ABSTRACT: Previous trials of off-pump coronary artery bypass (OPCAB) have enrolled selected patients and have not rigorously evaluated long-term graft patency. A preliminary report showed OPCAB achieved improved inhospital outcomes, similar completeness of revascularization, and shorter lengths of stay compared with conventional coronary artery bypass grafting (CABG).
To assess graft patency, clinical and quality-of-life outcomes, and cost among patients while in the hospital and at 1-year follow-up.
Randomized controlled trial of patients unselected for coronary anatomy, ventricular function, or comorbidities between March 10, 2000, and August 20, 2001, at a US academic center. A total of 200 patients were enrolled; 3 patients were withdrawn after randomization for mitral valve repair or replacement. Follow-up was complete for 197 patients at 30 days; 185 at 1 year.
One surgical session consisting of elective OPCAB or CABG with cardiopulmonary bypass. The surgeon had extensive experience performing off-pump surgery; patients were subsequently managed by blinded protocols.
Coronary angiography documented graft patency prior to hospital discharge and at 1 year; health-related quality of life; and cost of the index and subsequent hospitalization(s).
Graft patency was similar for OPCAB and conventional CABG with cardiopulmonary bypass at 30 days (absolute difference, 1.3%; 95% confidence interval [CI], -0.66% to 3.31%; P =.19) and at 1 year (absolute difference, -2.2%; 95% CI, -6.1% to 1.7%; P =.27). Rates of death, stroke, myocardial infarction, angina, and reintervention were similar at 30 days and 1 year. There were no significant differences in health-related quality of life. Mean total hospitalization cost per patient at hospital discharge was 2272 dollars (95% CI, 755 dollars-3732 dollars) less for OPCAB (P =.002) and 1955 dollars (95% CI, -766 dollars to 4727 dollars) less at 1 year (P =.08).
In this randomized single-surgeon trial among unselected patients with angiographic follow-up, OPCAB achieved similar graft patency in the hospital and at 1 year. Cardiac outcomes and health-related quality of life at 30 days and 1 year were similar and patients incurred a lower cost. OPCAB may provide complete revascularization that is durable and cost-effective.
JAMA The Journal of the American Medical Association 05/2004; 291(15):1841-9. · 30.03 Impact Factor
ABSTRACT: Off-pump coronary artery bypass (OPCAB) hopes to avoid morbidity associated with cardiopulmonary bypass, improving clinical outcomes. Yet its technical difficulty and unfamiliarity raise concern that adoption of OPCAB might be associated with poorer outcomes during each surgeon's 'learning curve'. We examined trends in patient selection over time as a single surgeon's practice evolved to routine OPCAB.
Between 10-1-96 and 12-31-01, 1479 consecutive patients had isolated coronary artery bypass grafting (CABG). Clinical data were gathered prospectively and reviewed retrospectively. Trends in adoption of OPCAB and clinical outcomes were examined.
There were 756 OPCAB and 723 CABG/cardiopulmonary bypass patients. The practice evolved from 90% conventional CABG to 93% OPCAB. An abrupt transition coincided with evolution of techniques to expose the obtuse marginal arteries, and improvements in suction-based coronary stabilizers. Mortality was 1.0% for the off-pump group and 2.1% for the on-pump group. Careful patient selection helped maintain acceptable outcomes during the 'learning curve'. Patients with depressed left ventricular ejection fraction, left main disease, and complex three vessel disease were excluded from OPCAB until significant experience (>200 cases) was attained. Presently, all isolated coronary bypass cases are candidates for OPCAB except patients with ischemic ventricular arrhythmias, those in cardiac arrest, and those for whom previous left pneumonectomy or deep pectus excavatum prevent rightward mobilization of heart.
Despite a significant learning curve, evolution to routine OPCAB can be achieved while maintaining good patient outcomes. The development of specialized techniques, coronary stabilizers, and apical suction devices allows the application of OPCAB to virtually all coronary bypass patients, as surgeon experience matures.
European Journal of Cardio-Thoracic Surgery 12/2003; 24(6):947-52. · 2.55 Impact Factor
ABSTRACT: Cardiovascular disease remains a significant source of morbidity and mortality for patients with kidney disease. Coincident with the development of chronic renal failure, patients typically manifest a systemic vasculopathy often involving the cardiovascular system. The renal failure patient is also plagued by multiple comorbid conditions that may adversely affect cardiovascular outcomes. Consistent with the national trend of increasing numbers of patients requiring renal replacement therapy (RRT), patients requiring invasive cardiovascular procedures are also on the incline. The morbidity and mortality related to these procedures has remained high despite significant advances in delivery and maintenance of care. Is the African-American patient with renal failure unique in terms of cardiovascular morbidity and mortality? Numerous studies have documented racial differences in access to invasive cardiovascular procedures, even after controlling for multiple physiologic risk factors and socioeconomic and sociocultural factors. Studies have also shown higher morbidity and lower survival for African-American patients after cardiac procedures. In this high-risk population these same issues perhaps would persist. The following paper will examine the current status of cardiovascular disease in the renal failure patient with emphasis on the African-American patient population.
The Annals of Thoracic Surgery 11/2003; 76(4):S1370-6. · 3.74 Impact Factor