CABG Case Volume and Patient Outcomes at the Veterans Healthcare Administration: On-Pump versus Off-Pump

Authors

  • Sarah A. Halbert Division of Cardiothoracic Surgery, Veterans Affairs Medical Center, Washington, D.C. 20422, USA; Department of Surgery, MedStar Georgetown University Hospital, Washington, D.C. 20007, USA
  • Jared L. Antevil Division of Cardiothoracic Surgery, Veterans Affairs Medical Center, Washington, D.C. 20422, USA; Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, D.C. 20052, USA
  • Gregory D. Trachiotis Division of Cardiothoracic Surgery, Veterans Affairs Medical Center, Washington, D.C. 20422, USA; Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, D.C. 20052, USA

DOI:

https://doi.org/10.59958/hsf.7411

Keywords:

coronary artery bypass, off-pump, veterans

Abstract

Objective: To evaluate use trends and perioperative outcomes of on- and off-pump coronary artery bypass graft (CABG) in US Veterans. Methods: We retrospectively reviewed 44,960 Veteran Health Administration (VHA) patients who underwent isolated CABG between 2008–2021. Multivariable logistic regression was used to analyze associations between surgical technique and outcomes. Adjusted hazard ratios (aHR) are reported. p < 0.05 using two sided tests was considered significant. Results: 6169/44,960 (13.7%) patients underwent isolated off-pump CABG and 38,791/44,960 (86.3%) patients underwent on-pump CABG. Between 2008 and 2021, the proportion of off-pump procedures decreased: 18.8% between 2008–2012, 11.6% between 2013–2017, and 8.6% between 2018–2021 (χ2 = 712.78, df = 2, p < 0.001). Groups were found to be well balanced with respect to age, history of chronic obstructive pulmonary disease (COPD), history of diabetes, history of prior cardiac surgery, as well as left ventricular ejection fraction and history of smoking, and thus an analysis was conducted using the entire cohort. After covariate adjustment, group status was found to not be a predictor of death (aHR = 0.92, 95% confidence interval (95% CI) = 0.66–1.28, p = 0.62), stroke (aHR = 1.33, 95% CI = 0.83–2.12, p = 0.23), myocardial infarction (MI) (aHR = 0.86, 95% CI = 0.51–1.46, p = 0.58). However, given the large imbalance between group size, the groups were then propensity matched on age, history of chronic obstructive pulmonary disease (COPD), diabetes hypertension, smoking, prior cardiac surgery, and left ventricular ejection fraction, resulting in a smaller cohort of 12,130 patients: 5961 (49.1%) on pump and 6169 (50.9%) off pump. After covariate adjustment, the on-pump group in the matched cohort had increased risk of the following within 30 days: death (aHR = 2.60, 95% CI = 1.50–4.51, p < 0.001), stroke (aHR = 1.61, 95% CI = 1.09–2.38, p = 0.016), acute renal failure (aHR = 2.31, 95% CI = 1.46–3.66, p < 0.001), atrial fibrillation (aHR = 1.39, 95% CI = 1.23–1.57, p < 0.001), intraoperative death (aHR = 1.67, 95% CI = 1.07–2.59, p = 0.023), and prolonged intubation (aHR = 1.53, 95% CI = 1.27–1.85, p < 0.001). They also experienced increased length of stay (Beta = 0.05, p < 0.001). Group did not predict risk of reintubation, perioperative myocardial infarction, or postoperative cardiac arrest requiring cardiopulmonary resuscitation (CPR). Conclusions: In a propensity matched cohort of veterans undergoing isolated CABG, off-pump technique was associated with decreased risk of multiple perioperative outcomes measures. However, the proportion of off-pump procedures within the VHA decreased between 2008–2021. This may be secondary to more selective use as overall volume has decreased, though additional study is needed to evaluate these trends.

References

D'Agostino RS, Jacobs JP, Badhwar V, Fernandez FG, Paone G, Wormuth DW, et al. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2018 Update on Outcomes and Quality. The Annals of Thoracic Surgery. 2018; 105: 15–23.

Benedetto U, Gaudino M, Ng C, Biondi-Zoccai G, D'Ascenzo F, Frati G, et al. Coronary surgery is superior to drug eluting stents in multivessel disease. Systematic review and meta-analysis of contemporary randomized controlled trials. International Journal of Cardiology. 2016; 210: 19–24.

Mohr FW, Morice MC, Kappetein AP, Feldman TE, Ståhle E, Colombo A, et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet. 2013; 381: 629–638.

Sürer S. Investigation of the effects of leukocyte filtration in congenital heart surgery. Turkish Journal of Thoracic and Cardiovascular Surgery. 2014; 22.

Emerson D, Baldwin D, Pinales M, Greenberg M, Mattes M, Trachiotis GD. Experience with miniaturized cardiopulmonary bypass in cardiac surgery: A prospective comparison of the NovoSCI ready system to off-pump and conventional coronary artery bypass grafting. World Journal of Cardiovascular Surgery. 2014; 4.

Shroyer AL, Grover FL, Hattler B, Collins JF, McDonald GO, Kozora E, et al. On-pump versus off-pump coronary-artery bypass surgery. The New England Journal of Medicine. 2009; 361: 1827–1837.

Shroyer AL, Hattler B, Wagner TH, Collins JF, Baltz JH, Quin JA, et al. Five-Year Outcomes after On-Pump and Off-Pump Coronary-Artery Bypass. The New England Journal of Medicine. 2017; 377: 623–632.

Quin JA, Wagner TH, Hattler B, Carr BM, Collins J, Almassi GH, et al. Ten-Year Outcomes of Off-Pump vs On-Pump Coronary Artery Bypass Grafting in the Department of Veterans Affairs: A Randomized Clinical Trial. JAMA Surgery. 2022; 157: 303–310.

