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Ann Thorac Surg 1999;68:1490-1493
© 1999 The Society of Thoracic Surgeons
a London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
b Health Sciences Centre, Winnipeg, Manitoba, Canada
Address reprint requests to Dr Boyd, London Health Sciences Centre, University Campus, 339 Windermere Rd, London, ON, Canada, N6A 5A5
e-mail: douglas.boyd{at}lhsc.on.ca
Presented at Evolving Techniques and Technologies in Minimally Invasive Cardiac Surgery Meeting, San Antonio, TX, Jan 22–23, 1999.
Abstract
Background. Bypass surgery in the elderly (age >70 years) has increased mortality and morbidity, which may be a consequence of cardiopulmonary bypass. We compare the outcomes of a cohort of elderly off-pump coronary artery bypass (OPCAB) patients with elderly conventional coronary artery bypass grafting (CABG) patients.
Methods. Chart and provincial cardiac care registry data were reviewed for 30 consecutive elderly OPCAB patients (age 74.7 ± 4.2 years) and 60 consecutive CABG patients (age 74.9 ± 4.1 years, p = 0.82) with similar risk factor profiles: Parsonnet score 17.2 ± 8.1 (OPCAB) versus 15.6 ± 6.5 (CABG), p = 0.31; and Ontario provincial acuity index 4.5 ± 1.9 (OPCAB) versus 4.3 ± 2.0 (CABG), p = 0.65.
Results. Mean hospital stay was 6.3 ± 1.8 days for OPCAB patients and 7.7 ± 3.9 days for CABG patients (p < 0.05). Average intensive care unit stay was 24.0 ± 10.9 h for OPCAB patients versus 36.6 ± 33.5 h for CABG patients (p < 0.05). Atrial fibrillation occurred in 10.0% of OPCAB patients and 28.3% of CABG patients (p < 0.05). Low output syndrome was observed in 10% of OPCAB patients and 31.7% of CABG patients (p < 0.05). Cost was reduced by $1,082 (Canadian) per patient in the OPCAB group. Postoperative OPCAB graft analysis showed 100% patency.
Conclusions. OPCAB is safe in the geriatric population and significantly reduces postoperative morbidity and cost.
The elderly are the fastest growing segment of the coronary artery bypass graft (CABG) patient population. Data provided by the Cardiac Care Network of Ontario (CCN) indicate that the proportion of CABG patients over the age of 70 years has increased from 15% to 25% between 1993 and 1997 (website: http//:www.ccn.on.ca). Over the last two decades, despite a steady increase in acuity, the mortality from CABG surgery has consistently declined [1]. Nevertheless, age continues to be an independent predictor of increased mortality and morbidity after myocardial revascularization [2, 3].
Advanced age is associated with diminished physiologic reserve and increased comorbid illnesses, including diabetes, chronic obstructive pulmonary disease, cerebrovascular disease, and peripheral vascular disease. These characteristics lead to increased postoperative complications and resource utilization in this population. In an era of fiscal constraint and fixed resources, management of the elderly CABG patient poses significant medical and ethical challenges for both healthcare providers and healthcare administrators. Recently, we demonstrated that CABG surgery without cardiopulmonary bypass is associated with a decreased mortality as well a reduction in resource utilization (intensive care unit [ICU] stay, postoperative hospital stay) in high-risk patients [4]. Based on our previous work, we hypothesized that elimination of cardiopulmonary bypass would confer the potential benefits of decreased mortality and morbidity in an elderly patient population undergoing CABG surgery.
To investigate this hypothesis, we examined the clinical outcomes of patients over age 70 years. Specifically, we studied 30 consecutive elderly patients in whom off-pump coronary artery bypass (OPCAB) was the method of revascularization, and compared these individuals with 60 consecutive patients over age 70 years who underwent conventional CABG surgery during the same 18-month period.
Patients and methods
From the inception of a minimally invasive CABG surgery program at the London Health Sciences Centre in November 1996 to June 1998, 120 off-pump operations have been performed at our institution. An analysis of the database identified 30 consecutive patients over 70 years of age in whom myocardial revascularization was achieved via OPCAB. These individuals were compared with 60 consecutive patients over age 70 years who underwent conventional CABG surgery with cardiopulmonary bypass by the same four surgeons during the same time period.
The mean age of the OPCAB patients was 74.7 ± 4.2 years, while that in the conventional CABG group was 74.9 ± 4.1 years (p = 0.8). The proportion of urgent or emergent cases was 46.7% in the OPCAB groups and 28.3% in the conventional CABG group (p = 0.001). Furthermore, within the OPCAB population, 16.7% of patients had redo surgery. In contrast, 3.3% of patients in the conventional CABG group had redo surgery (p = 0.07). There were no differences in the proportion female patients, or the incidence of diabetes, chronic obstructive pulmonary disease (COPD), and peripheral vascular disease (PVD) between the two groups. Furthermore, the number of renal failure patients on dialysis, or patients with impaired left ventricular (LV) function (ejection fraction [EF] < 40%) in the two groups was similar. The majority of patients in both groups had Canadian Cardiovascular Society class IV symptoms at the time of surgery: 56.7% OPCAB versus 66.7% conventional CABG (p = 0.4).
