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Coronary artery bypass grafting without cardiopulmonary bypass--an attractive alternative in high risk patients
J Bergsland1, S Hasnan, A N Lewin
1Division of Cardiothoracic Surgery, The Buffalo General Hospital, NY, USA.
Insights
Coronary artery bypass grafting without cardiopulmonary bypass is safe for selected patients, showing similar mortality rates and fewer complications. This approach offers significant benefits, especially for reoperation cases.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Medical Technology
Background:
- Coronary artery bypass grafting (CABG) is a common cardiac procedure.
- The use of cardiopulmonary bypass (CPB) is standard in many CABG operations.
- Alternative techniques aim to reduce CPB-related complications.
Purpose of the Study:
- To compare preoperative risk factors, mortality, and postoperative complications in CABG patients with and without cardiopulmonary bypass.
- To evaluate the safety and efficacy of off-pump coronary artery bypass grafting (OPCAB) versus conventional CABG.
- To identify patient subgroups that may benefit most from OPCAB.
Main Methods:
- Retrospective comparison of 1829 patients undergoing CABG with CPB (Group A) and 172 patients undergoing OPCAB (Group B).
- Data collected and analyzed from the NY-state database for patients operated between January 1995 and August 1996.
- Patients in Group B were selected based on surgeon's assessment of contraindications or lack of need for CPB.
Main Results:
- Identical risk-adjusted mortality (2.8%) was observed between Group A and Group B.
- While not statistically significant, reoperation patients showed lower risk-adjusted mortality in Group B (2.1% vs. 3.1%).
- Cardiovascular and other complications were significantly lower in Group B, particularly in reoperative patients (P=0.05).
- Need for postoperative mechanical assistance was significantly reduced in Group B (1.3% vs. 14.9%, P=0.01).
Conclusions:
- Coronary artery bypass surgery can be performed safely without cardiopulmonary bypass in carefully selected patients.
- Off-pump CABG is associated with reduced postoperative complications and similar mortality compared to on-pump CABG.
- The benefits of OPCAB are most pronounced in patients undergoing reoperations.
Objective:
This study compares preoperative risk factors, estimated, observed, and risk adjusted mortality, and postoperative complications in patients undergoing coronary artery bypass grafting. Patients were divided in two groups depending on operative method: Group A patients had coronary artery bypass grafting using cardiopulmonary bypass. In group B cardiopulmonary bypass was not utilized. Patients operated on between January 1 1995 and August 31 1996 were compared. Group A consisted of 1829 patients and Group B 172.
Methods:
Patients were selected to undergo coronary artery bypass grafting without the use of cardiopulmonary bypass either because the surgeon felt that there were contraindications to--or no need for the heart-lung machine. The decision to avoid the use of cardiopulmonary bypass was taken pre-operatively by the individual surgeon. Median sternotomy, formal left thoracotomy or left anterior small thoracotomy were used. The data was collected and validated by the hospital's professional data collectors. Data-analysis was performed using the NY-state database.
Results:
Previous heart surgery and extensively calcified ascending aorta were significantly more common in Group B as was estimated and observed mortality. This resulted in identical risk-adjusted mortality of 2.8%. When reoperations were reviewed separately risk adjusted mortality was lower in Group B (2.1 versus 3.1%) but this difference was not statistically significant. Cardiovascular-and other-complications were higher in group A patients. In reoperative patients this difference was significant (P = 0.05). The need for postoperative mechanical assistance was also reduced (Group A: 14.9% versus Group B: 1.3% P = 0.01).
Conclusion:
We conclude that coronary artery bypass surgery can be done safely in selected patients without cardiopulmonary bypass. Mortality is unchanged and complications are less frequent. Cost and hospital utilization are decreased. The greatest benefit is observed in reoperations.