Increasing Long-Term Major Vascular Events and Resource Consumption in Patients Receiving Off-Pump Coronary Artery Bypass

Abstract

Background-Despite its widespread use and short-term efficacy, substantial uncertainty remains about the long-term outcomes and cost-effectiveness of off-pump coronary artery bypass (OPCAB). Methods and Results-A retrospective review of prospectively collected data was conducted of 6665 consecutive patients undergoing isolated coronary artery bypass graft (CABG) at our institution during 1999 to 2006. All patients were followed up until September 30, 2008. Short-and long-term outcomes were compared between OPCAB and conventional CABG. The 2 main long-term outcome measures were repeat revascularization and the composite outcome of major vascular events. Cost comparison at 2 years in a propensity-matched sample during follow-up was also a study interest. The overall mean baseline age was 60.3Ϯ8.6 years, and 17.0% were women. Compared with conventional CABG, patients who underwent OPCAB had lower rates of atrial fibrillation (Pϭ0.003) and requirements for blood transfusion (Pϭ0.03) and ventilation time Ͼ24 hours (PϽ0.001). After an average of 4.5 years of follow-up, the rates of repeat revascularization (adjusted hazard ratio, 1.40; 95% confidence interval, 1.03 to 1.89) and major vascular events (adjusted hazard ratio, 1.23; 95% confidence interval, 1.09 to 1.39) were significantly higher in the OPCAB than the conventional CABG group. At 2 years, OPCAB was associated with increased additional direct costs per patient compared with conventional CABG and had a similar survival rate. Conclusions-Compared with conventional CABG, OPCAB is associated with small short-term gain but increased long-term risks of repeat revascularization and major vascular events, especially among high-risk patients. Moreover, OPCAB consumes more resources and is less cost-effective in the long run. (Circulation. 2010;121:1800-1808.)Key Words: coronary artery bypass grafting Ⅲ coronary disease Ⅲ coronary artery bypass, off-pump Ⅲ surgery C urrently, increasing volume of off-pump coronary artery bypass (OPCAB) has been noted not only in Western countries but also in developing countries such as China and India. OPCAB was first introduced in China in 1996, 1 and Ͼ50 major cardiovascular centers across the country have routinely used the technique. On the basis of a large registration study involving Ϸ10 000 patients from 35 centers across China, 2 OPCAB accounts for Ͼ70% of all coronary artery bypass graft (CABG) surgeries done in these centers, a proportion that was Ϸ3 times as high as that reported in other populations such as the United States. 3 Unfortunately, when confronted with the growing volume, we seldom have adequate evidence from the literature. Several randomized controlled trials were reported but tended either to be small or to have short follow-up (seldom Ͼ5 years). 4 -6 A recent randomized controlled trial involving 18 centers and 2203 patients was released, but the patients included were mostly male. 5 Studies with long-term follow-up exist but tend to emphasize primarily all-cause mortalities, 7 and data on long-term adver...

2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery

“…In a randomized study comparing off-pump and on-pump CABG, the mean total hospitalization cost per patient was $2272 less for off-pump CABG at hospital discharge and $1955 less at 1 year. 1248 Another study of 6665 patients who underwent CABG between 1999 and 2005 determined that off-pump CABG provided a small short-term gain, 1249 although off-pump patients had increased long-term risks of repeat revascularization and major vascular events, especially if they were considered to be high risk. In the long run, in fact, off-pump patients utilized more resources.…”

Off-Pump Coronary Artery Bypass Surgery Is Associated With Worse Arterial and Saphenous Vein Graft Patency and Less Effective Revascularization

“…A higher repeat revascularization rate after offpump CABG has also been found in other large nonrandomized trials. 22,23 As noted in a recent editorial, surgeons continue to fear incomplete revascularization with off-pump CABG, and anastomotic performance may be the Achilles heel of off-pump surgery. 24 Incomplete or ineffective revascularization was associated with worse cardiovascular outcomes at 1 year.…”

Off-Pump Coronary Artery Bypass Grafting

“…In a recent prospective observational analysis, Hu et al showed a statistically significant increase in long-term major cardiovascular events with OPCAB compared with ONCAB (43.8% vs. 41.2%, P=0.002), although the absolute difference was small. 78 Long-term repeat revascularization (9.4% vs. 7.6%, P=0.03), recurrent angina (39.0% vs. 26.9%, P<0.001), and cardiovascular disease-related hospitalization (56.5% vs. 41.6%, P<0.0001) were all significantly higher with OPCAB compared with ONCAB.…”