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J Thorac Cardiovasc Surg 2003;125:797-808
© 2003 The American Association for Thoracic Surgery
Surgery for Acquired Cardiovascular Disease |
From the Divisions of Cardiothoracic Surgery,a Cardiology,b and Cardiac Anesthesiology,c Emory University School of Medicine, and the Emory Center for Outcomes Research,d Atlanta, Ga.
Supported by grants from Medtronic, Inc, Minneapolis, Minn, and The Carlyle Fraser Heart Center Foundation, Atlanta, Ga.
Read at the Eighty-second Annual Meeting of The American Association for Thoracic Surgery, Washington, DC, May 5-8, 2002.
Received for publication May 5, 2002. Revisions requested June 14, 2002; revisions received June 27, 2002. Accepted for publication July 8, 2002. Address for reprints: John D. Puskas, MD, MSc, FACS, Associate Professor of Surgery (Cardiothoracic), Emory University School of Medicine, Crawford Long Hospital, Sixth Floor, Medical Office Tower, 550 Peachtree St, NE, Atlanta, GA 30308 (E-mail: john_puskas{at}emoryhealthcare.org).
Objective: Retrospective comparisons of selected
patients undergoing off-pump versus conventional on-pump coronary artery
bypass grafting have yielded inconsistent results and raised concerns about
completeness of revascularization in off-pump coronary artery bypass
grafting.
Methods: Two hundred unselected patients referred for
elective primary coronary artery bypass grafting were randomly assigned to
undergo off-pump coronary artery bypass grafting with an Octopus tissue
stabilizer (Medtronic, Inc, Minneapolis, Minn) or conventional coronary
artery bypass grafting with cardiopulmonary bypass by a single surgeon.
Revascularization intent determined before random assignment was compared
with the revascularization performed. All management followed strict,
unbiased, criteria-driven protocols. Patients and nonoperative care
providers were blinded to surgical group.
Results: Baseline
characteristics were similar. The number of grafts performed per patient
(mean ± SD 3.39 ± 1.04 for off-pump coronary artery bypass
grafting, 3.40 ± 1.08 for conventional coronary artery bypass
grafting) and the index of completeness of revascularization (number of
grafts performed/number of grafts intended, 1.00 ± 0.18 for off-pump
coronary artery bypass grafting, 1.01 ± 0.09 for conventional
coronary artery bypass grafting) were similar. Likewise, the index of
completeness of revascularization was similar between groups for the
lateral wall. Combined hospital and 30-day mortalities and stroke rates
were similar. Postoperative myocardial serum enzyme measures were
significantly lower after off-pump coronary artery bypass grafting,
suggesting less myocardial injury. Adjusted postoperative thromboelastogram
indices, fibrinogen, international normalized ratio, and platelet levels
all showed significantly less coagulopathy after off-pump coronary artery
bypass grafting. Patients undergoing off-pump coronary artery bypass
grafting received fewer units of blood, were more likely to avoid
transfusion altogether, and had a higher hematocrit at discharge.
Cardiopulmonary bypass was an independent predictor of transfusion (odds
ratio 2.42, P = .0073) by multivariate analysis. More
patients undergoing off-pump coronary artery bypass grafting were extubated
in the operating room and within 4 hours. Postoperative length of stay (in
days) was shorter for off-pump coronary artery bypass grafting (5.1
± 6.5 for off-pump coronary artery bypass grafting, 6.1 ± 8.2
for conventional coronary artery bypass grafting, P = .005
by Wilcoxon test). One patient (in the conventional coronary artery bypass
grafting group) required angioplasty for graft closure within 30
days.
Conclusions: When compared with conventional coronary
artery bypass grafting with cardiopulmonary bypass, off-pump coronary
artery bypass grafting achieved similar completeness of revascularization,
similar in-hospital and 30-day outcomes, shorter length of stay, reduced
transfusion requirement, and less myocardial
injury.
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