Influence of diabetes on mortality and morbidity: off-pump coronary artery bypass grafting versus coronary artery bypass grafting with cardiopulmonary bypass.

BACKGROUND: Myocardial revascularization in diabetic patients is challenging with no established optimum treatment strategy. We reviewed our coronary artery bypass grafting experience to determine the impact of eliminating cardiopulmonary bypass on outcomes in diabetic patients relative to nondiabetic patients.

METHODS: From January 1995 through December 1999, 9,965 patients, of whom 2,891 (29%) had diabetes, underwent isolated coronary artery bypass grafting. Diabetic and nondiabetic patients were further divided into groups on the basis of cardiopulmonary bypass use. Twelve percent (346 of 2,891) of diabetic patients and 12% (829 of 7,074) of nondiabetic patients underwent coronary artery bypass grafting without cardiopulmonary bypass; the remainder had coronary artery bypass grafting with cardiopulmonary bypass. Nineteen preoperative variables were compared among treatment groups by univariate analysis.

RESULTS: Patients undergoing coronary artery bypass grafting without cardiopulmonary bypass compared with those having coronary artery bypass grafting with cardiopulmonary bypass had higher mean predicted mortalities (diabetic, 3.96% versus 3.72%, p = 0.83; nondiabetic, 3.03% versus 2.86%, p = 0.79). In nondiabetic patients, coronary artery bypass grafting without cardiopulmonary bypass provides an actual and risk-adjusted survival advantage over coronary artery bypass grafting with cardiopulmonary bypass (1.81% versus 3.44%, p = 0.0127; risk-adjusted mortality, 1.79% versus 3.61%, p = 0.007). This survival benefit of coronary artery bypass grafting without cardiopulmonary bypass was not seen in diabetic patients (2.89% versus 3.69%, p = 0.452; risk-adjusted mortality, 2.19% versus 2.98%, p = 0.42). Diabetic patients undergoing coronary artery bypass grafting without cardiopulmonary bypass had fewer complications, including decreased blood product use (34.39% versus 58.4%, p = 0.001), and reduced incidence of prolonged ventilation (6.94% versus 12.10%, p = 0.005), atrial fibrillation (15.90% versus 23.26%, p = 0.002), and renal failure requiring dialysis (0.87% versus 2.75%, p = 0.036).

CONCLUSIONS: The survival advantage in nondiabetic patients treated with coronary artery bypass grafting without cardiopulmonary bypass is not apparent in diabetic patients. Coronary artery bypass grafting without cardiopulmonary bypass in diabetic patients is nevertheless associated with a significant reduction in morbidity.