title: Off-pump coronary artery bypass grafting versus optimal medical therapy alone: effectiveness of incomplete revascularization in high risk patients.
abstract: BACKGROUND
  Geriatric patients with multivessel coronary artery disease (CAD) are a challenging group to treat; these cases elicit discussion within heart teams regarding the actual benefit of undertaking major surgery on these patients and often lead to abandon the surgical option. Percutaneous procedures represent an important option, but coronary anatomy may be unfavorable. Off-pump coronary artery bypass (OPCAB) provides good quality graft on left anterior descending (LAD) without exposing the patient to cardiopulmonary bypass, and might be the ideal choice in patients with multiple comorbidities, not eligible to percutaneous or on-pump procedures. The objective of this study was to compare survival during a mid-term follow-up in high-risk patients with no percutaneous alternative, either treated with OPCAB or discharged in medical therapy.
  
  
  METHODS
  We retrospectively evaluated from June 2008 to June 2013, 83 high-risk patients with multivessel CAD were included: 42 were treated with incomplete off-pump revascularization using left internal mammary artery (LIMA) on LAD; 41 were discharged in optimal medical therapy (OMT), having refused surgery. Follow-up ended in March 2015, with a telephonic interview. Primary endpoint was survival from all-cause mortality; secondary endpoints were survival from cardiac-related mortality and freedom from non-fatal major adverse cardiac events (MACEs).
  
  
  RESULTS
  During follow up, 11 deaths in OPCAB group and 27 deaths in OMT group occurred. Death was due to cardiac factors in 6 and 15 patients, respectively. MACEs were observed in 6 patients in OPCAB group and in 4 patients in OMT group. With regards to survival from all-cause mortality, patients who underwent OPCAB survived more than those discharged in OMT (Log Rank < 0.001), and OMT group carries a propensity score-adjusted hazard ratio of 3.862 (P < 0.001). With regards to survival from cardiac-related events, patients who underwent OPCAB survived more than those discharged in OMT (Log Rank = 0.002), and OMT group carries a propensity score-adjusted hazard ratio of 3.663 (P = 0.010). There is no statistically significant difference concerning freedom from MACEs (Log Rank = 0.273).
  
  
  CONCLUSIONS
  For high-risk patients with multivessel CAD, not eligible to on-pump complete revascularization surgery or percutaneous procedures, incomplete revascularization with OPCAB LIMA-on-LAD offers benefits in survival when compared to OMT alone.
authors.affiliation: Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy.
authors.forename: Filippo
authors.initials: F
authors.lastname: Prestipino
authors.affiliation: Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Clydebank, Glasgow, UK.
authors.forename: Cristiano
authors.initials: C
authors.lastname: Spadaccio
authors.affiliation: Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Nenna
authors.affiliation: Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Clydebank, Glasgow, UK.
authors.forename: Fraser Wh
authors.initials: FW
authors.lastname: Sutherland
authors.affiliation: Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Clydebank, Glasgow, UK.
authors.forename: Gwyn W
authors.initials: GW
authors.lastname: Beattie
authors.affiliation: Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy.
authors.forename: Mario
authors.initials: M
authors.lastname: Lusini
authors.affiliation: Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France.
authors.forename: Francesco
authors.initials: F
authors.lastname: Nappi
authors.affiliation: Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Chello
keywords: Coronary artery disease; Myocardial revascularization; Off-pump coronary artery bypass; Survival analysis