Reduced Hospital Length of Stay (LOS)

Several studies have shown that OPCAB reduces ICU time and total hospital length of stay.^2,4,5,6,8 Decreases of approximately 50% in average ICU time for patients with OPCAB compared to CABG with CPB were reported by both Muneretto et al. (22 hours vs. 43 hours, p=.003)⁶ and Meharwal et al. (18 hours vs. 33 hours, p<.001).⁴ In addition, other studies, including two prospective randomized studies, have demonstrated significantly shorter hospital mean length of stay by 1 to 2 days for OPCAB patients compared to CABG with CPB patients.^5,6

2. Clinical outcomes and resource usage in 100 consecutive patients after off-pump coronary bypass procedures

Lee JH, Abdelhady K, Capdeville M.

Departments of Surgery and Anesthesiology, University Hospitals Heart Institute, University Hospitals of Cleveland, Cleveland, Ohio.

BACKGROUND: Cardiopulmonary bypass initiates a cascade of inflammatory processes that may result in end-organ damage, leading to the increased prevalence of noncardiac complications.

Therefore, off-pump coronary artery bypass graft (OPCAB) procedures have recently been introduced into clinical practice.

METHODS: This study was a case-controlled study that compared the outcomes and cost of 100 consecutive OPCAB procedures with a control group of 100 contemporary matched conventional coronary artery bypass grafting procedures. All operations were performed by a single surgeon (J.H.L.) and complete revascularization that used off-pump techniques was achieved with the use of innovative exposure techniques to the lateral and posterior wall vessels.

RESULTS: An average of 3.1 grafts per patient were performed in the OPCAB group (range, 1-5). The incidence of conversion to conventional coronary artery bypass grafting was 1%. The overall mortality rate was 2.0%. There were no instances of stroke, renal failure, or sternal infections in the OPCAB group. Thus, the OPCAB group had a shorter length of stay (6.1 + 2.5 versus 7.1 + 3.3 d; P=.003), with a corresponding reduction in variable direct cost per case of 29% (P<.001).

CONCLUSION: Our experience suggests that OPCAB procedures are feasible for most patients who currently require complete revascularization. It is associated with very a low morbidity rate and may represent the ideal revascularization strategy for patients at high risk for undergoing cardiopulmonary bypass.

Surgery. 2000 Oct;128(4):548-55.

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.

5. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting

Puskas JD, Williams WH, Duke PG, Staples JR, Glas KE, Marshall JJ, Leimbach M, Huber

P, Garas S, Sammons BH, McCall SA, Petersen RJ, Bailey DE, Chu H, Mahoney EM, Weintraub WS, Guyton RA.

Division of Cardiothoracic Surgery, Emory University School of Medicine, and the Emory Center for Outcomes Research, Crawford Long Hospital, Atlanta, GA.

OBJECTIVE: Retrospective comparisons of selected patients undergoing off-pump versus conventional on-pump coronary artery bypass grafting have yielded inconsistent results and raised concerns about completeness of revascularization in off-pump coronary artery bypass grafting.

METHODS: Two hundred unselected patients referred for elective primary coronary artery bypass grafting were randomly assigned to undergo off-pump coronary artery bypass grafting with an Octopus tissue stabilizer (Medtronic, Inc, Minneapolis, Minn) or conventional coronary artery bypass grafting with cardiopulmonary bypass by a single surgeon. Revascularization intent determined before random assignment was compared with the revascularization performed. All management followed strict, unbiased, criteria-driven protocols. Patients and nonoperative care providers were blinded to surgical group.

RESULTS: Baseline characteristics were similar. The number of grafts performed per patient (mean + SD 3.39 + 1.04 for off-pump coronary artery bypass grafting, 3.40 + 1.08 for conventional coronary artery bypass grafting) and the index of completeness of revascularization (number of grafts performed/number of grafts intended, 1.00 + 0.18 for off-pump coronary artery bypass grafting, 1.01 + 0.09 for conventional coronary artery bypass grafting) were similar. Likewise, the index of completeness of revascularization was similar between groups for the lateral wall. Combined hospital and 30-day mortalities and stroke rates were similar. Postoperative myocardial serum enzyme measures were significantly lower after off-pump coronary artery bypass grafting, suggesting less myocardial injury. Adjusted postoperative thromboelastogram indices, fibrinogen, international normalized ratio, and platelet levels all showed significantly less coagulopathy after off-pump coronary artery bypass grafting. Patients undergoing off-pump coronary artery bypass grafting received fewer units of blood, were more likely to avoid transfusion altogether, and had a higher hematocrit at discharge. Cardiopulmonary bypass was an independent predictor of transfusion (odds ratio 2.42, P =.0073) by multivariate analysis. More patients undergoing off-pump coronary artery bypass grafting were extubated in the operating room and within 4 hours. Postoperative length of stay (in days) was shorter for off-pump coronary artery bypass grafting (5.1 + 6.5 for off-pump coronary artery bypass grafting, 6.1 + 8.2 for conventional coronary artery bypass grafting, P =.005 by Wilcoxon test). One patient (in the conventional coronary artery bypass grafting group) required angioplasty for graft closure within 30 days.

