title: Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting.
abstract: OBJECTIVE
  Retrospective comparisons of selected patients undergoing off-pump versus conventional on-pump coronary artery bypass grafting have yielded inconsistent results and raised concerns about completeness of revascularization in off-pump coronary artery bypass grafting.
  
  
  METHODS
  Two hundred unselected patients referred for elective primary coronary artery bypass grafting were randomly assigned to undergo off-pump coronary artery bypass grafting with an Octopus tissue stabilizer (Medtronic, Inc, Minneapolis, Minn) or conventional coronary artery bypass grafting with cardiopulmonary bypass by a single surgeon. Revascularization intent determined before random assignment was compared with the revascularization performed. All management followed strict, unbiased, criteria-driven protocols. Patients and nonoperative care providers were blinded to surgical group.
  
  
  RESULTS
  Baseline characteristics were similar. The number of grafts performed per patient (mean +/- SD 3.39 +/- 1.04 for off-pump coronary artery bypass grafting, 3.40 +/- 1.08 for conventional coronary artery bypass grafting) and the index of completeness of revascularization (number of grafts performed/number of grafts intended, 1.00 +/- 0.18 for off-pump coronary artery bypass grafting, 1.01 +/- 0.09 for conventional coronary artery bypass grafting) were similar. Likewise, the index of completeness of revascularization was similar between groups for the lateral wall. Combined hospital and 30-day mortalities and stroke rates were similar. Postoperative myocardial serum enzyme measures were significantly lower after off-pump coronary artery bypass grafting, suggesting less myocardial injury. Adjusted postoperative thromboelastogram indices, fibrinogen, international normalized ratio, and platelet levels all showed significantly less coagulopathy after off-pump coronary artery bypass grafting. Patients undergoing off-pump coronary artery bypass grafting received fewer units of blood, were more likely to avoid transfusion altogether, and had a higher hematocrit at discharge. Cardiopulmonary bypass was an independent predictor of transfusion (odds ratio 2.42, P =.0073) by multivariate analysis. More patients undergoing off-pump coronary artery bypass grafting were extubated in the operating room and within 4 hours. Postoperative length of stay (in days) was shorter for off-pump coronary artery bypass grafting (5.1 +/- 6.5 for off-pump coronary artery bypass grafting, 6.1 +/- 8.2 for conventional coronary artery bypass grafting, P =.005 by Wilcoxon test). One patient (in the conventional coronary artery bypass grafting group) required angioplasty for graft closure within 30 days.
  
  
  CONCLUSIONS
  When compared with conventional coronary artery bypass grafting with cardiopulmonary bypass, off-pump coronary artery bypass grafting achieved similar completeness of revascularization, similar in-hospital and 30-day outcomes, shorter length of stay, reduced transfusion requirement, and less myocardial injury.
authors.affiliation: Division of Cardiothoracic Surgery, Emory University School of Medicine, and the Emory Center for Outcomes Research, Crawford Long Hospital, Atlanta, Ga 30308, USA. john_puskas@emoryhealthcare.org <john_puskas@emoryhealthcare.org>
authors.forename: J D
authors.initials: JD
authors.lastname: Puskas
authors.forename: W H
authors.initials: WH
authors.lastname: Williams
authors.forename: P G
authors.initials: PG
authors.lastname: Duke
authors.forename: J R
authors.initials: JR
authors.lastname: Staples
authors.forename: K E
authors.initials: KE
authors.lastname: Glas
authors.forename: J J
authors.initials: JJ
authors.lastname: Marshall
authors.forename: M
authors.initials: M
authors.lastname: Leimbach
authors.forename: P
authors.initials: P
authors.lastname: Huber
authors.forename: S
authors.initials: S
authors.lastname: Garas
authors.forename: B H
authors.initials: BH
authors.lastname: Sammons
authors.forename: S A
authors.initials: SA
authors.lastname: McCall
authors.forename: R J
authors.initials: RJ
authors.lastname: Petersen
authors.forename: D E
authors.initials: DE
authors.lastname: Bailey
authors.forename: H
authors.initials: H
authors.lastname: Chu
authors.forename: E M
authors.initials: EM
authors.lastname: Mahoney
authors.forename: W S
authors.initials: WS
authors.lastname: Weintraub
authors.forename: R A
authors.initials: RA
authors.lastname: Guyton
mesh_terms: D001803:Blood Transfusion; D001026:Coronary Artery Bypass / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies