title: Off-pump versus on-pump coronary artery bypass grafting in consecutive patients: decision-making algorithm and outcomes.
abstract: BACKGROUND
  Debate continues between on-pump or off-pump approach for coronary artery bypass grafting (CABG). We used off-pump coronary artery bypass grafting (OPCAB) as a tool within a decision-making algorithm driven by the patient-related factors of coronary anatomy and comorbidity. Our analysis presents this decision algorithm and describes outcomes using this approach.
  
  
  METHODS
  From January 2000 to December 2003, 592 consecutive patients undergoing isolated CABG were assigned by one surgeon to a technique: on-pump CABG or OPCAB according to (1) anatomy and (2) predicted risk. Anatomic factors against OPCAB were target vessel size less than 1.25 mm, calcification, poor quality, intramyocardial location, and multiple stenoses. Given that OPCAB could be performed safely, patients in the moderate risk range, ie, those elderly with multiple comorbidities, were preferentially treated using OPCAB.
  
  
  RESULTS
  The OPCAB group had higher predicted 30-day mortality compared with the on-pump CABG group, consistent with the protocol's intent. However, morbidity and mortality were similar between on-pump CABG and OPCAB. The OPCAB patients received the same number of internal mammary artery grafts but fewer distal grafts. Mortality and observed to expected ratios were favorable for both groups and below those The Society of Thoracic Surgeons' predicted for OPCAB.
  
  
  CONCLUSIONS
  Matching surgical strategy to patient-related factors and needs resulted in excellent outcomes. Our data support the use of a protocol based on patient characteristics to drive the surgeon's choice between an on-pump CABG or OPCAB approach. As such, OPCAB can be viewed as a tool to be used by the surgeon developing a best practice in treating coronary artery disease.
authors.affiliation: Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland 21201, USA. jbrown@smail.umaryland.edu
authors.forename: James M
authors.initials: JM
authors.lastname: Brown
authors.forename: Robert S
authors.initials: RS
authors.lastname: Poston
authors.forename: James S
authors.initials: JS
authors.lastname: Gammie
authors.forename: Marcello G
authors.initials: MG
authors.lastname: Cardarelli
authors.forename: Kimberly
authors.initials: K
authors.lastname: Schwartz
authors.forename: Jo Ann H
authors.initials: JA
authors.lastname: Sikora
authors.forename: Susan
authors.initials: S
authors.lastname: Yi
authors.forename: Richard N
authors.initials: RN
authors.lastname: Pierson
authors.forename: Bartley P
authors.initials: BP
authors.lastname: Griffith
mesh_terms: D000368:Aged; D000465:Algorithms; D019985:Benchmarking; D015897:Comorbidity; D001026:Coronary Artery Bypass / Q000401:mortality; D047549:Coronary Artery Bypass, Off-Pump / Q000401:mortality; D003324:Coronary Artery Disease / Q000401:mortality / Q000601:surgery; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome