Off-Pump Surgery Is Not a Contraindication for Patients with a Severely Decreased Ejection Fraction
Background: A severely impaired left ventricular ejection fraction (EF) (30%) increases the risk of surgical myocardial revascularization. We evaluated the safety and feasibility of off-pump coronary artery bypass (OPCAB) surgery in patients with a severely decreased EF.
Methods: We compared 79 patients with an EF ?30% (group A) with 863 patients with an EF >30% (group B) who underwent myocardial revascularization between 2003 and 2008. The relationship between EF and outcome after OPCAB was assessed by univariate and logistic regression analyses. A composite end point was constructed from 30-day mortality, renal failure, length of stay in the intensive care unit (ICU) >2 days, neurologic complications, and use of an intra-aortic balloon pump (IABP). Additionally, the completeness of revascularization was assessed.
Results: The mortality rates for groups A and B were comparable (1.3% and 2.0%, respectively; P = .55), and the 2 groups did not differ with regard to serious postoperative complications, such as stroke (2.5% versus 1.4% for groups A and B, respectively; P = .42), peripheral neurologic complications (2.5% versus 0.7%, P = .14), renal failure (0% versus 1.1%, P = 1.00), use of an IABP (1.3% versus 0.8%, P = .50), ICU length of stay >2 days (17.7% versus 19.6%, P = .77). Similarly, groups A and B did not differ with regard to ventilation time (11.2 ± 12.7 hours versus 12.4 ± 15.5 hours, P = .82), indicating similar postoperative courses for the 2 groups of patients. In contrast, the composite end point occurred significantly more frequently in group A (43.0% versus 29.7%, P = .02), a result driven by the increased rate of rethoracotomy for bleeding in that group (11.4% versus 2.9%, P = .001). The 2 groups were similar with respect to the total number of grafts used per patient (3.82 ± 0.89 versus 3.63 ± 1.01, P = .10) and the completeness of revascularization (94% versus 93%, P = .49).
Conclusion: A standardized OPCAB approach is safe for patients with a severely decreased EF, and its use does not come at the cost of less complete revascularization.
Al-Ruzzeh S, Nakamura K, Athanasiou T 2003. Does off-pump coronary artery bypass (OPCAB) surgery improve the outcome in highrisk patients?: a comparative study of 1398 high-risk patients. Eur J Cardiothorac Surg 23:50-5.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.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.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.nEagle KA, Guyton RA, Davidoff R 2004. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation 110:e340-437.nEmmert MY, Salzberg SP, Seifert B 2010. Despite modern off-pump coronary artery bypass grafting women fare worse than men. Interact Cardiovasc Thorac Surg 10:737-41.nHannan EL, Wu C, Smith CR 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.nLattouf OM, Thourani VH, Kilgo PD 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.nMagee MJ, Coombs LP, Peterson ED, Mack MJ. 2003. Patient selection and current practice strategy for off-pump coronary artery bypass surgery. Circulation 108(suppl 1):II9-14.nMoshkovitz Y, Sternik L, Paz Y 1997. Primary coronary artery bypass grafting without cardiopulmonary bypass in impaired left ventricular function. Ann Thorac Surg 63:S44-7.nO'Connor GT, Plume SK, Olmstead EM 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.nPlomondon ME, Cleveland JC Jr, Ludwig ST 2001. Off-pump coronary artery bypass is associated with improved risk-adjusted outcomes. Ann Thorac Surg 72:114-9.nPuskas JD, Kilgo PD, Lattouf OM 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, Thourani VH, Kilgo P 2009. Off-pump coronary artery bypass disproportionately benefits high-risk patients. Ann Thorac Surg 88:1142-7.nPuskas JD, Williams WH, Duke PG 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.nShroyer AL, Grover FL, Hattler B 2009. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med 361:1827-37.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.nThomas GN, Martinez EC, Woitek F 2009. Off-pump coronary bypass grafting is safe and efficient in patients with left main disease and higher EuroScore. Eur J Cardiothorac Surg 36:616-20.nWan IY, Arifi AA, Wan S 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 2005. Functional renal outcome in on-pump and off-pump coronary revascularization: a propensity-based analysis. Ann Thorac Surg 79:1577-83.nYeatman M, Caputo M, Ascione R, Ciulli F, Angelini GD. 2001. Off-pump coronary artery bypass surgery for critical left main stem disease: safety, efficacy and outcome. Eur J Cardiothorac Surg 19:239-44.n