Off-Pump Coronary Artery Bypass Disproportionately Benefits High-Risk Patients. Discussion (original) (raw)
Related papers
European Journal of Cardio-thoracic Surgery, 2003
Objective: Although there has been some evidence supporting the theoretical and practical advantages of off-pump coronary artery bypass (OPCAB) over the conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB), it has not yet been determined which group of patients would benefit most from it. It has been advocated recently that high-risk patients could benefit most from avoidance of CPB. The aim of this retrospective study is to assess the efficacy of the OPCAB technique in multi-vessel myocardial revascularization in a large series of high-risk patients. Methods: The records of 1398 consecutive high-risk patients who underwent primary isolated CABG at Harefield Hospital between August 1996 and December 2001 were reviewed retrospectively. Patients were considered as high-risk and included in the study if they had a preoperative EuroSCORE of $5. Two hundred and eighty-six patients were operated on using the OPCAB technique while 1112 patients were operated on using the conventional CABG technique with CPB. The OPCAB patients were significantly older than the CPB patients (68.1^8.3 vs. 63.7^9.9 years, respectively, P , 0:001). The OPCAB group included significantly more patients with poor left ventricular (LV) function (ejection fraction (EF) #30%) (P , 0:001) and more patients with renal problems (P , 0:001). Results: There was no significant difference in the number of grafts between the groups. The CPB patients received 2.8^1.2 grafts per patient while OPCAB patients received 2.8^0.5 grafts per patient (P ¼ 1). Twenty-one (7.3%) OPCAB patients had one or more major complications, while 158 (14.2%) CPB patients (P ¼ 0:008) developed major complications. Thirty-eight (3.4%) CPB patients developed peri-operative myocardial infarction (MI) while only two (0.7%) OPCAB patients developed peri-operative MI (P ¼ 0:024). The intensive therapy unit (ITU) stay for OPCAB patients was 29.3^15.4 h while for CPB patients it was 63.6^167.1 h (P , 0:001). There were ten (3.5%) deaths in the OPCAB patients compared to 78 (7%) deaths in the CPB patients (P ¼ 0:041) within 30 days postoperatively. Conclusions: This retrospective study shows that using the OPCAB technique for multi-vessel myocardial revascularization in high-risk patients significantly reduces the incidence of peri-operative MI and other major complications, ITU stay and mortality. Even though the OPCAB group included a significantly higher proportion of older patients with poor LV function (EF #30%) and renal problems, the beneficial effect of OPCAB was evident. q
Outcomes for Off-Pump Coronary Artery Bypass Grafting in High-Risk Groups: A Historical Perspective
The Heart Surgery Forum, 2005
Background: The outcomes of off-pump coronary artery bypass (OPCAB) and conventional coronary artery bypass grafting with cardiopulmonary bypass (cCABG) have been compared in detail. Similarly, several reports have examined outcomes of high-risk subsets of patients in OPCAB as a selection strategy for reducing morbidity and mortality compared to cCABG. We undertook a retrospective study comparing outcomes from the early years in our experience of beating-heart surgery in high-risk patients selected for OPCAB compared to low-risk patients having OPCAB. This study was premised on strict selection criteria in an era prior to stabilizing devices and cardiac positioners. Methods: A total of 384 patients underwent OPCAB over a 10-year period. Clinical outcomes were compared for 280 low-risk patients and 104 high-risk patients (redo CABG, CABG with simultaneous carotid endarterectomy, or renal insufficiency/failure). Results: The high-risk group patients were significantly older than the l...
Scientific Reports
Coronary artery bypass grafting (CABG) remains the most frequent surgery in the practice of an adult cardiac surgeon and the most frequently performed cardiac surgical procedure worldwide. Despite the ongoing debates regarding the superiority or inferiority of off-pump coronary artery bypass grafting, it still comprises 15-30% of all CABG cases varying in different national registries. We performed a propensity matched study of 302 consecutive CABG patients,143 off-pump cases performed by the four experienced off-pump surgeons and the on-pump CABG cases performed by those surgeons and four other experienced coronary surgeons. The five year follow up was performed and data collected comprised of mortality, rehospitalization due to cardiac origin, repeated revascularization, myocardial infarction and cerebrovascular accident. Overall, the off-pump group of patients had a higher risk profile than the patients in the on-pump group. After matching, fewer differences were found between the groups. Propensity score matching analysis showed no difference in long-term survival as well as MACCE and repeated revascularization. The higher risk profile of the patients subjected to OPCAB and the comparable survival to lower risk CPB patients in this series indicate that in experienced hands, OPCAB is a valuable option in this important subgroup of patients. Coronary artery bypass grafting (CABG) laid the foundation for the modern era of cardiac surgery and remains the most frequent surgery in the practice of an adult cardiac surgeon. Despite all ongoing debates regarding off-pump and on-pump CABG, we cannot ignore the fact that the first CABG interventions were performed on beating hearts 1. The interest for the off-pump coronary surgery (OPCAB) option arose in the 90's and led to creation of numerous papers managing this subject spanning from superiority to non-inferiority of OPCAB. The largest randomized study comparing OPCAB with conventional surgery (the CORONARY trial) clearly showed no significant difference in terms of survival after five year follow up 2. Several broad systematic reviews and meta-analyses questioned the superiority of OPCAB over conventional surgery with some of them showing better survival for the latter 3-5. However, all of them have shown that results were biased by underexperienced off-pump surgeons (<20 cases in the ROOBY trial) as well as low volume centers, with some of them having less than two OPCAB cases per month. As stated by Kirmani et al., the lack of experience was an important issue in several published national registries and propensity score matching studies 6. Despite the ongoing debates regarding the superiority or inferiority of OPCAB, it still comprises 15-30% of all CABG cases varying in different national registries. Thus, we decided to compare long-term results of OPCAB surgery vs on-pump surgery in "real-world" framework-in a high-volume center with experienced OPCAB surgeons.
