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Published on: November 28, 2018
OPCAB surgery: a critical review of two different categories of pre-operative ejection fraction
K V Arom1, R W Emery, T F Flavin
1John Nasseff Heart Hospital, and Minneapolis Heart Institute, St. Paul and Minneapolis, Minneapolis, MN 55407, USA. karom@csa-heart.com
Insights
Off-pump coronary artery bypass (OPCAB) is safe for patients with low ejection fraction (EF), showing similar outcomes to those with normal EF. This study supports OPCAB for a wider patient range.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery Outcomes
- Minimally Invasive Cardiac Procedures
Background:
- Limited data exists on off-pump coronary artery bypass (OPCAB) in patients with poor left ventricular function.
- No studies have directly compared OPCAB outcomes between low ejection fraction (EF) and normal EF patient groups.
Purpose of the Study:
- To compare the clinical outcomes of OPCAB in patients with low EF (<=30%) versus normal EF (>30%).
- To evaluate the safety and efficacy of OPCAB in a broader patient population, including those with impaired cardiac function.
Main Methods:
- Retrospective analysis of 387 OPCAB patients from 1/1/1998 to 6/30/1999.
- Comparison of 45 patients with LVEF <=30% against those with LVEF >30% using univariate analysis.
- Assessment of pre-operative characteristics, intra-operative data, and post-operative outcomes.
Main Results:
- Patients with low EF were older, more female, and had higher NYHA class and pre-operative risk scores.
- No significant differences in intra-operative parameters (grafts, blood loss, OR time) were observed between groups.
- Similar post-operative major neurological deficit rates and comparable operative mortality (4.4% vs. 1.8%) were found.
Conclusions:
- Despite higher pre-operative risk, OPCAB demonstrated favorable short-term clinical outcomes for patients with low EF.
- The study supports the continued use of OPCAB for a diverse patient population, including those with reduced left ventricular function.
- Longer hospital stay (discharge) was noted in the low EF group, necessitating further investigation.
Objective:
Literature review found little information on off-pump coronary artery bypass (OPCAB) procedure in patients with poor left ventricular function and there was no information comparing the low EF and normal EF patients undergoing OPCAB procedure.
Methods:
Between 1/1/1998 and 6/30/1999, 387patients had surgery performed utilizing the off-pump technique and 45 of these patients had pre-operative left ventricular function of equal to or less than 30% (LVEF < or =30). The two groups (LVEF < or =30 and LVEF>30) were compared using univariate analysis. Patients in LVEF < or =30 were older and more female gender. LVEF< 30 had more NYHA class IV patients (64 vs. 50%) and more symptoms related to depressed left ventricular function. The mean pre-operative left ventricular function was 25% in LVEF < or =30 and 56% in LVEF>30. Pre-operative predicted risk was 6.4+/-5.5% in LVEF < or =30 and 2.7+/-4.5% in LVEF>30 (P< 0.001). Most (> 95%) of the patients in both groups were elective status, and LVEF < or =30 patients had increased incidence of redo (11 vs. 6%, P=0.2). In LVEF>30, 84% of the patients had stable angina while only 69% in LVEF < or =30 (P=0.009).
Results:
Intra-operatively no significant differences were measured in number of grafts per patient (2.7 vs. 2.8), amount of blood loss, peak CK-MB, skin-to-skin time, or OR time. Patients with LVEF < or =30 have more frequent utilization IABP during pre, intra and post-operative period. The statistical analysis yields no significance in post-operative major neurological deficit between these two groups; and are comparative to the nationally reported incidence of neurological deficit for on-pump patients. The operative mortality in the low EF group was 4.4 and 1.8% in LVEF>30 group (P=0.23).
Conclusions:
Given the clinical presentation of the low EF group, higher prediction risk, longer pre-operative stay, and length of ventilation (24 vs. 8 h P=0.12) a longer surgery to discharge stay (8 vs. 6 days, P=0.02) is anticipated. Short-term clinical outcomes for both groups of OPCAB patients encouraged us to continue to offer this approach to this broad base of patient population.
