Effect of off-pump coronary artery bypass grafting on risk-adjusted and cumulative sum failure outcomes after coronary artery surgery.
OBJECTIVE
We have shown that cumulative sum (CUSUM) failure analysis may be more sensitive than standard statistical methods in detecting a cluster of adverse patient outcomes after cardiac surgical procedures. We therefore applied CUSUM, as well as standard statistical techniques, to analyze a surgeon's experience with off-pump coronary artery bypass grafting (OPCAB) and on-pump procedures to determine whether the two techniques have similar or different outcomes.


METHODS
In 320 patients undergoing nonemergent, first time coronary artery bypass grafting, preoperative patient characteristics, rates of mortality and major complications, and ICU and hospital lengths of stay were compared between the on-pump and OPCAB cohorts using Fisher's exact tests and Wilcoxon two sample tests. Predicted mortality and length of stay were determined using previously validated models of the Cardiac Care Network of Ontario. Observed versus expected ratios of both variables were calculated for the two types of procedures. Furthermore, CUSUM curves were constructed for the on-pump and OPCAB cohorts. A multivariable analysis of the predictors of hospital length of stay was also performed to determine whether the type of coronary artery bypass procedure had an independent impact on this variable.


RESULTS
The predicted mortality risk and predicted hospital length of stay were almost identical in the 208 on-pump patients (2.2 +/- 3.9%; 8.2 +/- 2.5 days) and the 112 OPCAB patients (2.0 +/- 2.2%; 7.8 +/- 2.1 days). The incidence of hospital mortality and postoperative stroke were 2.9% and 2.4% in on-pump patients versus zero in OPCAB patients (p = 0.09 and 0.17, respectively). Mechanical ventilation for greater than 48 hours was significantly less common in OPCAB (1.8%) than in on-pump patients (7.7%, p = 0.04). The rate of 10 major complications was 14.9% in on-pump versus 8.0% in OPCAB patients (p = 0.08). OPCAB patients experienced a hospital length of stay that was a median of 1.0 day shorter than on-pump patients (p = 0.01). The observed versus expected ratio for length of stay was 0.78 in OPCAB patients versus 0.95 in on-pump patients. On CUSUM analysis, the failure curve in OPCAB patients was negative and was flatter than that of on-pump patients throughout the duration of the study. Furthermore, OPCAB was an independent predictor of a reduced hospital length of stay on multivariable analysis.


CONCLUSIONS
OPCAB was associated with better outcomes than on-pump coronary artery bypass despite a similar predicted risk. This robust finding was documented on sensitive CUSUM analysis, using standard statistical techniques and on a multivariable analysis of the independent predictors of hospital length of stay.
Novick
Richard J
RJ
Division of Cardiac Surgery, London Health Sciences Center, London, Ontario, Canada. rjnovick@uwo.ca
Fox
Stephanie A
SA
Stitt
Larry W
LW
Kiaii
Bob B
BB
Abu-Khudair
Walid
W
Lee
Alex
A
Benmusa
Anas
A
Swinamer
Stuart A
SA
Rayman
Reiza
R
Menkis
Alan H
AH
McKenzie
F Neil
FN
Quantz
Mackenzie A
MA
Boyd
W Douglas
WD
D000368:Aged; D001026:Coronary Artery Bypass; D003324:Coronary Artery Disease / Q000401:mortality* / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D015994:Incidence; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D011237:Predictive Value of Tests; D020379:Risk Adjustment; D015996:Survival Rate; D017211:Treatment Failure