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Gianni D. Angelini
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J Thorac Cardiovasc Surg 2009;137:295-303
© 2009 The American Association for Thoracic Surgery

Acquired Cardiovascular Disease

Effects of on- and off-pump coronary artery surgery on graft patency, survival, and health-related quality of life: Long-term follow-up of 2 randomized controlled trials

Gianni D. Angelini, MCh, MD, FRCS, FETCSa,*, Lucy Culliford, BSc, MSc, PhDa, David K. Smith, BSc, MRCPa, Mark C.K. Hamilton, MRCP, FRCRb, Gavin J. Murphy, BSc, ChB, MD, FRCS(CTh)a, Raimondo Ascione, MD, MCh, FRCS, FETCSa, Andreas Baumbach, MD, FRCP, FESCb, Barnaby C. Reeves, BA, MSc, DPhila

a Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, United Kingdom
b United Bristol Healthcare NHS Trust, Bristol Royal Infirmary, Bristol, United Kingdom

Received for publication March 26, 2008; revisions received August 19, 2008; accepted for publication September 19, 2008.

* Address for correspondence: Gianni D. Angelini, MCh, MD, FRCS, FETCS, Bristol Heart Institute, University of Bristol, Level 7, Bristol Royal Infirmary, Bristol BS2 8HW, United Kingdom. (Email: g.d.angelini{at}bristol.ac.uk).

Objective: Off-pump coronary artery bypass grafting reduces postoperative morbidity and uses fewer resources than conventional surgical intervention with cardiopulmonary bypass. However, only 15% to 20% of coronary artery bypass grafting operations use off-pump coronary artery bypass. One reason for not using off-pump coronary artery bypass might be the surgeon's concern about the long-term patency of grafts performed with this technique. Therefore our objective was to compare long-term outcomes in patients randomized to off-pump coronary artery bypass or coronary artery bypass grafting with cardiopulmonary bypass.

Methods: Participants in 2 randomized trials comparing off-pump coronary artery bypass and coronary artery bypass grafting with cardiopulmonary bypass were followed up for 6 to 8 years after surgical intervention to assess graft patency, major adverse cardiac-related events, and health-related quality of life. Patency was assessed by using multidetector computed tomographic coronary angiographic analysis with a 16-slice scanner. Two blinded observers classified proximal, body, and distal segments of each graft as occluded or not. Major adverse cardiac-related events and health-related quality of life were obtained from questionnaires given to participants and family practitioners.

Results: Patency was studied in 199 and health-related quality of life was studied in 299 of 349 survivors. There was no evidence of attrition bias. The likelihood of graft occlusion was no different between off-pump coronary artery bypass (10.6%) and coronary artery bypass grafting with cardiopulmonary bypass (11.0%) groups (odds ratio, 1.00; 95% confidence interval, 0.55–1.81; P > .99). Graft occlusion was more likely at the distal than the proximal anastomosis (odds ratio, 1.11; 95% confidence interval, 1.02–1.20). There were also no differences between the off-pump coronary artery bypass and coronary artery bypass grafting with cardiopulmonary bypass groups in the hazard of death (hazard ratio, 1.24; 95% confidence interval, 0.72–2.15) or major adverse cardiac-related events or death (hazard ratio, 0.84; 95% confidence interval, 0.58–1.24), or mean health-related quality of life across a range of domains and instruments.

Conclusions: Long-term health outcomes with off-pump coronary artery bypass are similar to those with coronary artery bypass grafting with cardiopulmonary bypass when both operations are performed by experienced surgeons.

Abbreviations and Acronyms BHACAS = Beating Heart Against Cardioplegic Arrest Study; CABG = coronary artery bypass grafting; CI = confidence interval; CPB = cardiopulmonary bypass; HRQoL = health-related quality of life; ITA = internal thoracic artery; MACE = major adverse cardiac-related event; MDCTA = multidetector computed tomography coronary angiography; OPCAB = off-pump coronary artery bypass; RCT = randomized controlled trial; SD = standard deviation; SV = saphenous vein


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