Benefits of off-pump bypass on neurologic and clinical morbidity: a prospective randomized trial.
BACKGROUND
Neurologic and clinical morbidity after coronary artery bypass grafting (CABG) can be significant. By avoiding cardiopulmonary bypass, off-pump CABG (OPCAB) may reduce morbidity.


METHODS
Sixty patients (30 CABG and 30 OPCAB) were prospectively randomized. Neurocognitive testing was performed before the operation and 2 weeks and 1 year after the operation. Neurologic testing to detect stroke and (99m)Tc-HMPAO whole-brain single photon emission computed tomography scanning to assess cerebral perfusion were performed before the operation and 3 days afterward. Bilateral middle cerebral artery transcranial Doppler scanning was performed intraoperatively to detect cerebral microemboli. All examiners were blinded to treatment group. Clinical morbidity and costs were compared.


RESULTS
Coronary artery bypass grafting was associated with more cerebral microemboli (575 +/- 278.5 CABG versus 16.0 +/- 19.5 OPCAB (median +/- semiinterquartile range) and significantly reduced cerebral perfusion after the operation to the bilateral occipital, cerebellar, precunei, thalami, and left temporal lobes (p < or = 0.01). Cerebral perfusion with OPCAB was unchanged. Compared with base line, OPCAB patients performed better on the Rey Auditory Verbal Learning Test (total and recognition scores) at both 2 weeks and at 1 year (p < or = 0.05), whereas CABG performance was statistically unchanged for all cognitive measures. Patients who underwent CABG had more chest tube drainage (1389 +/- 1256 mL CABG versus 789 +/- 586 mL OPCAB, p = 0.02) and required more blood (3.9 +/- 5.8 U CABG versus 1.2 +/- 2.2 U OPCAB, p = 0.02), fresh frozen plasma (3.0 +/- 6.0 U CABG versus 0.5 +/- 2.2 U OPCAB, p = 0.03), and hours of postoperative use of dopamine (16.3 +/- 21.2 hours CABG versus 7.3 +/- 9.7 hours OPCAB, p = 0.04). These differences culminated in higher costs for CABG ($23,053 +/- $5,320 CABG versus $17,780 +/- $4,390 OPCAB, p < 0.0001). One stroke occurred with CABG, compared with none with OPCAB (p = NS). One OPCAB patient died because of a pulmonary embolus (p = NS).


CONCLUSIONS
Compared with CABG, OPCAB may reduce neurologic and clinical morbidity as well as cost.
Lee
Jeffrey D
JD
Department of Surgery, University of Hawaii School of Medicine, Honolulu, Hawaii 96813, USA. jdl@heartsurgery-hawaii.com
Lee
Shay J
SJ
Tsushima
William T
WT
Yamauchi
Hideko
H
Lau
William T
WT
Popper
Jordan
J
Stein
Alan
A
Johnson
David
D
Lee
David
D
Petrovitch
Helen
H
Dang
Collin R
CR
D000368:Aged; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000379:methods*; D003327:Coronary Disease / Q000175:diagnosis / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection; D006085:Graft Survival; D006353:Heart-Assist Devices; D006801:Humans; D020766:Intracranial Embolism / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D009017:Morbidity / Q000639:trends; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000175:diagnosis; D011336:Probability; D011446:Prospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D020521:Stroke / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology*; D015996:Survival Rate; D014055:Tomography, Emission-Computed; D016896:Treatment Outcome