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Benefits of off-pump bypass on neurologic and clinical morbidity: a prospective randomized trial
Jeffrey D Lee1, Shay J Lee, William T Tsushima
1Department of Surgery, University of Hawaii School of Medicine, Honolulu, Hawaii 96813, USA. jdl@heartsurgery-hawaii.com
Insights
Off-pump coronary artery bypass grafting (OPCAB) significantly reduces cerebral microemboli and improves cognitive function compared to traditional coronary artery bypass grafting (CABG). OPCAB also lowers clinical morbidity and healthcare costs.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Medical Technology
Background:
- Coronary artery bypass grafting (CABG) is associated with significant neurologic and clinical morbidity.
- Off-pump coronary artery bypass grafting (OPCAB) aims to reduce this morbidity by avoiding cardiopulmonary bypass.
Purpose of the Study:
- To compare the neurologic and clinical outcomes, including cognitive function and cerebral perfusion, between OPCAB and CABG.
- To evaluate the incidence of cerebral microemboli and associated costs in both surgical groups.
Main Methods:
- A prospective randomized study of 60 patients (30 CABG, 30 OPCAB) was conducted.
- Neurocognitive testing, neurologic examination, SPECT scanning for cerebral perfusion, and transcranial Doppler for cerebral microemboli were performed.
- Clinical morbidity, resource utilization, and costs were compared between groups.
Main Results:
- CABG showed significantly more cerebral microemboli and reduced cerebral perfusion postoperatively compared to OPCAB.
- OPCAB patients demonstrated improved performance on memory tests at 2 weeks and 1 year, while CABG patients showed no change.
- CABG patients experienced greater chest tube drainage, required more blood products and dopamine, and incurred higher costs.
Conclusions:
- OPCAB may offer reduced neurologic and clinical morbidity compared to CABG.
- OPCAB is associated with improved cognitive outcomes and lower overall costs.
Background:
Neurologic and clinical morbidity after coronary artery bypass grafting (CABG) can be significant. By avoiding cardiopulmonary bypass, off-pump CABG (OPCAB) may reduce morbidity.
Methods:
Sixty patients (30 CABG and 30 OPCAB) were prospectively randomized. Neurocognitive testing was performed before the operation and 2 weeks and 1 year after the operation. Neurologic testing to detect stroke and (99m)Tc-HMPAO whole-brain single photon emission computed tomography scanning to assess cerebral perfusion were performed before the operation and 3 days afterward. Bilateral middle cerebral artery transcranial Doppler scanning was performed intraoperatively to detect cerebral microemboli. All examiners were blinded to treatment group. Clinical morbidity and costs were compared.
Results:
Coronary artery bypass grafting was associated with more cerebral microemboli (575 +/- 278.5 CABG versus 16.0 +/- 19.5 OPCAB (median +/- semiinterquartile range) and significantly reduced cerebral perfusion after the operation to the bilateral occipital, cerebellar, precunei, thalami, and left temporal lobes (p < or = 0.01). Cerebral perfusion with OPCAB was unchanged. Compared with base line, OPCAB patients performed better on the Rey Auditory Verbal Learning Test (total and recognition scores) at both 2 weeks and at 1 year (p < or = 0.05), whereas CABG performance was statistically unchanged for all cognitive measures. Patients who underwent CABG had more chest tube drainage (1389 +/- 1256 mL CABG versus 789 +/- 586 mL OPCAB, p = 0.02) and required more blood (3.9 +/- 5.8 U CABG versus 1.2 +/- 2.2 U OPCAB, p = 0.02), fresh frozen plasma (3.0 +/- 6.0 U CABG versus 0.5 +/- 2.2 U OPCAB, p = 0.03), and hours of postoperative use of dopamine (16.3 +/- 21.2 hours CABG versus 7.3 +/- 9.7 hours OPCAB, p = 0.04). These differences culminated in higher costs for CABG ($23,053 +/- $5,320 CABG versus $17,780 +/- $4,390 OPCAB, p < 0.0001). One stroke occurred with CABG, compared with none with OPCAB (p = NS). One OPCAB patient died because of a pulmonary embolus (p = NS).
Conclusions:
Compared with CABG, OPCAB may reduce neurologic and clinical morbidity as well as cost.