Does off-pump coronary artery bypass (OPCAB) surgery improve the outcome in high-risk patients?: a comparative study of 1398 high-risk patients.

OBJECTIVE: Although there has been some evidence supporting the theoretical and practical advantages of off-pump coronary artery bypass (OPCAB) over the conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB), it has not yet been determined which group of patients would benefit most from it. It has been advocated recently that high-risk patients could benefit most from avoidance of CPB. The aim of this retrospective study is to assess the efficacy of the OPCAB technique in multi-vessel myocardial revascularization in a large series of high-risk patients.

METHODS: The records of 1398 consecutive high-risk patients who underwent primary isolated CABG at Harefield Hospital between August 1996 and December 2001 were reviewed retrospectively. Patients were considered as high-risk and included in the study if they had a preoperative EuroSCORE of > or =5. Two hundred and eighty-six patients were operated on using the OPCAB technique while 1112 patients were operated on using the conventional CABG technique with CPB. The OPCAB patients were significantly older than the CPB patients (68.1+/-8.3 vs. 63.7+/-9.9 years, respectively, P<0.001). The OPCAB group included significantly more patients with poor left ventricular (LV) function (ejection fraction (EF) < or =30%) (P<0.001) and more patients with renal problems (P<0.001).

RESULTS: There was no significant difference in the number of grafts between the groups. The CPB patients received 2.8+/-1.2 grafts per patient while OPCAB patients received 2.8+/-0.5 grafts per patient (P=1). Twenty-one (7.3%) OPCAB patients had one or more major complications, while 158 (14.2%) CPB patients (P=0.008) developed major complications. Thirty-eight (3.4%) CPB patients developed peri-operative myocardial infarction (MI) while only two (0.7%) OPCAB patients developed peri-operative MI (P=0.024). The intensive therapy unit (ITU) stay for OPCAB patients was 29.3+/-15.4 h while for CPB patients it was 63.6+/-167.1 h (P<0.001). There were ten (3.5%) deaths in the OPCAB patients compared to 78 (7%) deaths in the CPB patients (P=0.041) within 30 days postoperatively.

CONCLUSIONS: This retrospective study shows that using the OPCAB technique for multi-vessel myocardial revascularization in high-risk patients significantly reduces the incidence of peri-operative MI and other major complications, ITU stay and mortality. Even though the OPCAB group included a significantly higher proportion of older patients with poor LV function (EF < or =30%) and renal problems, the beneficial effect of OPCAB was evident.