (group I, n=3, 12%; group II, n=1, 4%; and group III, n=1, 4%; P=0.64).

Freedom from cardiac events

The cardiac events included repeated cardiac interventions whether PCI or redo surgery, myocardial infarction, congestive heart failure, and cardiac death. The freedom from cardiac events curve is shown in [Table 3] and [Figure 2]. The 1–6-year freedom from cardiac event rates were 87.1±4.0, 80.5±4.9, 78.5±5.9, 76.3±5.5, 71.5±6.5, and 65.8±8.4% in the conventional CABG group; 94.3±3.2, 81.9±5.5, 77.6±8.5, 68.0±7.8 64.0±6.3, and 59.4±8.5% in the off-pump CABG group; and 95.7±3.0, 92.8±6.1, 86.7±5.1, 82.0±7.3, 76.0±7.9, and 76.0±7.9% in the on-pump beating-heart CABG group. There were no statistical differences among the three groups (P=0.143).
Table 3 Freedom from cardiac events

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Figure 2 Cumulative survival rate.

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[Table 4] and [Figure 1] show the survival curve. The survival analysis included hospital mortality rate, and the 1–6-year survival rates in the conventional CABG group were 78.1±5.0, 69.4±6.3, 66.7±5.3, 66.7±5.3, 65.6±3.4, and 61.3±4.4% in the conventional CABG group; 91.1±3.8, 84.4±5.3, 81.4±5.3, 73.8±6.4, 72.6±5.4, and 72.6±5.4% in the off-pump CABG group; and 93.7±3.5, 87.0±5.6, 85.3±4.0, 85.3±4.0, 82.0±4.3, and 82.0±4.3% in the on-pump beating-heart CABG group. Significant differences in survival were observed among the three groups (P=0.008).
Table 4 Cumulative survival rate (%)

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Figure 1 Freedom from cardiac events.

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  Discussion Top

ESRD is a strong risk factor for early and late morbidity and mortality after CABG [6],[7]. The ideal way for revascularization in these patients is still a matter of debate.

The conventional use of CPB with cardioplegic arrest has led to obvious progress in CABG as well as all cardiac surgeries, but the well-known adverse effects of the machine, the systemic inflammatory response (SIR), the cardiac global ischemia with different grades of cardiac preservations according to the type of cardioplegia and the reperfusion injury owing to the nonphysiological nature of this technique may lead to mortality and morbidity. Off-pump CABG has the potential to overcome and reduce these adverse effects of the conventional CABG. Many authors have reported the superiority of this procedure regarding early or midterm outcome compared with the conventional approach [4],[5],[8]. It eliminates the two major mechanisms of possible cardiac injury, namely, the CPB and the cardioplegic arrest.

The SIR can be avoided by elimination of CPB that leads to reduction of the physiologic derangement caused by its use [9],[10]. Moreover, the avoidance of cardioplegic arrest and the chemical components of the cardioplegic solution may decrease the myocardial injury which is usually caused by the well-known ischemia/reperfusion injury [11],[12]. The technical difficulty and the possibility of hemodynamic collapse during off-pump CABG, especially during revascularization of the lateral wall, remain limitations of this procedure. Therefore, beating-heart CABG with CPB provides good operative exposure and surgeon comfort without the adverse effect of the cardioplegic arrest.

Patients with ESRD who depend on hemodialysis generally have an increased risk of death owing to cardiovascular and noncardiovascular causes [1],[2],[3]. Only 23% of patients with ESRD exhibit regular cardiac function as determined by echocardiography [14], and it was recorded that at the time of dialysis initiation, 19% of patients have severe LV hypertrophy. In addition, a uremic environment is cardiotoxic and causes LV dysfunction of variable degrees and with different mechanisms whether directly or through atherosclerotic changes in the coronary blood supply [15]. A very important indirect remote factor is hyperparathyroidism secondary to renal failure that has been demonstrated to be associated with accelerated atherosclerosis and the calcification of cardiac structures [16].

Selection of candidate patients for off-pump CABG with expected good results is usually taking into consideration different issues starting from the hemodynamic stability of the patient, the targeted vessel, the extension of the lesion, and the general condition of the patient. Van Dijk et al. [17] found that only 25% of patients had triple-vessel disease and 78% had normal LV function; moreover, there were marked lower number of distal anastomoses per patient in the off-pump CABG when compared with the conventional CABG group. This marked decrease in the number of anastomoses is mainly due to the difficult exposure specially when the targets are on the lateral and posterior walls [18],[19]. In unstable patients in whom collapse was expected during doing the anastomosis, such as those with multiple vessel disease, LV dilatation, low ejection fraction, and higher Euro-SCOREs, off-pump CABG is better not to be used. In contrast, in patients with ascending aortic calcification, conventional CABG with cross-clamp of the aorta should be avoided even if the revascularization is incomplete.

Recent clinical data revealed a benefit of CPB-supported beating-heart CABG in selected high-risk patients [18],[19],[20],[21]. The technique unloads the heart during performing the anastomosis and gives good organ perfusion to the whole body including the cardiac muscle itself through maintaining the coronary blood flow. Therefore, our present study was designed to assess the outcome of beating-heart CABG with CPB in hemodialysis patients in comparison with the other techniques in usual daily practice, namely, the off-pump CABG and the standard conventional CABG with cardioplegic arrest. On-pump beating-heart CABG can also eliminate the effect of cardioplegic arrest and the deleterious effects of the cardioplegic solution itself with its chemical components.

As shown in [Table 1], the off-pump CABG patients had significantly lower Euro-SCOREs (P=0.01), better LV contractility (P≤0.001), and less severity degree of LV dilatation (P=0.04). The conventional CABG patients showed by definition significantly less aortic calcification (P≤0.001) as previously discussed. Many authors have shown that the off-pump technique can significantly reduce the incidence of the deleterious perioperative myocardial infarction, stroke, respiratory failure, and total mortality in some subgroups of ischemic cardiac patients as compared when using the cardioplegic arrest [5],[22],[23]. In our current study, there were no significant differences regarding postoperative morbidity, namely, the incidence of arrhythmia, stroke, pneumonia, sepsis, low cardiac output, and additional IABP initiation in patients with ESRD.

The 30-day mortality rate was lower in group II and III (4%) than in group I (12%), but with nonsignificant statistical difference (P=0.64). The effect of the CPB on the lung parenchyma and the subsequent prolonged ventilation was discussed in few studies [24],[25]. Rothenburger et al. [24] emphasized that the CPB induces both proinflammatory as well as an anti-inflammatory immune responses, and a state of imbalance is generated between both mediators causing what is known as SIR with the subsequent prolonged mechanical ventilation. Cislaghi et al. [25] after analysis of more than 3000 patients reported that a CPB time of more than 91 min was a very important independent factor predicting the prolonged mechanical ventilation. In our data, the on-pump beating-heart CABG group had a lower CPB time than the conventional CABG group (116.5±23.2 min for on-pump beating-heart CABG vs. 155.3±43.6 min for conventional CABG), and it was believed to contribute to the benefit regarding the time to extubation. The on-pump beating-heart CABG group did exhibit a benefit regarding reduced prolonged ventilation for patients with ESRD compared with the conventional group (P≤0.01) in our study.

Reducing the requirement of homologous blood products and its transfusion during open heart surgery is a major target for all cardiac surgeons as it has been linked to increased neurological dysfunction, wound infection, and long-term morbidity and mortality [26]. Many reports discussed the issue of the postoperative bleeding and the subsequent need for blood transfusion in the off-pump CABG versus the conventional CABG and was in favor of the off-pump [19],[20],[21]. Most of them attributed this advantage to the hemodilution [27], the hypothermia, and the contact of the blood with the tubing system of the CPB and the air, as well as with the alteration of the coagulation factors [28],[29].

In our study, the amount of postoperative bleeding in group III was almost equal to that of group II (P=0.34) but was significantly less in group I (P<0.01). The avoidance of hypothermia, cardioplegia, less hemodilution, and the decreased CPB time are all contributing factors for the less amount of bleeding in group III in comparison with group I. These explanations were shown also by others [30],[31].

Many factors are attributed to the length of hospital stay after CABG, and some are related to patient demographics, associated comorbidities, the cardiac condition preoperatively and the newly developed postoperative morbidity [32]. The off-pump technique has the advantages in this field. In our study, it was nonstatistically different between group II and III (P=0.09) but lower than that in group I (P=0.01), although there were more confounding different comorbid conditions, with significantly higher Euro-SCORE.The off-pump technique had shown better rescue results in frail patients in many studies. These frail issues included the old age, previous strokes, renal impairment, chronic obstructive pulmonary disease as well as the local cardiac issues of the low ejection fraction or dilated hearts [22],[23],[31],[32]. Despite it being recommended in patients with ESRD with good early outcome, few studies have discussed the long-term results. In the studies by Hu et al. [33] and Shroyer et al. [34], off-pump CABG is associated with small short-term gains but increased long-term risks of repeat revascularization and major vascular events, especially among high-risk patients. There are concerns about the accuracy and patency of the anastomosis [21],[35],[36]. In a long-term 6-year observation follow-up, we found that the long-term risks of freedom from cardiac events were better for the on-pump beating-heart CABG patients than for off-pump CABG patients, although no statistical difference was observed.

In our study, although the number of diseased vessels indicated for revasularization was significantly higher in the group 1 and group 3 than group 2 (P<0.001), there was no statistical significant difference regarding achievement of complete revascularization, and we believe that the technique of revascularization, the degree of good and easy exposure, and the stability of the HDs of the patients make great difference in the opinion of the surgeon regarding the possibility of grafting the target. Good evidence is available that incomplete revascularization at CABG can lead to poor long-term prognosis [36],[37]. This can explain the difference in the cardiac-free events during the follow-up period, although it was nonstatistically significant, but it is better in group 3 than group 1 and least in group 2 ([Table 3] and [Figure 1]).

The cumulative survival ([Table 4] and [Figure 2]) being statistically significant in group 3 than group I, which even started in the first postoperative year and continued till the last year follow-up period shown in our current study and others [38], invites us to consider on-pump beating technique the first option to revascularize patients with ESRD specially if they have New York Heart Association classification III or IV or with impaired LV function, moderate or severe LV dilatation defined as LV diastolic dimension of at least 60 mm, and higher Euro-SCOREs, which are believed to influence the surgical outcome. This was also recommended by others.

In the current study, we believe that the on-pump beating-heart technique provides optimal operative exposure and a more stable operative environment, mainly the stability of the HDs, than the off-pump approach, and it reduces the reluctance of surgeons to graft small, multiple diseased, and calcified coronary vessels. This technique combines the advantages of off-pump CABG with the better exposure provided by CPB to facilitate complete revascularization in hemodialysis patients with multiple vessel coronary disease.

Study limitation

To our mind, the number of each group being small made the chance to apply any proportional hazard model to calculate the influence of preoperative and operative factors on survival unsatisfactory. Moreover, the lack of routine use of an objective means of graft function assessment and taking a cutoff reading as inclusion or exclusion criteria to achieve better randomization of the three groups is considered a major limitation in comparing the three techniques in terms of the patency of anastomosis. Indeed, the study is limited by its retrospective nature although being randomized one, and it involves too many confounding factors to reveal any clear advantage of the on-pump beating-heart technique during the follow-up period rather than the great advantages during the surgery itself. The study is limited also by patient numbers.

  Conclusion Top

In patients receiving hemodialysis owing to chronic renal failure, when the use of CPB is mandatory to achieve full revascularization, the on-pump beating-heart technique provides superior results regarding both short-term and long-term outcomes than cardioplegic arrest.


This work was supported by the staff members and doctors of Saud AlBabtin Cardiac Center (SBCC) and Kanoo-Kidney Center (KKC), Dammam, KSA.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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