While many comparative studies support equivalent clinical outcomes between OPCAB and CABG with CPB, various studies have suggested that OPCAB may reduce perioperative morbidity and complications compared to CABG with CPB. In a large database review of 11,717 OPCAB patients and 106,423 conventional CABG patients, the risk-adjusted incidence of complications was significantly lower for the OPCAB group (10.62% OPCAB versus 14.15% CABG with CPB, p<.0001).9 An extensive meta-analysis of 53 studies showed OPCAB to have a statistically significant benefit compared to conventional CABG in reduced atrial fibrillation, wound infections, perioperative myocardial infarction, renal failure, and reoperation for bleeding.24 Similarly, several other studies on high-risk patient groups have also shown favorable outcomes with OPCAB, including reduced renal failure, atrial fibrillation, sternal wound infections, ventilation requirements, and reoperation for bleeding.3,4,12,13,23
3. Multivessel off-pump coronary artery bypass surgery in the elderly Demers P, Cartier R. Department of Surgery, Montreal Heart Institute, Research Center, Montreal, Quebec, Canada. OBJECTIVE: Coronary artery bypass grafting in the elderly patient is associated with increased perioperative morbidity and mortality. The avoidance of cardiopulmonary bypass (CPB) in this population is potentially beneficial. We examined our initial experience with off-pump multivessel coronary artery revascularization in patients aged 70 years and older. METHODS: In a consecutive series of 300 off-pump coronary artery bypass (OPCAB) operations performed by a single surgeon between 1996 and 1999, 98 patients were aged 70 years and older. These patients were compared with a consecutive cohort of 497 patients aged 70 years and older operated on with CPB in the same institution from 1995 to 1996, period where OPCAB surgery was not performed in our institution. RESULTS: Patients in the beating heart group were older (75 + 4 vs. 74 + 3 years; P=0.001). Gender distribution and other preoperative risk factors were comparable for the two groups. On average, 3.0 + 0.8 and 2.8 + 0.7 grafts per patient were completed in the OPCAB and the CPB groups, respectively (P=0.007). Perioperative mortality rates (OPCAB group, 3.1%; CPB group, 3.6%), perioperative myocardial infarction (OPCAB, 2.0%; CPB, 5.1%) and neurologic events (OPCAB, 1.0%; CPB, 3.2%) were comparable for the two groups. The incidence of postoperative atrial fibrillation was lower in the OPCAB group (42 vs. 54%; P=0.05). The need for allogenic blood transfusions was significantly less in the OPCAB group (53 vs. 82%; P=0.001). CONCLUSIONS: In patients aged 70 years and older, multivessel OPCAB surgery is associated with lower rates of postoperative atrial fibrillation and reduced transfusion requirements. Multivessel OPCAB in the elderly patient is an acceptable alternative to procedures performed with CPB. European Journal of Cardio-Thoracic Surgery. 2001 Nov;20(5):908-12.
