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J Thorac Cardiovasc Surg 2004;127:406-413
© 2004 The American Association for Thoracic Surgery

Surgery for acquired cardiovascular disease

Propensity case-matched analysis of off-pump coronary artery bypass grafting in patients with atheromatous aortic disease

^a Division of Cardiothoracic Surgery, Department of Surgery, New York University School of Medicine, New York, NY, USA

Read at the Eighty-third Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass, May 4-7, 2003.

Received for publication May 4, 2003; revisions received July 9, 2003; accepted for publication August 11, 2003.

^* Address for reprints: Eugene A. Grossi, MD, New York University Medical Center, 530 First Ave, Suite 9V, New York, NY 10016, USA
grossi{at}cv.med.nyu.edu

OBJECTIVE: Atheromatous aortic disease is a risk factor for excessive mortality and stroke in patients undergoing coronary artery bypass grafting. Outcomes of off-pump coronary artery bypass grafting and coronary artery bypass grafting with cardiopulmonary bypass in patients with severe atheromatous aortic disease were compared by propensity case-match methods.

METHODS: Routine intraoperative transesophageal echocardiography identified 985 patients undergoing isolated coronary artery bypass grafting with severe atheromatous disease in the aortic arch or ascending aorta. Off-pump coronary artery bypass grafting was performed in 281 patients (28.5%). Propensity matched-pairs analysis was used to match patients undergoing off-pump coronary artery bypass grafting (n = 245) with patients undergoing coronary artery bypass grafting with cardiopulmonary bypass.

RESULTS: Univariate analysis revealed decreased hospital mortality (16/245, 6.5% vs 28/245, 11.4%; P = .058) and stroke prevalence (4/245, 1.6% vs 14/245, 5.7%; P = .03) in off-pump coronary artery bypass grafting compared with coronary artery bypass grafting with cardiopulmonary bypass. Freedom from any postoperative complication was higher in off-pump coronary artery bypass grafting compared with coronary artery bypass grafting with cardiopulmonary bypass (226/245, 92.2% vs 196/245, 80.0%; P < .001). Multivariable analysis of preoperative risk factors showed that increased hospital mortality was associated with coronary artery bypass grafting with cardiopulmonary bypass (odds ratio = 2.7; P = .01), fewer grafts (P = .05), acute myocardial infarction (odds ratio = 11.5; P < .001), chronic obstructive pulmonary disease (odds ratio = 2.4; P = .03), previous cardiac surgery (odds ratio = 10.2, P = .05), and peripheral vascular disease (odds ratio = 2.1; P = .05). Cardiopulmonary bypass was the only independent risk factor for stroke (odds ratio = 3.6, P = .03). At 36 months' follow-up, comparable survival was observed in the off-pump coronary artery bypass grafting and coronary artery bypass grafting with cardiopulmonary bypass groups (74% vs 72%). Multivariable analysis revealed that renal disease (P < .001), advanced age (P < .001), previous myocardial infarction (P = .03), and lower number of grafts (P = .02) were independent risks for late mortality.

CONCLUSIONS: Patients with severe atherosclerotic aortic disease who undergo off-pump coronary artery bypass grafting have a significantly lower prevalence of hospital mortality, perioperative stroke, and overall complications than matched patients who underwent coronary artery bypass grafting with cardiopulmonary bypass. Routine intraoperative transesophageal echocardiography identifies severe atheromatous aortic disease and directs the choice of surgical technique.

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