Does off-pump surgery offer benefit in high respiratory risk patients? A respiratory risk stratified analysis in a propensity-matched cohort

• Published in: European journal of cardio-thoracic surgery Vol. 30; no. 1; pp. 126 - 131
• Main Authors: REDDY, Shekar L. C, GRAYSON, Antony D, OO, Aung Y, PULLAN, Mark D, POONACHA, Thejaswi, FABRI, Brian M
• Format: Journal Article
• Language: English
• Published: Amsterdam Elsevier Science 01.07.2006
• Subjects: Aged; Biological and medical sciences; Body Mass Index; Cardiology. Vascular system; Cohort Studies; Coronary Artery Bypass, Off-Pump - adverse effects; Dyspnea - complications; Female; Forced Expiratory Volume; Humans; Male; Medical sciences; Middle Aged; Pneumology; Postoperative Care - methods; Postoperative Complications - prevention & control; Respiration, Artificial; Respiratory Distress Syndrome, Adult - prevention & control; Risk Assessment; Smoking - adverse effects; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Human; High risk; Respiratory risk; Gradient; Off pump; Risk analysis; Phlebology; Propensity matching; Artery; Respiratory tract; Treatment; Benefit risk analysis; Alveolar arterial gradient; Aortocoronary; Bypass; Surgery; Cohort study; Risk factor; Graft; Ventilation; Circulatory system; Cardiology; CABG
• ISSN: 1010-7940; 1873-734X
• DOI: 10.1016/j.ejcts.2006.03.045

The role of off-pump surgery in high respiratory risk patients remains unclear. In this study, we aim to evaluate the effect of off-pump surgery on high respiratory risk patients. To achieve comparative groups, a five digit propensity score matching with 18 pre-operative variables was performed on 4406 consecutive CABG patients operated between January 2000 and September 2003. Respiratory risk stratification was performed with the following variables: (1) FEV(1)<65% of predicted, (2) patients>75 years old, (3) history of current smoking, (4) body mass index more than 40 kg/m(2) and (5) NYHA class IV dyspnoea in combination with current respiratory medication. The presence of two or more variables defined high risk. The primary end point was post-operative ventilation time. We also compared alveolar arterial gradients (A-a gradient) on admission to ITU, 2 and 4h using Friedman rank time analysis. We matched 1353 off-pump patients with 1353 unique on-pump patients. Respiratory risk stratified selection resulted in 73 off-pump and 55 on-pump high-risk patients. In the off-pump group, four (5.5%) patients had more than two selection criteria, compared to one (1.8%) for on-pump patients (p=0.29). The off-pump group had more patients with FEV1<65% compared to on-pump: 65 (89.0%) versus 40 (72.7%); p=0.017. The median ventilation time was significantly shorter for off-pump patients (7h [IQR: 5-14] vs 12h [IQR: 7-18], p=0.003). In the off-pump group, three (4.1%) patients had a ventilation time>48 h compared to eight (14.6%) in the on-pump group, p=0.037. A-a gradient measurements on admission to ITU were lower in off-pump patients (median: 182.3 [IQR: 126.6-216.2]) compared to on-pump patients (median: 194.7 [IQR 139.7-245.4], p=0.064). Off-pump surgery offers benefit to high respiratory risk patients by reducing post-operative ventilation time. Off-pump patients also have lower A-a gradients in the early post-operative period but this failed to reach significance.