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J Thorac Cardiovasc Surg 2004;127:167-173
© 2004 The American Association for Thoracic Surgery
Surgery for acquired cardiovascular disease |
a Cardiopulmonary Research Science and Technology Institute (CRSTI), Medical City Dallas Hospital, Dallas, Tex, USA
b Lenox Hill Hospital, New York, NY, USA
c Cardiac Surgical Associates, P.A., Minneapolis, Minn, USA
d Washington Hospital Center, Washington, DC, USA
Received for publication February 14, 2003; revisions received June 11, 2003; accepted for publication August 18, 2003.
* Address for reprints: Michael J. Mack, MD, 7777 Forest Lane, Suite A323, Dallas, TX 75230, USA
mjmack{at}earthlink.net
BACKGROUND: Coronary artery bypass grafting can now be performed with or without cardiopulmonary bypass. Our objective was to determine whether off-pump coronary artery bypass grafting is associated with better early outcomes compared with conventional coronary artery bypass grafting.
METHODS: In 4 centers with off-pump coronary surgery experience, a retrospective analysis of all coronary artery bypass grafting in a 3-year period was performed. Groups were compared to determine selection criteria, mortality, and morbidity, then computer-matched by propensity score to control for selection bias. Multivariate logistic regression identified risk factors predictive of mortality. Specific subgroups most likely to benefit were identified.
RESULTS: In all, 17,401 isolated coronary artery bypass grafts were performed, 7283 (41.9%) off-pump coronary artery bypass grafts and 10,118 (58.1%) conventional coronary artery bypass with cardiopulmonary bypass. Factors determining selection of patients for off-pump coronary artery bypass grafting included female gender (55.5% vs 44.5%), preexisting renal failure (57.0% vs 43.0%), and reoperations (52.6% vs 47.4%). Operative mortality was 2.8%; off-pump coronary artery bypass grafting versus conventional coronary artery bypass with cardiopulmonary bypass (1.9% vs 3.5%, P < .001) had the same predicted risk. Of the patients with multivessel disease, 11,548 were matched by propensity scoring. Mortality was significantly less in the off-pump coronary artery bypass grafting group (2.8% vs 3.7%, P < .001). By multivariate logistic regression analysis of the matched sample, predictors for mortality were female gender (odds ratio 1.83, confidence interval 1.37-2.44), preexisting renal failure (odds ratio 2.85, confidence interval 2.64-4.95), history of stroke (odds ratio 1.74, confidence interval 1.08-2.80), previous coronary artery bypass grafting surgery (odds ratio 4.22, confidence interval 2.92-6.09), use of cardiopulmonary bypass (odds ratio 2.08, confidence interval 1.52-2.83), and recent myocardial infarction (odds ratio 2.31, confidence interval 1.68-3.22). Cardiopulmonary bypass was predictive of mortality in reoperations, female patients, and patients aged 
75 years. Off-pump coronary artery bypass grafting was associated with less morbidity, including reductions in blood transfusion (32.6% vs 40.6%, P < .001), stroke (1.4% vs 2.1%, P = .002), renal failure (2.6% vs 5.2%, P < .001), pulmonary complications (4.1% vs 9.5%, P < .001), reoperation (1.7% vs 3.2%, P < .001), atrial fibrillation (21.1% vs 24.99%, P < .001), and gastrointestinal complications (3.6% vs 4.8%, P = .02).
CONCLUSION: In 4 centers with beating-heart operation experience, there is an overall early benefit in off-pump surgery, especially in patients traditionally considered at high risk for coronary artery bypass grafting.
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