title: Total arterial off-pump surgery provides excellent outcomes and does not compromise complete revascularization.
abstract: OBJECTIVE
  The combination of aortic 'no-touch' off-pump surgery (OPCAB) and total arterial revascularization (TAR) can reduce peri-procedural morbidity and yields excellent long-term outcomes albeit at a reported risk of incomplete revascularization. The feasibility of OPCAB-TAR with specific regards to the complete revascularization (CR) in patients with multi-vessel disease was evaluated.
  
  
  METHODS
  From 2003 to 2010, 712 patients underwent TAR including 526 patients who had OPCAB-TAR and 186 patients who received on-pump TAR [(ONCAB grafting (ONCABG)-TAR)]. Of these, 52% (n = 272; OPCAB) vs. 83% (n = 155; ONCABG) had triple-vessel disease (TVD). To balance patient characteristics, a non-parsimonious, propensity score (PS) model was applied. Endpoints evaluated were mortality, stroke, major adverse cardiac and cerebrovascular events (MACCE). To evaluate CR, an 'Index of CR' (ICOR) was calculated, defined as the number of distal anastomoses divided by the number of the diseased coronary vessels. CR was assumed when the following requirements were fulfilled: the number of distal anastomoses was equal to or higher than that of diseased vessels (ICOR ≥ 1), and all affected coronary territories (left anterior descending, circumflex artery and/or right coronary artery) were grafted.
  
  
  RESULTS
  Mortality was comparable between groups, whereas OPCAB patients suffered from significantly decreased rates of MACCE [3.0 vs. 7.0%; propensity-adjusted odd ratio (PAOR) = 0.24; confidence interval (CI) 95% 0.08-0.66; P = 0.006] including a clear trend towards reduced stroke and myocardial infarction. In the subgroup with TVD, OPCAB patients presented with significantly reduced rates for MACCE (1.8 vs. 5.8%; PAOR = 0.07; CI 95% 0.01-0.65; P = 0.02), including a significantly lower rate for stroke. For all-comers, the number of diseased vessels was lower after OPCAB (2.36 ± 0.73 vs. 2.87 ± 0.39; P < 0.001) and consequently, these patients received an overall lower number of distal anastomoses (2.42 ± 1.15 vs. 3.06 ± 0.98; P < 0.001). Although the ICOR was slightly lower (1.04 ± 0.37 vs. 1.07 ± 0.37; P = 0.02), CR was achieved more frequently in OPCAB patients (82.1 vs. 73.1%; P = 0.01). In the subgroup with TVD, the number of distal anastomoses (2.99 ± 1.14 vs. 3.10 ± 0.98; P = 0.19) and the ICOR (1.00 ± 0.38 vs. 1.03 ± 0.33; P = 0.19) was comparable between groups. The frequency of CR was slightly higher (75 vs. 67.7%; P = 0.11), and the proportion of complete in situ grafting was significantly higher after OPCAB (37.1 vs. 23.9%; P = 0.005).
  
  
  CONCLUSIONS
  Aortic 'no-touch' OPCAB-TAR leads to a significant reduction of MACCE. It does not compromise CR in patients with TVD and thus can be safely applied to these patients.
authors.affiliation: Clinic for Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland. maximilian.emmert@usz.ch
authors.forename: Maximilian Y
authors.initials: MY
authors.lastname: Emmert
authors.forename: Sacha P
authors.initials: SP
authors.lastname: Salzberg
authors.forename: Hector Rodriguez
authors.initials: HR
authors.lastname: Cetina Biefer
authors.forename: Simon H
authors.initials: SH
authors.lastname: Sündermann
authors.forename: Burkhardt
authors.initials: B
authors.lastname: Seifert
authors.forename: Jürg
authors.initials: J
authors.lastname: Grünenfelder
authors.forename: Stephan
authors.initials: S
authors.lastname: Jacobs
authors.forename: Volkmar
authors.initials: V
authors.lastname: Falk
mesh_terms: D000368:Aged; D002315:Cardiopulmonary Bypass / Q000009:adverse effects; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000379:methods; D047549:Coronary Artery Bypass, Off-Pump / Q000009:adverse effects* / Q000379:methods; D003327:Coronary Disease / Q000473:pathology / Q000601:surgery*; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology; D020521:Stroke / Q000209:etiology; D016896:Treatment Outcome