4. Off-pump multivessel coronary artery surgery in high-risk patients Meharwal ZS, Mishra YK, Kohli V, Bapna R, Singh S, Trehan N. Department of Cardiovascular Surgery, Escorts Heart Institute and Research Centre, New Delhi, India. BACKGROUND: Coronary artery bypass surgery on cardiopulmonary bypass is associated with significant morbidity and mortality, which may be more marked in high-risk patients. We evaluated our results of off-pump coronary artery bypass (OPCAB) in high-risk patients with multivessel coronary artery disease and compared them with results in similar patients who underwent operation on cardiopulmonary bypass. METHODS: A total of 1,075 patients who underwent OPCAB between October 1996 and June 2001 and who had one or more of the following risk factors were included in the study: poor left ventricular function (EF < 30%), advanced age (> 70 years), left main stenosis, acute myocardial infarction, and redo coronary artery surgery. These patients were compared with 2,312 similar patients who underwent coronary artery bypass grafting on cardiopulmonary bypass during the same period. Preoperative risk factors, intraoperative variables, and postoperative results were analyzed and compared between two groups. RESULTS: The average number of grafts was 3.0 + 0.4 and 3.2 + 0.3 in the off-pump (OPCAB) and on-pump (CCAB) groups, respectively. Hospital mortality was 3.2% and 4.5% in OPCAB and CCAB groups respectively (p = 0.109). Perioperative myocardial infarction, requirement of inotropic agents, stroke, and renal dysfunction were comparable in two groups. Intubation time (19 + 5 vs 24 + 6 hours, p < 0.001), mean blood loss (362 + 53 vs 580 + 66 mL, p < 0.001), atrial fibrillation (14.3 vs 19.7%, p < 0.001), and prolonged ventilation (4.6 vs 7.6%, p = 0.002) were less in OPCAB group. Intensive care unit stay (20 + 8 hours) and hospital stay (6 + 3 days) were significantly less in the OPCAB group (p < 0.001). CONCLUSIONS: Off-pump coronary artery surgery can be safely performed in high-risk patients with multivessel coronary artery disease. Operative mortality is comparable to that associated with on-pump surgery, and avoidance of cardiopulmonary bypass is associated with reduced postoperative morbidity in these patients. Annals of Thoracic Surgery. 2002 Oct;74(4):S1353-7.
9. Off-pump coronary artery bypass grafting decreases risk-adjusted mortality and morbidity Cleveland JC Jr, Shroyer AL, Chen AY, Peterson E, Grover FL. Division of Cardiothoracic Surgery, University of Colorado Health Sciences Center, Denver, USA. BACKGROUND: The purpose of this study was to determine whether coronary artery bypass grafting without cardiopulmonary bypass (off-pump CABG) decreases risk-adjusted operative death and major complications after coronary artery bypass grafting in selected patients. METHODS: Using The Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, procedural outcomes were compared for conventional and off-pump CABG procedures from January 1, 1998, through December 31, 1999. Mortality and major complications were examined, both as unadjusted rates and after adjusting for known base line patient risk factors. RESULTS: A total of 126 experienced centers performed 118,140 total CABG procedures. The number of off-pump CABG cases was 11,717 cases (9.9% of total cases). The use of an off-pump procedure was associated with a decrease in risk-adjusted operative mortality from 2.9% with conventional CABG to 2.3% in the off-pump group (p < 0.001). The use of an off-pump procedure decreased the risk-adjusted major complication rate from 14.15% with conventional CABG to 10.62% in the off-pump group (p < 0.0001). Patients receiving off-pump procedures were less likely to die (adjusted odds ratio 0.81, 95% CI 0.70 to 0.91) and less likely to have major complications (adjusted odds ratio 0.77, 95% CI 0.72 to 0.82). CONCLUSIONS: Off-pump CABG is associated with decreased mortality and morbidity after coronary artery bypass grafting. Off-pump CABG may prove superior to conventional CABG in appropriately selected patients. Annals of Thoracic Surgery. 2001 Oct;72(4):1282-8; discussion 1288-9.
