Long-Term Survival and Freedom From Reintervention After Off-Pump Coronary Artery Bypass Grafting: A Propensity-Matched Study

• Published in: Circulation (New York, N.Y.) Vol. 134; no. 17; pp. 1209 - 1220
• Main Authors: Kirmani, Bilal H., Holmes, Michael V., Muir, Andrew D.
• Format: Journal Article
• Language: English
• Published: United States by the American College of Cardiology Foundation and the American Heart Association, Inc 25.10.2016
• Subjects: Coronary Artery Bypass, Off-Pump - mortality; Disease-Free Survival; Female; Follow-Up Studies; Humans; Male; Retrospective Studies; Survival Rate; cardiopulmonary bypass; coronary artery bypass graft; off-pump surgery; outcome
• DOI: 10.1161/CIRCULATIONAHA.116.021933
• ISSN: 0009-7322; 1524-4539

BACKGROUND:The long-term outcomes of off-pump coronary artery bypass grafting (CABG) are the subject of speculation. Our institution has >15 years of experience performing CABG both off-pump (OPCAB) and on cardiopulmonary bypass (CPB). Our null hypothesis was that there would be no difference in a long-term composite of death and revascularisation between the 2 methods. METHODS:We performed a retrospective cohort study of all isolated CABG at our institution from 2001 to 2015. We used an intention-to-treat analysis, performing risk adjustment with adjustment for and matching to propensity score. In total, 13 226 patients had CABG5882 had OPCAB and 7344 had CPB, with a median follow-up of 6.2 years. RESULTS:Of the 5882 OPCAB, 76 (1.3%) converted to CPB. One-, 5-, and 10-year survivals in each group were similar (OPCAB vs CPB96.7%, 87.9%, 72.1% vs 96.2%, 87.4%, 72.8%). No difference was found in long-term survival (adjusted hazards ratio [HR] 1.03; 95% confidence interval [CI]0.94–1.11 for OPCAB vs CPB; P=0.56) or freedom from death and reintervention (HR 0.98; 95% CI0.92–1.06 for OPCAB vs CPB; P=0.23). Patients receiving OPCAB had higher EuroSCOREs (median [quartiles]2.81 [1.53–5.57] vs 2.73 [1.51–5.22]; P=0.01), fewer grafts (mean±SD3.0±0.9 vs 3.3±0.9; P<0.001), but more total arterial grafting (45.9% vs 8.4%; P<0.001). OPCAB also had more trainee first operators (15.3% vs 12.5%), lower cardiac enzyme rise, shorter length of stay, and fewer complications (such as myocardial infarction). CONCLUSIONS:OPCAB is associated with similar long-term outcomes to CABG performed on CPB in our institution. Our low conversion rate to CPB, while training junior surgeons, demonstrates that OPCAB can be taught safely. The number of grafts performed between the 2 approaches is clinically comparable, if statistically different, and appears to provide equal benefits to survival and freedom from reintervention as on-pump CABG.