Although off-pump coronary artery bypass (OPCAB) may result in improved clinical outcomes, there has been limited clinical adoption of this technique in the US. Further comparison of OPCAB with conventional on-pump coronary artery bypass (CABG) is needed to define and enhance ideal patient selection, especially as applied in routine clinical practice.
Comparative data was collected and analyzed on 2,471 consecutive patients (933 OPCAB, 1538 CABG) who underwent isolated coronary artery bypass between January 1, 2000 and December 31, 2003, at a single community hospital. The vast majority of OPCAB procedures were performed by a single surgeon (CS) who does OPCAB almost exclusively. Patient selection for OPCAB was based on individual surgeon preference.
OPCAB and CABG patients were similar in age, gender, LV function, presence of left main coronary artery disease and most co-morbid conditions. CABG patients had a greater average number of grafts performed. Overall 4-year surgical mortality was 1.2%. OPCAB mortality was 0.6% versus 1.5% for CABG (Relative Risk (RR) 0.43, 95% Confidence Interval (CI) 0.17-1.05). There was less post-op respiratory failure with OPCAB (OPCAB 2.9% vs CABG 3.8%; RR 0.75, CI 0.48-1.18) in spite of the higher incidence of preop COPD. OPCAB patients also had lower rates of post-op sternal wound infection (OPCAB 1.0% vs CABG 1.8%; RR 0.52, CI 0.25-1.12), acute renal failure (OPCAB 0.4% vs CABG 1.0%; RR 0.41, CI 0.14-1.22), return to OR (OPCAB 1.3% vs CABG 1.9%; RR 0.68, CI 0.35-1.33), post-op stroke (OPCAB 1.2% vs CABG 1.5%; RR 0.78, CI 0.39-1.61), and post-op MI (OPCAB 0.3% vs CABG 0.7%; RR 0.49, CI 0.14-1.79).
Although overall outcomes for CABG were excellent, OPCAB applied in a community hospital setting resulted in a substantial reduction in surgical mortality and morbidity. Patient selection bias may have influenced the outcomes, however our results affirm the value of OPCAB in routine clinical practice.
The learning-curve for OPCAB is steep, and surgeon experience must be factored into any comparative trial conducted in the future. VariablesOpcabPercentCabgPercentNumber93337%153862%Age6665Woman31334%45329%Mortality60.6%231.5%Obesity9210%18312%Pul Htn414%372%COPD21123%19313%EF< 40%29231%44329%CHF323%413%Renal Dis616%463%Redo293%775%Left Main19621%34022%# of Grafts3.03.9Lad Disease85492%142993%Circ Disease67072%128483%RCA Disease73879%134087%
C.T. Strzalka, None.