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Ann Thorac Surg 2002;74:S1340-S1343
© 2002 The Society of Thoracic Surgeons

Supplement: Cardiothoracic Techniques and Technologies

Coronary artery bypass in patients 80 years and over: is off-pump the operation of choice?

Steven J. Hoff, MDa*, Stephen K. Ball, MDa, William H. Coltharp, MDa, David M. Glassford, Jr, MDa, John W. Lea, IV, MDa, Michael R. Petracek, MDa

a St. Thomas Heart Institute, St. Thomas Hospital, Nashville, Tennessee, USA

* Address reprint requests to Dr Hoff, 4230 Harding Road, Suite 501, Nashville, TN 37205 USA
e-mail: shoff{at}csapc.net

Presented at the Eighth Annual Cardiothoracic Techniques and Technologies Meeting 2002, Miami Beach, FL, Jan 23–26, 2002.


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: Octogenarians are at increased risk for perioperative morbidity and mortality after coronary artery bypass. In this study we compared our experience with patients undergoing on-pump coronary artery bypass (CAB) and those undergoing off-pump coronary artery bypass (OPCAB) to assess outcomes.

METHODS: We used hospital database analysis in patients 80 years and older who underwent nonemergent coronary artery bypass with (N = 169) and without (N = 60) cardiopulmonary bypass from January 1999 through June 2001.

RESULTS: Both groups were at increased perioperative risk based on the Society of Thoracic Surgeons risk model (7.7% OPCAB vs 5.8% CAB, p = 0.03). There were no operative deaths in the OPCAB group but there were eight (4.7%) in the CAB group (p = NS). Perioperative stroke (0% OPCAB vs 7.1% CAB, p = 0.04), prolonged ventilation (1.7% OPCAB vs 11.8% CAB, p = 0.02), and transfusion rate (33% OPCAB vs 70.4% CAB, p < 0.001) were all lower in the OPCAB group. A shorter hospital stay (6.3 days OPCAB vs 11.5 days CAB, p < 0.001) resulted in lower hospital cost in the OPCAB group ($9,363 OPCAB vs $12,312 CAB, p < 0.001).

CONCLUSIONS: In this study, off-pump coronary artery bypass grafting in elderly patients was associated with fewer complications, a shorter hospital stay, and lower hospital cost. Off-pump coronary artery bypass grafting may be the operation of choice for octogenarians requiring surgical myocardial revascularization.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Acknowledgments
 References
 

Dr Hoff discloses that he has a financial relationship with Medtronic, Inc.

 

As the population of the United Sates ages, older patients are increasingly being considered for coronary artery bypass grafting. Patients of advanced age are known to be at increased risk for morbidity and mortality after bypass surgery [1–4]. In recent years, experience with performing coronary artery bypass without the use of cardiopulmonary bypass has increased dramatically. Many early reports suggest that this approach may improve outcome by lowering postoperative cardiac, pulmonary, renal, and neurologic complications, with concomitant reduction in hospital stay and cost [5–7]. The benefit of this approach to elderly patients seems appealing but is not well studied. We sought to review our experience with coronary artery bypass without the use of cardiopulmonary bypass in the elderly to better define the potential benefit of this approach in this high-risk group of patients.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Acknowledgments
 References
 
Study population
Between January 1, 1999, and June 30, 2001, a total of 3,819 patients underwent isolated coronary artery bypass grafting at St. Thomas Hospital. In January 1999, the first author (S.J.H.) first performed multivessel off-pump coronary artery bypass at St. Thomas. Since that time, he hasapproached all patients requiring coronary artery bypass with the intent to treat without cardiopulmonary bypass. In that time, he has performed elective off-pump coronary bypass on 60 patients 80 years of age or older. This group comprises the study population. It is compared to a group of 169 consecutive patients 80 years of age or older who underwent elective coronary artery bypass over the same period on cardiopulmonary bypass. This group underwent operation by one of nine cardiac surgeons, including the first author (6 patients). To control as many variables as possible, patients undergoing emergency operation and minimally invasive direct coronary artery bypass (MIDCAB) procedures were excluded from the study populations.