Based on preoperative demographics, patients were assigned a risk-acuity score. In all cases, the Parsonnet [3] and Tu [2] methods were used to determine the acuity score. As summarized in Table 1, using either method, there were no differences in risk acuity between the two groups.
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OPCAB was performed through either a limited left anterior thoracotomy or median sternotomy. In patients who underwent OPCAB via the left chest, stabilization of the target segment was achieved with aid of the CTS I stabilization system (Cardiothoracic Systems, Cupertino, CA). Stabilization of the anastomotic region during revascularization procedures performed through a median sternotomy was accomplished with the assistance of either the Octopus (Medtronic, Minneapolis, MN) or the CTS II retractor (Cardiothoracic Systems, Cupertino, CA).
All distal anastomoses were constructed with 7-0 or 8-0 polypropylene suture using a continuous technique. In the cardioplegia-arrested heart, a single suture was used, while for anastomoses on the beating heart, a two-suture technique was generally employed. The heel and the toe of the anastomosis were constructed before parachuting the conduit onto the coronary artery. After mechanical verification of patency of both heel and toe with an appropriately sized probe, the sides of the anastomosis were then completed. Before departure from the operating theatre, in all OPCAB cases, the quality of the anastomosis was assessed with use of an intraoperative real-time Doppler (Transonic Systems Inc, Ithaca, NY). Blood flow of less than 10 mL/min was used as an absolute cutoff; below this value, the anastomosis was revised before the patient left the operating theatre.
Statistical analysis
All data were analyzed using SAS v. 6.12 statistical software (SAS Institute Inc, Cary, NC). Continuous variables are presented as mean ± standard deviation, while categorical variables are presented as either absolute counts or percentages. Categorical variables were analyzed using either 
2 analysis or Fisher’s exact test. Continuous variables were analyzed by analysis of variance. Corrections were not made for multiple comparisons, and in all instances, statistical significance was assumed at p = 0.05.
Results
Operative results
OPCAB patients received fewer grafts than their conventional CABG counterparts (1.7 ± 0.6 vs 2.9 ± 0.9, p < 0.001). The number of arterial conduits was similar between groups (1.0 ± 0.4 vs 0.9 ± 0.5, p = 0.3). No patient in the OPCAB group required conversion to CPB.
In the OPCAB group, 28 of 30 cases were performed through a median sternotomy incision, while the remaining 2 cases were performed through a limited left anterior thoracotomy. Within the OPCAB group, in 1 patient, the left thoracotomy approach was converted to a median sternotomy due to subclavian stenosis, while a second patient with a severely calcified aorta underwent combined left internal mammary artery bypass to the left anterior coronary artery with transmyocardial laser revascularization.
No patient in the OPCAB group received perioperative blood products, while conventional CABG patients received an average of 1.2 ± 2.6 U of packed red blood cells (p < 0.001). In total, 19 CABG patients (32%) received a blood transfusion.
Resource utilization
Data on hospital resource utilization are summarized in Table 2. There were significant decreases in ventilation time, ICU stay, and postoperative hospital stay in OPCAB patients. These differences were particularly significant considering the higher proportion of redo operations in the OPCAB group. No patients in the conventional group were extubated intraoperatively, while 20% of OPCAB patients underwent intraoperative extubation.
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Cost impact analyses
In an effort to determine the effect of complications on resource utilization, patients with a hospital stay of greater than 8 days or an ICU stay greater than 48 hours were grouped and labeled as adverse economic outcomes. The data indicate that OPCAB was associated with a marked reduction in the proportion of patients with adverse economic outcomes (OPCAB 10% vs CABG 40%, p < 0.005).
To determine the average cost of each procedure (in Canadian dollars), we employed a cost analysis formula that we have previously described [9]:
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The cost of the procedure is based on fixed operating room and supply costs plus hospital and ICU bed costs, which are dependent on length of stay (and therefore variable). Professional fees were not included in this analysis. The mean cost in the OPCAB group was CAN $6,702 ± 1,047 per patient and was CAN $7,784 ± 2,846 per patient in the CABG group (p < 0.05). On average, the cost of beating heart procedures was $1,082 less than the cost of conventional revascularization with cardiopulmonary bypass in this patient population, a savings of 14% per patient.
Graft patency studies
Postoperative angiography and/or transthoracic Doppler ultrasound were performed in OPCAB patients to determine graft patency. With angiography, 42 grafts in 24 of the 30 OPCAB patients (80%) were examined. Transthoracic Doppler was performed on an additional 3 OPCAB patients. Therefore, a total of 45 of the 52 grafts (86%) performed on 27 of the 30 OPCAB patients (90%) were assessed. There were no cases of anastomotic failure (100% patency).
