Coronary revascularization without cardiopulmonary bypass versus the conventional approach in high-risk patients.
BACKGROUND
The premise of coronary revascularization without cardiopulmonary bypass (off-pump coronary artery bypass graft [CABG]) proposes that patient morbidity and, potentially, mortality can be reduced without compromising the excellent results of conventional revascularization techniques (on-pump CABG). High-risk patients may benefit the most from off-pump CABG. The aim of this study was to compare early and mid-term clinical outcomes after off-pump CABG with on-pump CABG in a subset of high-risk patients.


METHODS
Between January 1, 2000 and December 31, 2000, 513 high-risk patients with a Parsonnet's risk scores of 20 or higher underwent CABG; 38.6% (n = 198) underwent on-pump CABG, and 61.4% (n = 315) had off-pump CABG. Logistic regression was used to calculate the probability of being selected for on-pump CABG given a set of preoperative risk factors. Propensity scores or the probability of being selected for on-pump CABG were computed. Relative risks, heterogeneity among strata, and interactions between surgery type and the propensity score were assessed by a multivariate Cox proportional-hazards regression for the outcomes mortality and major adverse cardiac events (death, acute myocardial infarction, stroke, reoperative CABG, percutaneous coronary intervention).


RESULTS
Operative mortality was lower after off-pump versus on-pump CABG between the two groups after controlling for preoperative risk factors using the propensity score (odds ratio = 2.10; 95% confidence intervals = 1.02 to 4.36, p = 0.04). In the Cox-regression analysis, off-pump CABG was associated with an improved survival rate compared with on-pump CABG (p = 0.03). Off-pump CABG was associated with a comparable event-free survival (p = 0.14) compared with on-pump CABG.


CONCLUSIONS
Off-pump CABG can be performed with a reasonably low morbidity and lower early and late mortality in high-risk patients. Off-pump CABG may be a better operative strategy in this subset of patients.
Stamou
Sotiris C
SC
Section of Cardiac Surgery, Washington Hospital Center, Washington, DC 20010, USA. cvsisfun@hotmail.com
Jablonski
Kathleen A
KA
Hill
Peter C
PC
Bafi
Ammar S
AS
Boyce
Steven W
SW
Corso
Paul J
PJ
D000368:Aged; D001026:Coronary Artery Bypass; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D008297:Male; D009204:Myocardial Revascularization / Q000379:methods* / Q000401:mortality*; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome