Selective use of off-pump coronary bypass surgery reduces mortality and neurologic morbidity associated with high-risk coronary bypass surgery: a 400-case comparative experience

The frequency of use of off-pump coronary artery bypass (CAB) surgery to surgically treat coronary artery disease has varied greatly from center to center and from surgeon to surgeon because of preference, training, and experience. We report an experience with 400 consecutive isolated CAB procedures selectively managed with on-pump or off-pump surgery, according to the perceived potential for aortic embolization or stroke as determined by clinical and imaging determinations. The off-pump CAB group (46 patients) was 7.1 years older (P < .05) and had an 11% lower ejection fraction (P < .03) than the on-pump group. There was no difference in gender, urgency of surgery, hemodynamic stability, angina class, or incidence of prior myocardial infarction. All 400 patients underwent intraoperative transesophageal echocardiography, and many underwent an epiaortic study to supplement image quality. Patients without palpable or imaged advanced aortic disease or deemed to be at clinically high risk for stroke (advanced age, prior strokes, or advanced cerebrovascular or peripheral vascular disease) underwent on-pump procedures requiring 55 minutes of aortic ischemia and 97 minutes of high-flow, high-pressure bypass on average. All others underwent off-pump procedures. The numbers of grafts per patient were similar (3.2 on-pump, 2.8 off-pump; = ns). There was no in-hospital or 30-day mortality in either group. Using the New York State risk-adjustment algorithm, we found the predicted mortality rate for the off-pump group was higher (2.24% on-pump versus 5.54% off-pump, P = .008). The postoperative length of stay was longer in the off-bypass group (3.67 days versus 4.31 days, P = .003). The frequencies of hospital readmission and perioperative complications (renal, pulmonary, infection, bleeding, cardiac, neurologic) were similar, and there were no postoperative strokes in either group. The selective use of off-pump surgery safely managed patients at higher risk for perioperative stroke and associated embolic multisystem organ failure and death. Individual surgeon and center-wide use of a selective approach is recommended as an alternative to a single-procedure nonselective approaches.