Off-Pump Coronary Bypass Surgery Is Safe in Patients with a Low Ejection Fraction (?25%)
DOI:
https://doi.org/10.1532/HSF98.20091178Abstract
Background: A severely decreased ejection fraction (EF) of ?25% is an established risk factor for a worse outcome after heart surgery and therefore has been incorporated into the EuroSCORE risk-stratification model. We compare clinical outcomes after off-pump coronary artery bypass grafting (OPCAB) and on-pump coronary artery bypass grafting in patients with a severely compromised EF.
Methods: We compared 112 patients with a low EF (?25%) who underwent myocardial revascularization between 2003 and 2008. Forty-four patients underwent OPCAB (group A), and 68 patients underwent on-pump surgery (group B). We compared demographics, intraoperative parameters, intraoperative outcomes, and the completeness of revascularization for the 2 groups.
Results: Demographic and EuroSCORE data were comparable for groups A and B. The 2 groups appeared to be similar with respect to mortality rate during the first 30 days (2.2% and 8.8%, respectively; P = .11) and the rate of major complications such as stroke (2.2% and 2.9%, respectively; P = 0.83). The patients in group A had fewer pulmonary complications (7% versus 25%, P < .01), received fewer blood transfusions (15.9% versus 47.0%, P < .01), required fewer postoperative pacing procedures (atrial, 11.4% versus 39.7%; ventricular, 13.6% versus 47.1%; P < .01), and had fewer wound infections (2.2% versus 16.1%, P = .02). The numbers of diseased vessels were comparable, and although the OPCAB patients received more arterial grafts (1.05 ± 0.43 versus 0.84 ± 0.37, P < .01), the total number of grafts per patient was lower among these patients (2.50 ± 0.88 versus 3.53 ± 0.92, P = .03). Similarly, complete revascularization was achieved less frequently within this group (80% versus 94%, P = .02).
Conclusions: A standardized OPCAB approach in patients with a severely decreased EF is safe and may benefit this subset of patients with respect to fewer postoperative complications. Although complete revascularization is the optimal approach for these patients, they benefit from avoiding cardiopulmonary bypass.
References
Akins CW, Boucher CA, Pohost GM. 1984. Preservation of interventricular septal function in patients having coronary artery bypass grafts without cardiopulmonary bypass. Am Heart J 107:304-9.nArom KV, Flavin TF, Emery RW, Kshettry VR, Petersen RJ, Janey PA. 2000. Is low ejection fraction safe for off-pump coronary bypass operation? Ann Thorac Surg 70:1021-5.nBrown PM Jr, Kim VB, Boyer BJ, Lust RM, Chitwood WR Jr, Elbeery JR. 1999. Regional left ventricular systolic function in humans during off-pump coronary bypass surgery. Circulation 100(suppl):II125-7.nChamberlain MH, Ascione R, Reeves BC, Angelini GD. 2002. Evaluation of the effectiveness of off-pump coronary artery bypass grafting in high-risk patients: an observational study. Ann Thorac Surg 73:1866-73.nChristakis GT, Weisel RD, Fremes SE, et al. 1992. Coronary artery bypass grafting in patients with poor ventricular function. Cardiovascular Surgeons of the University of Toronto. J Thorac Cardiovasc Surg 103:1083-91; discussion 1091-2.nCleveland JC Jr, Shroyer AL, Chen AY, Peterson E, Grover FL. 2001. Off-pump coronary artery bypass grafting decreases risk-adjusted mortality and morbidity. Ann Thorac Surg 72:1282-8; discussion 1288-9.nDarwazah AK, Abu Sham'a RA, Hussein E, Hawari MH, Ismail H. 2006. Myocardial revascularization in patients with low ejection fraction < or =35%: effect of pump technique on early morbidity and mortality. J Card Surg 21:22-7.nHannan EL, Wu C, Smith CR, et al. 2007. Off-pump versus on-pump coronary artery bypass graft surgery: differences in short-term outcomes and in long-term mortality and need for subsequent revascularization. Circulation 116:1145-52.nKoh TW, Carr-White GS, DeSouza AC, et al. 1999. Intraoperative cardiac troponin T release and lactate metabolism during coronary artery surgery: comparison of beating heart with conventional coronary artery surgery with cardiopulmonary bypass. Heart 81:495-500.nKrejca M, Skiba J, Szmagala P, Gburek T, Bochenek A. 1999. Cardiac troponin T release during coronary surgery using intermittent cross-clamp with fibrillation, on-pump and off-pump beating heart. Eur J Cardiothorac Surg 16:337-41.nLattouf OM, Thourani VH, Kilgo PD, et al. 2008. Influence of on-pump versus off-pump techniques and completeness of revascularization on long-term survival after coronary artery bypass. Ann Thorac Surg 86:797-805.nMoshkovitz Y, Sternik L, Paz Y, et al. 1997. Primary coronary artery bypass grafting without cardiopulmonary bypass in impaired left ventricular function. Ann Thorac Surg 63(suppl):S44-7.nMurkin JM, Boyd WD, Ganapathy S, Adams SJ, Peterson RC. 1999. Beating heart surgery: why expect less central nervous system morbidity? Ann Thorac Surg 68:1498-501.nNesher N, Frolkis I, Vardi M, et al. 2006. Higher levels of serum cytokines and myocardial tissue markers during on-pump versus off-pump coronary artery bypass surgery. J Card Surg 21:395-402.nO'Connor GT, Plume SK, Olmstead EM, et al. 1992. Multivariate prediction of in-hospital mortality associated with coronary artery bypass graft surgery. Northern New England Cardiovascular Disease Study Group. Circulation 85:2110-8.nPuskas JD, Kilgo PD, Lattouf OM, et al. 2008. Off-pump coronary bypass provides reduced mortality and morbidity and equivalent 10-year survival. Ann Thorac Surg 86:1139-46; discussion 1146.nPuskas JD, Williams WH, Duke PG, et al. 2003. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg 125:797-808.nShennib H, Endo M, Benhamed O, Morin JF. 2002. Surgical revascularization in patients with poor left ventricular function: on- or off-pump? Ann Thorac Surg 74:S1344-7.nStamou SC, Corso PJ. 2001. Coronary revascularization without cardiopulmonary bypass in high-risk patients: a route to the future. Ann Thorac Surg 71:1056-61.nStamou SC, Jablonski KA, Hill PC, Bafi AS, Boyce SW, Corso PJ. 2005. Coronary revascularization without cardiopulmonary bypass versus the conventional approach in high-risk patients. Ann Thorac Surg 79:552-7.nTaylor KM. 1998. Central nervous system effects of cardiopulmonary bypass. Ann Thorac Surg 66:S20-4; discussion S25-8.nVirani SS, Lombardi P, Tehrani H, et al. 2005. Off-pump coronary artery grafting in patients with left main coronary artery disease. J Card Surg 20:537-41.nWan IY, Arifi AA, Wan S, et al. 2004. Beating heart revascularization with or without cardiopulmonary bypass: evaluation of inflammatory response in a prospective randomized study. J Thorac Cardiovasc Surg 127:1624-31.nWeerasinghe A, Athanasiou T, Al-Ruzzeh S, et al. 2005. Functional renal outcome in on-pump and off-pump coronary revascularization: a propensity-based analysis. Ann Thorac Surg 79:1577-83.n
