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Clinical outcomes of nonelective coronary revascularization with and without cardiopulmonary bypass
Sotiris C Stamou1, Peter C Hill, Elizabeth Haile
1Department of Cardiac Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Insights
Off-pump coronary artery bypass in nonelective cases shows similar mortality and stroke rates compared to on-pump procedures. This technique offers shorter hospital stays and reduced complications like renal failure and bleeding.
Area of Science:
- Cardiovascular Surgery
- Surgical Outcomes
- Minimally Invasive Procedures
Background:
- Emergent coronary artery bypass grafting (CABG) presents higher risks than elective procedures.
- Off-pump CABG (OPCAB) may mitigate risks by avoiding cardiopulmonary bypass (CPB) and its associated inflammatory response.
- This study compares early clinical outcomes of nonelective OPCAB versus on-pump CABG.
Purpose of the Study:
- To compare the early clinical outcomes of nonelective off-pump coronary artery bypass (OPCAB) with a matched cohort undergoing on-pump coronary artery bypass (CABG).
- To evaluate the safety and efficacy of OPCAB in high-risk, nonelective cardiac surgery patients.
Main Methods:
- A retrospective comparison of 2273 nonelective OPCAB patients and 3487 on-pump CABG patients (Jan 2000-Oct 2003).
- Propensity score matching was used to control for preoperative risk factors.
- Logistic regression analysis assessed operative mortality, stroke, length of stay, intra-aortic balloon pump use, renal failure, and re-exploration.
Main Results:
- OPCAB demonstrated comparable operative mortality and stroke rates to on-pump CABG after risk factor matching.
- OPCAB was associated with a significantly shorter length of stay (P < .01).
- Reduced rates of postoperative renal failure, intra-aortic balloon pump placement, and hemorrhage-related re-exploration were observed with OPCAB (P < .01 for renal failure and balloon pump).
Conclusions:
- Nonelective coronary revascularization via OPCAB offers comparable safety to on-pump CABG regarding mortality and stroke.
- OPCAB is associated with improved short-term outcomes, including shorter hospital stays.
- OPCAB may reduce the need for postoperative interventions such as intra-aortic balloon pumps and decrease complications like renal failure and bleeding.
Background:
Patients who undergo emergent coronary artery bypass grafting pose a greater challenge in terms of intraoperative and postoperative mortality and morbidity compared to elective coronary artery bypass. Coronary artery bypass without cardiopulmonary bypass (off-pump coronary artery bypass) might benefit these high-risk patients by eliminating the cardiopulmonary bypass and therefore decreasing the systemic inflammatory response associated with it. The aim of this study was to compare the early clinical outcome after nonelective off-pump coronary artery bypass with a matched set of patients undergoing coronary artery bypass with cardiopulmonary bypass (on pump).
Methods:
Between January 2000 and October 2003, 2273 patients underwent nonelective (urgent or emergent) off-pump coronary artery bypass and were compared with a contemporaneous control group of 3487 patients undergoing on-pump coronary artery bypass. Logistic regression analysis was used to compare operative mortality, postoperative stroke, length of stay, postoperative placement of intra-aortic balloon pump, postoperative renal failure, and hemorrhage-related re-exploration between the groups, controlling for preoperative risk factors. The patients undergoing off-pump coronary artery bypass were matched to patients undergoing on-pump bypass by propensity scores.
Results:
Patients undergoing off-pump coronary artery bypass had comparable operative mortality (odds ratio, 0.8; 95% confidence interval, 0.57-1.15; P = .24) and stroke rate (odds ratio, 0.6; 95% confidence interval, 0.33-1.08; P = .09) with the patients undergoing on-pump coronary artery bypass after controlling for preoperative risk factors through matching. Off-pump coronary artery bypass was associated with an abbreviated length of stay (odds ratio, 0.5; 95% confidence interval, 0.47-0.64; P < .01), lower rate of postoperative renal failure (odds ratio, 0.5; 95% confidence interval, 0.37-0.72; P < .01), intra-aortic balloon pump placement (odds ratio, 0.5; 95% confidence interval, 0.3-0.71; P < .01), and hemorrhage-related re-exploration rate (odds ratio, 0.70; 95% confidence interval, 0.5-1.0; P = .5) compared with on-pump coronary artery bypass after matching by propensity scores.
Conclusions:
Nonelective coronary revascularization without cardiopulmonary bypass is associated with comparable operative mortality and stroke and abbreviated length of stay. Off-pump coronary artery bypass might also decrease the need for intra-aortic balloon pump placement and lower the rate of postoperative renal failure and hemorrhage-related re-exploration compared with that of conventional on-pump coronary artery bypass in this subset of patients.
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