12. Comparison of coronary bypass surgery with and without cardiopulmonary bypass in patients with multivessel disease Mack MJ, Pfister A, Bachand D, Emery R, Magee MJ, Connolly M, Subramanian V. Cardiopulmonary Research Science and Technology Institute, Medical City Dallas Hospital, TX, USA. BACKGROUND: Coronary artery bypass grafting can now be performed with or without cardiopulmonary bypass. Our objective was to determine whether off-pump coronary artery bypass grafting is associated with better early outcomes compared with conventional coronary artery bypass grafting. METHODS: In 4 centers with off-pump coronary surgery experience, a retrospective analysis of all coronary artery bypass grafting in a 3-year period was performed. Groups were compared to determine selection criteria, mortality, and morbidity, then computer-matched by propensity score to control for selection bias. Multivariate logistic regression identified risk factors predictive of mortality. Specific subgroups most likely to benefit were identified. RESULTS: In all, 17,401 isolated coronary artery bypass grafts were performed, 7,283 (41.9%) off-pump coronary artery bypass grafts and 10,118 (58.1%) conventional coronary artery bypass with cardiopulmonary bypass. Factors determining selection of patients for off-pump coronary artery bypass grafting included female gender (55.5% vs 44.5%), preexisting renal failure (57.0% vs 43.0%), and reoperations (52.6% vs 47.4%). Operative mortality was 2.8%; off-pump coronary artery bypass grafting versus conventional coronary artery bypass with cardiopulmonary bypass (1.9% vs 3.5%, P <.001) had the same predicted risk. Of the patients with multivessel disease, 11,548 were matched by propensity scoring. Mortality was significantly less in the off-pump coronary artery bypass grafting group (2.8% vs 3.7%, P <.001). By multivariate logistic regression analysis of the matched sample, predictors for mortality were female gender (odds ratio 1.83, confidence interval 1.37-2.44), preexisting renal failure (odds ratio 2.85, confidence interval 2.64- 4.95), history of stroke (odds ratio 1.74, confidence interval 1.08-2.80), previous coronary artery bypass grafting surgery (odds ratio 4.22, confidence interval 2.92-6.09), use of cardiopulmonary bypass (odds ratio 2.08, confidence interval 1.52-2.83), and recent myocardial infarction (odds ratio 2.31, confidence interval 1.68-3.22). Cardiopulmonary bypass was predictive of mortality in reoperations, female patients, and patients aged > 75 years. Off-pump coronary artery bypass grafting was associated with less morbidity, including reductions in blood transfusion (32.6% vs 40.6%, P <.001), stroke (1.4% vs 2.1%, P =.002), renal failure (2.6% vs 5.2%, P <.001), pulmonary complications (4.1% vs 9.5%, P <.001), reoperation (1.7% vs 3.2%, P <.001), atrial fibrillation (21.1% vs 24.99%, P <.001), and gastrointestinal complications (3.6% vs 4.8%, P =.02). CONCLUSION: In 4 centers with beating-heart operation experience, there is an overall early benefit in off-pump surgery, especially in patients traditionally considered at high risk for coronary artery bypass grafting. Journal of Thoracic and Cardiovascular Surgery. 2004 Jan;127(1):167-73.
13. Propensity case-matched analysis of off-pump coronary artery bypass grafting in patients with atheromatous aortic disease Sharony R, Grossi EA, Saunders PC, Galloway AC, Applebaum R, Ribakove GH, Culliford AT, Kanchuger M, Kronzon I, Colvin SB. Department of Surgery, New York University School of Medicine, New York, USA. OBJECTIVE: Atheromatous aortic disease is a risk factor for excessive mortality and stroke in patients undergoing coronary artery bypass grafting. Outcomes of off-pump coronary artery bypass grafting and coronary artery bypass grafting with cardiopulmonary bypass in patients with severe atheromatous aortic disease were compared by propensity case-match methods. METHODS: Routine intraoperative transesophageal echocardiography identified 985 patients undergoing isolated coronary artery bypass grafting with severe atheromatous disease in the aortic arch or ascending aorta. Off-pump coronary artery bypass grafting was performed in 281 patients (28.5%). Propensity matched-pairs analysis was used to match patients undergoing off-pump coronary artery bypass grafting (n = 245) with patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. RESULTS: Univariate analysis revealed decreased hospital mortality (16/245, 6.5% vs 28/245, 11.4%; P =.058) and stroke prevalence (4/245, 1.6% vs 14/245, 5.7%; P =.03) in off-pump coronary artery bypass grafting compared with coronary artery bypass grafting with cardiopulmonary bypass. Freedom from any postoperative complication was higher in off-pump coronary artery bypass grafting compared with coronary artery bypass grafting with cardiopulmonary bypass (226/245, 92.2% vs 196/245, 80.0%; P <.001). Multivariable analysis of preoperative risk factors showed that increased hospital mortality was associated with coronary artery bypass grafting with cardiopulmonary bypass (odds ratio = 2.7; P =.01), fewer grafts (P =.05), acute myocardial infarction (odds ratio = 11.5; P <.001), chronic obstructive pulmonary disease (odds ratio = 2.4; P =.03), previous cardiac surgery (odds ratio = 10.2, P =.05), and peripheral vascular disease (odds ratio = 2.1; P =.05). Cardiopulmonary bypass was the only independent risk factor for stroke (odds ratio = 3.6, P =.03). At 36 months' follow-up, comparable survival was observed in the off-pump coronary artery bypass grafting and coronary artery bypass grafting with cardiopulmonary bypass groups (74% vs 72%). Multivariable analysis revealed that renal disease (P <.001), advanced age (P <.001), previous myocardial infarction (P =.03), and lower number of grafts (P =.02) were independent risks for late mortality. CONCLUSIONS: Patients with severe atherosclerotic aortic disease who undergo off-pump coronary artery bypass grafting have a significantly lower prevalence of hospital mortality, perioperative stroke, and overall complications than matched patients who underwent coronary artery bypass grafting with cardiopulmonary bypass. Routine intraoperative transesophageal echocardiography identifies severe atheromatous aortic disease and directs the choice of surgical technique. Journal of Thoracic and Cardiovascular Surgery. 2004 Feb;127(2):406-13.