Comment
The pioneering work of Bennetti and Buffolo and their collaborators demonstrated that it is possible to perform coronary anastomoses on the beating heart [5, 6]. While beating heart surgery continues to be explored as an alternative to conventional CABG surgery in many cardiac units worldwide, this revascularization strategy continues to generate controversy. A recurrent criticism of studies evaluating the efficacy of minimally invasive or off-pump cardiac procedures stems from the argument that beating heart surgery is performed on a group of patients that are inherently different from those undergoing conventional CABG surgery. If the patient populations are different, then the comparison of one technique with another becomes invalid.
A major difficulty in comparing OPCAB with conventional CABG arises from a consistent difference in the number of grafts constructed with one versus the other method. It is assumed that the higher number of grafts performed with conventional CABG surgery signifies more advanced cardiac disease in this patient population. Therefore, it is also assumed that these patients have an increased acuity. However, these assumptions are not supported by any statistical models used to assess the surgical risk of myocardial revascularization. Indeed, in the risk assessment models developed by Tu and Parsonnet, the number of diseased vessels was not identified as a risk factor for increased mortality or morbidity [2, 3]. The risk factors most associated with increased mortality and morbidity in models developed in Ontario include advanced age, redo operation, female gender, impaired left ventricular ejection fraction, urgent operation, and left main disease [7].
In the current study, the risk assessment methods of Parsonnet [3] and Tu [2] were used to compare the two patient populations. As we demonstrated in Table 1, there were no differences between the two groups using either method, and we would anticipate that the clinical outcomes of the two groups would be similar. Consistent with this hypothesis, the mortality in the two groups was not different. There were no deaths in the OPCAB group and one death in the conventional CABG group. However, the incidence of low-output syndrome was significantly higher in the conventional CABG group (31.7% vs 10.0%, p < 0.02). The incidence of atrial fibrillation was also significantly higher in conventional CABG group (28.3% vs 10.0%, p < 0.05). Although not significant, the incidence of postoperative stroke was 6.7% in the conventional CABG group, while there were no strokes in the OPCAB patients (p = 0.4). This lack of statistical significance may in part be due to the relatively small size of the patient groups. Furthermore, revascularization via OPCAB was associated with a significant reduction in hospital resource utilization (Table 2). OPCAB patients on average were discharged from the ICU 12.6 h and from the hospital 1.4 days sooner than their conventional CABG counterparts. Our data suggest that the shorter ICU and hospital stays were achieved in the OPCAB group from a substantial reduction in postoperative complications. The significant decreases in the incidences of low-output syndrome and of atrial fibrillation are particularly impressive, given their high prevalence in elderly patients after conventional CABG surgery [8]. An additional benefit of beating heart surgery is the significant reduction in the need for postoperative blood products.
Previous work by our group demonstrated that beating heart surgery was associated with a significant reduction in cost in high-risk surgical patients [4]. In the current study, we examined the cost of OPCAB and conventional CABG surgery in the geriatric population. We hypothesized that postoperative morbidity was responsible for longer ICU and hospital stays. Therefore, we grouped together patients who had an ICU stay longer than 24 hours and/or a hospital stay longer than 8 days, and defined these individuals as adverse economic outcomes. The prevalence of adverse economic outcomes was four times higher in the CABG population (OPCAB 10% vs CABG 40%, p < 0.005). Furthermore, the reduction in hospital resources in the OPCAB patients resulted in an average savings of CAN $1,082 per patient in this group. These savings were based solely on decreases in hospital stay and ICU stay, and did not include additional savings yielded from decreased operating room equipment costs or blood product usage.
Calafiore and colleagues have rapidly accumulated the largest worldwide contemporary experience with left internal mammary artery (LIMA) to left anterior descending coronary artery (LAD) grafting through a left anterior thoracotomy [9]. In 176 patients, postoperative angiography was performed with an overall patency rate of 89.8%, and "perfect" patency (stenosis < 50%) was found in 85.2%. These results suggest that anastomotic patency falls short of the results that can be achieved by a LIMA bypass to the LAD constructed via a median sternotomy in the setting of a cardioplegia-arrested heart. In an effort to improve patency, we have used an intraoperative real-time Doppler (Transonic Systems Inc.) to assess the quality of the anastomosis. Based on intraoperative Doppler flow data, anastomotic revision has been carried out in about 8% of the 120 off-pump cases we have performed. We believe this approach can improve patency. In the current series, postoperative angiographic follow-up of the OPCAB grafts showed 100% patency in the 90% of OPCAB patients that were reviewed with angiography or postoperative transthoracic doppler.
Cost containment is highly desirable in the elderly population because their higher propensity for resource utilization may disadvantage these patients in an economically constrained healthcare system. Comparison of long-term quality of life and neuropsychological outcome in OPCAB versus conventional CABG is warranted to delineate further potential differences in these.
Our preliminary experience with OPCAB in the elderly suggests it is a rational and safe alternative to conventional CABG surgery for the revascularization of selected geriatric patients. OPCAB offers the potential advantage of decreasing major postoperative complications, including low-output syndrome, atrial fibrillation, and blood usage. These improvements in postoperative outcome appear to have led to shorter ICU and hospital stay in the elderly with a resultant reduction in cost. While our results are encouraging, definitive comparison of these two techniques can only be made in the setting of a prospective randomized clinical trial.
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