CONCLUSIONS: When compared with conventional coronary artery bypass grafting with cardiopulmonary bypass, off-pump coronary artery bypass grafting achieved similar completeness

of revascularization, similar in-hospital and 30-day outcomes, shorter length of stay, reduced transfusion requirement, and less myocardial injury. Journal of Thoracic and Cardiovascular Surgery. 2003 Apr;125(4):797-808.

6. Total arterial myocardial revascularization with composite grafts improves results of coronary surgery in elderly: a prospective randomized comparison with conventional coronary artery bypass surgery

Muneretto C, Bisleri G, Negri A, Manfredi J, Metra M, Nodari S, Culot L, Dei Cas L.

Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy.

BACKGROUND: Total arterial myocardial revascularization with composite grafts proved to enhance the long-term benefits of coronary surgery. We assessed the hypothesis that full arterial revascularization (FAR) may improve clinical outcome even in elderly and at short term.

METHODS AND RESULTS: A prospective randomized study was designed to compare FAR with conventional coronary artery bypass grafting (CABG) surgery [left interval thoracic artery (LITA) on left anterior descending (LAD) plus additional saphenous vein grafts] with the following end points: early and late death, graft occlusion, reintervention, angina recurrence, and acute myocardial infarction (AMI). We enrolled 200 consecutive patients > 70 years of age; population was equally divided at random in Group 1 (G1, FAR) and Group 2 (G2, Conventional). The groups resulted comparable with respect to all preoperative continuous and discrete variables and risk factors (Euroscore: G1=8.4 versus G2=8.1). No differences between G1 versus G2 were observed in terms of postoperative complications (perioperative AMI:2% versus 3%), mean intensive care unit (ICU) (hours: 39 + 11 versus 40 + 9) and hospital stay (days: 6 + 2 versus 7 + 3) nor were there any differences in hospital mortality(G1=5% versus G2=4%). At the mean follow-up of 14 + 5 months the incidence of angina recurrence was 3% in G1 versus 12% in G2. Angiographic controls of grafts showed a superior graft patency rate of all the arterial grafts when compared with saphenous vein grafts. Conventional CABG surgery was identified as incremental risk factor for angina recurrence and as predictor for graft occlusion.

CONCLUSIONS: Total arterial myocardial revascularization improved clinical outcome of patients undergoing coronary surgery in the elderly, whereas saphenous vein grafts negatively affected patient prognosis in terms of graft patency and freedom from late cardiac events. Circulation. 2003 Sep 9;108 Suppl 1:II29-33.

8. Off-pump coronary artery bypass is associated with improved risk-adjusted outcomes

Plomondon ME, Cleveland JC Jr, Ludwig ST, Grunwald GK, Kiefe CI, Grover FL, Shroyer AL.

University of Colorado Health Sciences Center, Denver, USA.

BACKGROUND: The impact of off-pump median sternotomy coronary artery bypass grafting procedures on risk-adjusted mortality and morbidity was evaluated versus on-pump procedures.

METHODS: Using the Department of Veterans Affairs Continuous Improvement in Cardiac Surgery Program records from October 1997 through March 1999, nine centers were designated as having experience (with at least 8% coronary artery bypass grafting procedures performed off-pump). Using all other 34 Veterans Affairs cardiac surgery programs, baseline logistic regression models were built to predict risk of 30-day operative mortality and morbidity. These models were then used to predict outcomes for patients at the nine study centers. A final model evaluated the impact of the off-pump approach within these nine centers adjusting for preoperative risk.

RESULTS: Patients treated off-pump (n = 680) versus on-pump (n = 1,733) had lower complication rates (8.8% versus 14.0%) and lower mortality (2.7% versus 4.0%). Risk-adjusted morbidity and mortality were also improved for these patients (0.52 and 0.56 multivariable odds ratios for off-pump versus on-pump, respectively, p < 0.05).

CONCLUSIONS: An off-pump approach for coronary artery bypass grafting procedures is associated with lower risk-adjusted morbidity and mortality Annals of Thoracic Surgery. 2001 Jul;72(1):114-9.

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