23. Influence of diabetes on mortality and morbidity: off-pump coronary artery bypass grafting versus coronary artery bypass grafting with cardiopulmonary bypass Magee MJ, Dewey TM, Acuff T, Edgerton JR, Hebeler JF, Prince SL, Mack MJ. Cardiopulmonary Research Science and Technology Institute, Dallas, Texas, USA. BACKGROUND: Myocardial revascularization in diabetic patients is challenging with no established optimum treatment strategy. We reviewed our coronary artery bypass grafting experience to determine the impact of eliminating cardiopulmonary bypass on outcomes in diabetic patients relative to nondiabetic patients. METHODS: From January 1995 through December 1999, 9,965 patients, of whom 2,891 (29%) had diabetes, underwent isolated coronary artery bypass grafting. Diabetic and nondiabetic patients were further divided into groups on the basis of cardiopulmonary bypass use. Twelve percent (346 of 2,891) of diabetic patients and 12% (829 of 7,074) of nondiabetic patients underwent coronary artery bypass grafting without cardiopulmonary bypass; the remainder had coronary artery bypass grafting with cardiopulmonary bypass. Nineteen preoperative variables were compared among treatment groups by univariate analysis. RESULTS: Patients undergoing coronary artery bypass grafting without cardiopulmonary bypass compared with those having coronary artery bypass grafting with cardiopulmonary bypass had higher mean predicted mortalities (diabetic, 3.96% versus 3.72%, p = 0.83; nondiabetic, 3.03% versus 2.86%, p = 0.79). In nondiabetic patients, coronary artery bypass grafting without cardiopulmonary bypass provides an actual and risk-adjusted survival advantage over coronary artery bypass grafting with cardiopulmonary bypass (1.81% versus 3.44%, p = 0.0127; risk-adjusted mortality, 1.79% versus 3.61%, p = 0.007). This survival benefit of coronary artery bypass grafting without cardiopulmonary bypass was not seen in diabetic patients (2.89% versus 3.69%, p = 0.452; risk-adjusted mortality, 2.19% versus 2.98%, p = 0.42). Diabetic patients undergoing coronary artery bypass grafting without cardiopulmonary bypass had fewer complications, including decreased blood product use (34.39% versus 58.4%, p = 0.001), and reduced incidence of prolonged ventilation (6.94% versus 12.10%, p = 0.005), atrial fibrillation (15.90% versus 23.26%, p = 0.002), and renal failure requiring dialysis (0.87% versus 2.75%, p = 0.036). CONCLUSIONS: The survival advantage in nondiabetic patients treated with coronary artery bypass grafting without cardiopulmonary bypass is not apparent in diabetic patients. Coronary artery bypass grafting without cardiopulmonary bypass in diabetic patients is nevertheless associated with a significant reduction in morbidity. Annals of Thoracic Surgery. 2001 Sep;72(3):776-80; discussion 780-1. |
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