Ten-Year Outcome Analysis of Off-Pump Sequential Grafting: Single Surgeon, Single Center Experience
Objectives: Despite increasing recognition that off-pump coronary artery bypass surgery and sequential grafting strategy individually are associated with improved outcomes, concerns persist regarding the safety and efficacy of combining these 2 techniques. We compared in-hospital and midterm outcomes for off-pump multivessel sequential and conventional coronary artery bypass grafting.
Methods: From September 1998 to September 2008, 689 consecutive patients received off-pump multivessel sequential coronary artery bypass grafting performed by a single surgeon. These patients were propensity matched to 689 patients who underwent off-pump coronary artery bypass grafting without sequential anastomoses. A retrospective analysis of prospectively collected perioperative data was performed. In addition, medical notes and charts of all the study patients were reviewed. The mean duration of follow-up was 5.1 ± 2.0 years.
Results: The major in-hospital clinical outcomes in the sequential and control groups were found to be similar. After adjusting for clinical covariates, sequential grafting was not an independent predictor of in-hospital adverse events (odds ratio [OR], 1.18; 95% confidence interval [CI], 0.86-1.50; P = .31), medium-term mortality (hazard ratio [HR], 1.26; 95% CI, 1.06-1.32; P = .92), and readmission to hospital (HR, 1.12; 95% CI, 0.96-1.20; P = .80). Sequential grafting was an independent predictor of receiving more than 3 distal anastomoses (OR, 7.46; 95% CI, 4.27-11.45; P < .0001). Risk-adjusted survival was 89% for sequential grafting patients and 88% for conventional grafting patients (P = .96) during the medium-term follow-up.
Conclusion: Our analysis confirms the short- and midterm safety and efficacy of off-pump sequential coronary artery bypass grafting.
Al-Ruzzeh S, Epstein D, George S, et al. 2008. Economic evaluation of coronary artery bypass grafting surgery with and without cardiopulmonary bypass: cost-effectiveness and quality-adjusted life years in a randomized controlled trial. Artif Organs 32:891-7.nAl-Ruzzeh S, George S, Bustami M, et al. 2006. Effect of off-pump coronary artery bypass surgery on clinical, angiographic, neurocognitive, and quality of life outcomes: randomised controlled trial. BMJ 332:1365.nAl-Ruzzeh S, George S, Bustami M, et al. 2002. The early clinical and angiographic outcome of sequential coronary artery bypass grafting with the off-pump technique. J Thorac Cardiovasc Surg 123:525-30.nAustin PC. 2007. Propensity-score matching in the cardiovascular surgery literature from 2004 to 2006: a systematic review and suggestions for improvement. J Thorac Cardiovasc Surg 134:1128-35.nBell MR, Gersh BJ, Schaff HV, et al. 1992. Effect of completeness of revascularization on long-term outcome of patients with three-vessel disease undergoing coronary artery bypass surgery. A report from the Coronary Artery Surgery Study (CASS) Registry. Circulation 86:446-57.nCaliff RM, Phillips HR 3rd, Hindman MC, et al. 1985. Prognostic value of a coronary artery jeopardy score. J Am Coll Cardiol 5:1055-63.nCenters for Disease Control and Prevention. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Available at: http://www.cdc.gov/nchs/icd/icd9cm.htm'>www.cdc.gov/nchs/icd/icd9cm.htmnChristenson JT, Schmuziger M. 1996. How serious is a proximal occlusion of a posterolateral sequential bypass? Tex Heart Inst J 23:201-6.nGao C, Wang M, Wang G, et al. 2010. Patency of sequential and individual saphenous vein grafts after off-pump coronary artery bypass grafting. J Card Surg 25:633-7.nGrondin CM, Limet R. 1977. Sequential anastomoses in coronary artery grafting: technical aspects and early and late angiographic results. Ann Thorac Surg 23:1-8.nGwozdziewicz M, Nemec P, Simek M, Hajek R, Troubil M. 2006. Sequential bypass grafting on the beating heart: blood flow characteristics. Ann Thorac Surg 82:620-3.nKarthik S, Grayson AD, McCarron EE, Pullan DM, Desmond MJ. 2004. Reexploration for bleeding after coronary artery bypass surgery: risk factors, outcomes, and the effect of time delay. Ann Thorac Surg 78:527-34.nKieser TM, FitzGibbon GM, Keon WJ. 1986. Sequential coronary bypass grafts. Long-term follow-up. J Thorac Cardiovasc Surg 91:767-72.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.nMack MJ, Pfister A, Bachand D, et al. 2004. Comparison of coronary bypass surgery with and without cardiopulmonary bypass in patients with multivessel disease. J Thorac Cardiovasc Surg 127:167-73.nMeurala H, Valle M, Hekali P, Somer K, Frick MH, Harjola PT. 1982. Patency of sequential versus single vein grafts in coronary bypass surgery. Thorac Cardiovasc Surg 30:147-51.nNakajima H, Kobayashi J, Toda K, et al. 2010. Safety and efficacy of sequential and composite arterial grafting to more than five coronary branches in off-pump coronary revascularisation: assessment of intraoperative and angiographic bypass flow. Eur J Cardiothorac Surg 37:94-9.nParsons LS. 2001. Reducing bias in a propensity score matched-pairsample using greedy matching techniques. Proceedings of the 26th Annual SAS Users Group International Conference 2001. Cary, NC: SAS Institute, Inc.nQuigley RL. 2010. Sequential bypass on the beating heart can be achieved without compromising patient safety or regional myocardial blood flow. Int Surg 95:257-60.nRaja SG, Navaratnarajah M, Kitchlu CS, George S, Ilsley CD, Amrani M. 2010. 10-year follow-up of off-pump multivessel coronary artery bypass grafting. Asian Cardiovasc Thorac Ann 18:260-5.nRaja SG, Siddiqui H, Ilsley CD, Amrani M. 2009. In-hospital outcomes of off-pump multivessel total arterial and conventional coronary artery bypass grafting: single surgeon, single center experience. Ann Thorac Surg 88:47-52.nRaja SG. 2005. Pump or no pump for coronary artery bypass: current best available evidence. Tex Heart Inst J 32:489-501.nRizzoli G, Schiavon L, Bellini P. 2002. Does the use of bilateral internal mammary artery (IMA) grafts provide incremental benefit relative to the use of a single IMA graft? A meta-analysis approach. Eur J Cardiothorac Surg 22:781-6.nTaggart DP, D'Amico R, Altman DG. 2001. Effect of arterial revascularization on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet 358:870-5.n
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).