On-pump or off-pump? Impact of risk scores in coronary artery bypass surgery
Revista Brasileira de Cirurgia Cardiovascular, 2012
Objective: Remain controversies about the use of cardiopulmonary bypass (CPB) in coronary artery bypass grafting (CABG). The aim of this study was to evaluate the impact of the 2000 Bernstein Parsonnet (2000BP) and EuroSCORE (EU) for choice CPB in CABG. Methods: 1551 consecutive patients underwent CABG. CPB was used in 1,121 (72.3%) patients. The performance of 2000BP and EU was assessed by calibration, discrimination and correlation tests. For both risk scores, increasing the value of the score and presence of CPB were directly related to a higher risk of death (P <0.05). Therefore with these two variables was constructed a logistic regression model for each risk score, in order to determine in which value of score the presence of CPB increases significantly the risk of death. Results: The calibration, like the area under the ROC curve for the group with CPB [2000BP=0.80; EU=0.78] and without CPB [2000BP=0.81; EU=0.85] were appropriate. The Spearman correlation for groups with and without CPB was 0.66 (P<0.001) and 0.62 (P<0.001), respectively. Using the 2000BP, for a value>17.75 the presence of CPB increased the chance of death to 7.4 [CI 95% (4.4-12.3), P<0.0001]. With the EU, for a value >4.5 the presence of CPB increased the chance of death to 5.4 [CI 95% (3.3-9), P<0.0001]. Conclusion: In decision making, the 2000BP>17.75 or the EU>4.5 guide to identify patients who underwent CABG with CPB increases significantly the chance of death.
Interactive CardioVascular and Thoracic Surgery, 2021
OBJECTIVES Recent data suggested that off-pump coronary artery bypass (OPCAB) may carry a higher risk for mortality in the long term when compared to on-pump coronary artery bypass (ONCAB). We, therefore, compared long-term survival and morbidity in patients undergoing ONCAB versus OPCAB in a large single-centre cohort. METHODS A total of 8981 patients undergoing isolated elective/urgent coronary artery bypass grafting between January 2009 and December 2019 were analysed. Patients were stratified into 2 groups (OPCAB n = 6649/ONCAB n = 2332). The primary end point was all-cause mortality. Secondary endpoints included repeat revascularization, stroke and myocardial infarction. To adjust for potential selection bias, 1:1 nearest neighbour propensity score (PS) matching was performed resulting in 1857 matched pairs. Moreover, sensitivity analysis was applied in the entire study cohort using multivariable- and PS-adjusted Cox regression analysis. RESULTS In the PS-matched cohort, 10-y...
Safety and efficacy of off-pump coronary artery bypass grafting
The Annals of Thoracic Surgery, 2000
Background. We evaluated the application of the offpump coronary artery bypass (OPCAB) procedure relative to safety and efficiency as measured by operative mortality postoperative complications and longitudinal outcome.
Outcomes of off-pump versus on-pump coronary artery bypass grafting: Impact of preoperative risk
The Journal of Thoracic and Cardiovascular Surgery, 2013
Background: It is unknown whether purported benefits of off-pump coronary artery bypass grafting are patientspecific within the Society of Thoracic Surgeons National Cardiac Database or dependent on center volume or operating surgeon. Methods: The Society of Thoracic Surgeons National Cardiac Database was queried for all patients undergoing nonemergency, isolated coronary artery bypass between January 1, 2005, and December 31, 2010, who had Predicted Risk of Mortality scores and participant/surgeon identifiers. Of these 876,081 patients (''all sites''), 210,469 underwent surgery at participant sites that had performed more than 300 off-pump and 300 on-pump coronary artery bypass operations during the 6-year study period (''high-volume sites''). Operative mortality, stroke, acute renal failure, mortality or morbidity, and prolonged postoperative length of stay were analyzed with conditional logistic models for all sites and for high-volume sites, stratified by participant center and surgeon, and adjusted for 30 variables that comprise the Society of Thoracic Surgeons coronary artery bypass grafting risk models. Results: Off-pump coronary artery bypass was associated with a significant reduction in risk of death, stroke, acute renal failure, mortality or morbidity, and postoperative length of stay compared with on-pump coronary artery bypass after adjustment for 30 patient risk factors in the overall sample. This held true within highvolume centers. In the overall sample, there was a significant (P<.05) interaction between off-pump coronary artery bypass and Predicted Risk of Mortality for death, stroke, acute renal failure, and mortality or morbidity. Conclusions: Off-pump coronary artery bypass was associated with reduced adverse events compared with on-pump coronary artery bypass after adjustment for 30 patient risk factors and center and surgeon identity. Patients with higher Predicted Risk of Mortality scores had the largest apparent benefit.