Routine off-pump coronary artery bypass grafting is safe and feasible in high-risk patients with left main disease

Coronary artery bypass graft surgery (CABG) remains the method of choice for patients with left main disease (LMD). The precise role of off-pump coronary artery bypass graft surgery (OPCABG) remains unclear in this setting. We report the safety and feasibility of a routine OPCABG approach to patients with LMD.

From 2002 to 2007, 983 patients underwent myocardial revascularization at our institution. We compared 343 OPCABG patients with LMD (group A) to 640 OPCABG patients without LMD (group B). The relationship between the presence of LMD and outcome in OPCABG procedures was statistically assessed. A composite endpoint (30-day mortality, postoperative renal failure, intensive care unit length of stay [>2 days], neurologic complications, use of intra-aortic balloon pump, and conversion to cardiopulmonary bypass) was also used. In addition, completeness of revascularization was compared in both groups.

Group A had a lower mortality rate (1.7% versus 2.2%; p=0.81), and no differences were noted in conversion to cardiopulmonary bypass (6.7% versus 5.3%; p=0.39), intra-aortic balloon pump use (0.3% versus 1.4%; p=0.18), and occurrence of composite endpoint (30.9% versus 30.8%; p=0.99). The number of arterial grafts per patient was significantly higher among patients in group A (1.77+/-0.95 versus 1.66+/-0.95; p=0.029) owing to the more frequent use of the right internal mammary artery (49.6% versus 42.3%; p=0.031), whereas the total number of distal anastomoses (3.72+/-0.90 versus 3.62+/-1.01; p=0.28) and complete revascularization (94% versus 95%; p=0.55) were similar. Logistic regression confirmed that LMD is no risk factor for the occurrence of our composite endpoint (odds ratio 1.00; 95% confidence interval: 0.75 to 1.33; p=0.99).

A modern OPCABG approach offers low mortality, excellent clinical outcomes, and does not come at the price of less complete revascularization in these high-risk patients.