Coronary revascularization without cardiopulmonary bypass versus the conventional approach in high-risk patients
Sotiris C Stamou1, Kathleen A Jablonski, Peter C Hill
1Section of Cardiac Surgery, Washington Hospital Center, Washington, DC 20010, USA. cvsisfun@hotmail.com
Insights
Off-pump coronary artery bypass graft (CABG) surgery demonstrated lower operative mortality in high-risk patients compared to on-pump CABG. This approach may offer a superior surgical strategy for this patient group.
Area of Science:
- Cardiovascular Surgery
- Surgical Outcomes Research
Background:
- Coronary artery bypass graft (CABG) surgery is a standard treatment for coronary artery disease.
- Off-pump CABG aims to reduce patient morbidity and mortality compared to conventional on-pump CABG.
- High-risk patients may particularly benefit from the off-pump approach.
Purpose of the Study:
- To compare early and mid-term clinical outcomes of off-pump CABG versus on-pump CABG.
- To evaluate the safety and efficacy of off-pump CABG in high-risk patients.
Main Methods:
- A comparative study of 513 high-risk patients (Parsonnet's score ≥ 20) undergoing CABG between 2000 and 2001.
- Patients were divided into on-pump (38.6%) and off-pump (61.4%) groups.
- Propensity score matching and multivariate Cox proportional-hazards regression were used to analyze outcomes, including mortality and major adverse cardiac events.
Main Results:
- Off-pump CABG showed significantly lower operative mortality (OR = 2.10, p = 0.04) after controlling for preoperative risk factors.
- Cox-regression analysis indicated an improved survival rate with off-pump CABG (p = 0.03).
- Event-free survival was comparable between off-pump and on-pump CABG (p = 0.14).
Conclusions:
- Off-pump CABG can be performed with acceptable morbidity in high-risk patients.
- The off-pump approach is associated with lower early and late mortality.
- Off-pump CABG may represent a preferable operative strategy for selected high-risk individuals.
Background:
The premise of coronary revascularization without cardiopulmonary bypass (off-pump coronary artery bypass graft [CABG]) proposes that patient morbidity and, potentially, mortality can be reduced without compromising the excellent results of conventional revascularization techniques (on-pump CABG). High-risk patients may benefit the most from off-pump CABG. The aim of this study was to compare early and mid-term clinical outcomes after off-pump CABG with on-pump CABG in a subset of high-risk patients.
Methods:
Between January 1, 2000 and December 31, 2000, 513 high-risk patients with a Parsonnet's risk scores of 20 or higher underwent CABG; 38.6% (n = 198) underwent on-pump CABG, and 61.4% (n = 315) had off-pump CABG. Logistic regression was used to calculate the probability of being selected for on-pump CABG given a set of preoperative risk factors. Propensity scores or the probability of being selected for on-pump CABG were computed. Relative risks, heterogeneity among strata, and interactions between surgery type and the propensity score were assessed by a multivariate Cox proportional-hazards regression for the outcomes mortality and major adverse cardiac events (death, acute myocardial infarction, stroke, reoperative CABG, percutaneous coronary intervention).
Results:
Operative mortality was lower after off-pump versus on-pump CABG between the two groups after controlling for preoperative risk factors using the propensity score (odds ratio = 2.10; 95% confidence intervals = 1.02 to 4.36, p = 0.04). In the Cox-regression analysis, off-pump CABG was associated with an improved survival rate compared with on-pump CABG (p = 0.03). Off-pump CABG was associated with a comparable event-free survival (p = 0.14) compared with on-pump CABG.
Conclusions:
Off-pump CABG can be performed with a reasonably low morbidity and lower early and late mortality in high-risk patients. Off-pump CABG may be a better operative strategy in this subset of patients.
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