National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice, Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Eleventh Biennial Update). Veterans and Agent Orange: Update 11 (2018). 2018.

Sachs-Ericsson N, Joiner TE, Cougle JR, Stanley IH, Sheffler JL. Combat Exposure in Early Adulthood Interacts with Recent Stressors to Predict PTSD in Aging Male Veterans. The Gerontologist. 2016; 56: 82–91.

Clausen AN, Clarke E, Phillips RD, Haswell C, VA Mid-Atlantic MIRECC Workgroup, Morey RA. Combat exposure, posttraumatic stress disorder, and head injuries differentially relate to alterations in cortical thickness in military Veterans. Neuropsychopharmacology. 2020; 45: 491–498.

Agha Z, Lofgren RP, VanRuiswyk JV, Layde PM. Are patients at Veterans Affairs medical centers sicker? A comparative analysis of health status and medical resource use. Archives of Internal Medicine. 2000; 160: 3252–3257.

Khuri SF, Daley J, Henderson W, Hur K, Hossain M, Soybel D, et al. Relation of surgical volume to outcome in eight common operations: results from the VA National Surgical Quality Improvement Program. Annals of Surgery. 1999; 230: 414–429; discussion 429–32.

Massarweh NN, Kaji AH, Itani KMF. Practical Guide to Surgical Data Sets: Veterans Affairs Surgical Quality Improvement Program (VASQIP). JAMA Surgery. 2018; 153: 768–769.

Davis CL, Pierce JR, Henderson W, Spencer CD, Tyler C, Langberg R, et al. Assessment of the reliability of data collected for the Department of Veterans Affairs national surgical quality improvement program. Journal of the American College of Surgeons. 2007; 204: 550–560.

Puskas JD, Mack MJ, Smith CR. On-pump versus off-pump CABG. The New England Journal of Medicine. 2010; 362: 851; author reply 853–854.

Deo SV, Elgudin Y, Shroyer ALW, Altarabsheh S, Sharma V, Rubelowsky J, et al. Off-Pump Coronary Artery Bypass Grafting: Department of Veteran Affairs' Use and Outcomes. Journal of the American Heart Association. 2022; 11: e023514.

Emerson DA, Hynes CF, Trachiotis GD. Long-term outcomes after off-pump or conventional coronary artery bypass grafting within a veteran population. Innovations. 2015; 10: 133–137.

Dewey TM, Herbert MA, Prince SL, Magee MJ, Edgerton JR, Trachiotis G, et al. Avoidance of Cardiopulmonary Bypass Improves Early Survival in Multivessel Coronary Artery Bypass Patients with Poor Ventricular Function. The Heart Surgery Forum. 2004; 7: 45–50.

Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E, et al. Off-pump or on-pump coronary-artery bypass grafting at 30 days. The New England Journal of Medicine. 2012; 366: 1489–1497.

Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E, et al. Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year. The New England Journal of Medicine. 2013; 368: 1179–1188.

Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Straka Z, et al. Five-Year Outcomes after Off-Pump or On-Pump Coronary-Artery Bypass Grafting. The New England Journal of Medicine. 2016; 375: 2359–2368.

Houlind K, Kjeldsen BJ, Madsen SN, Rasmussen BS, Holme SJ, Nielsen PH, et al. On-pump versus off-pump coronary artery bypass surgery in elderly patients: results from the Danish on-pump versus off-pump randomization study. Circulation. 2012; 125: 2431–2439.

Scott R, Blackstone EH, McCarthy PM, Lytle BW, Loop FD, White JA, et al. Isolated bypass grafting of the left internal thoracic artery to the left anterior descending coronary artery: late consequences of incomplete revascularization. The Journal of Thoracic and Cardiovascular Surgery. 2000; 120: 173–184.

Marui A, Okabayashi H, Komiya T, Tanaka S, Furukawa Y, Kita T, et al. Benefits of off-pump coronary artery bypass grafting in high-risk patients. Circulation. 2012; 126: S151–S157.

Rao YM, Potdar S, Das D, Saha A, Kapoor L, Das M, et al. On-pump beating heart versus off-pump myocardial revascularization-a propensity-matched comparison. Indian Journal of Thoracic and Cardiovascular Surgery. 2021; 37: 639–646.

Mack MJ, Pfister A, Bachand D, Emery R, Magee MJ, Connolly M, et al. Comparison of coronary bypass surgery with and without cardiopulmonary bypass in patients with multivessel disease. The Journal of Thoracic and Cardiovascular Surgery. 2004; 127: 167–173.

Lemma MG, Coscioni E, Tritto FP, Centofanti P, Fondacone C, Salica A, et al. On-pump versus off-pump coronary artery bypass surgery in high-risk patients: operative results of a prospective randomized trial (on-off study). The Journal of Thoracic and Cardiovascular Surgery. 2012; 143: 625–631.

Lim JY, Deo SV, Altarabsheh SE, Cho YH, Shin E, Markowitz AH. Off-pump coronary artery bypass grafting may prevent acute renal failure in patients with non-dialysis dependent chronic renal dysfunction: an aggregate meta-analysis. International Journal of Cardiology. 2015; 182: 181–183.

Published

2024-09-11

How to Cite

Halbert, S. A., Antevil, J. L., & Trachiotis, G. D. (2024). CABG Case Volume and Patient Outcomes at the Veterans Healthcare Administration: On-Pump versus Off-Pump. The Heart Surgery Forum, 27(9), E1035-E1043. https://doi.org/10.59958/hsf.7411

Issue

Section

Article