Study methods
St. Thomas Hospital maintains a registry of all patients undergoing cardiac surgery. This hospital database was queried for multiple preoperative, intraoperative, and postoperative variables. Definitions of preoperative risk factors, estimated perioperative risk, and postoperative complications were made according to criteria established by The Society of Thoracic Surgeons. Mortality and morbidity data are reported in accordance with the Guidelines for Data Reporting and Nomenclature for The Society of Thoracic Surgeons. Hospital costs are reported as direct variable cost as the most valid way to define hospital cost directly related to the procedure within our institution. It may not be valid to compare these data to other reported hospital costs.

Surgical technique
Coronary artery bypass
Conventional on-pump coronary artery bypass (CAB) was performed with moderate systemic hypothermia (26° to 30°C). Antegrade cardioplegia with topical cooling, antegrade and retrograde cardioplegia with topical cooling, and intermittent crossclamping were variably used.

Off-pump coronary artery bypass
Off-pump coronary bypass (CAB) was performed through a median sternotomy in all cases. Deep pericardial traction sutures and a suction-based stabilizing system (Medtronic, Inc, Minneapolis, MN) were used to facilitate exposure. An intracoronary shunt (CardiothoracicSystems, Cupertino, CA) was used in all cases to improve visualization and to facilitate anastomoses.

Statistical analysis
Statistical analysis was performed using NCSS version 6.0 (NCSS, Kayesville, Utah). Statistical analysis was performed using Student’s t test for continuous variables and {chi}2 tests for categorical variables. Fisher’s exact test was used for any subset with N less than 5. A p value less than 0.05 was considered significant.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Acknowledgments
 References
 
Demographic data for each study group are summarized in Table 1. There were 169 patients 80 years or older in the on-pump coronary artery bypass (CAB) group and 60 patients in the off-pump coronary artery bypass (OPCAB) group. The average age in the CAB group (82.3 years, range 80 to 89 years) did not differ significantly from that of the OPCAB group (82.7 years, range 80 to 90 years). There were 92 men and 77 women in the CAB group, with 31 men and 29 women comprising the OPCAB group (p = NS).


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  		Table 1. Demographic and Preoperative Data

 
Preoperative risk factors for both study groups are also summarized in Table 1. There were no statistically significant differences noted between groups with regard to acute myocardial infarction, history of stroke, atrial fibrillation, or renal failure. Rates of chronic obstructive pulmonary disease (18.3% OPCAB vs 11.8% CAB), ejection fraction less than 30% (6.7% OPCAB vs 4.7% CAB), and diabetes (30% OPCAB vs 23.1% CAB) tended to be higher in the OPCAB group, but this did not reach statistical significance. When minor variations between groups were added together, the overall estimated STS risk was higher in the OPCAB group (7.7% vs 5.6%, p = 0.03).

Operative data are summarized in Table 2. Emergency operations were excluded from analysis. Complete revascularization was accomplished in all patients. There were no conversions to cardiopulmonary bypass in the off-pump (OPCAP) group of patients. A similar number of patients in each group had previously undergone bypass grafting (6/60, 10% OPCAB vs 18/169, 10.7% CAB, p = NS). There was a significant difference in the number of grafts performed per patient in each group (OPCAB 2.6, range 1 to 5, vs CAB 3.6, range 1 to 6, p < 0.001). There was also a significant difference in the number of patients in whom an internal mammary artery graft was used (OPCAB 51/60, 85%, vs CAB 89/169, 52.7%, p < 0.001). Fewer patients received lateral wall grafts in the OPCAB group (OPCAB 36/60, 60%, vs CAB 146/169, 86.4%, p < 0.001.


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  		Table 2. Operative Data

 
Postoperative outcomes are summarized in Table 3. The mortality rate for OPCAB patients tended to be lower than among CAB patients, although this did not reach statistical significance (OPCAB 0/60, 0%, vs CAB 8/169, 4.7%, p = NS). There were no deep sternal wound infections in either group. Rates of perioperative stroke (OPCAB 0/60, 0%, vs CAB 12/169, 7.1%, p = 0.04) and ventilator dependence for more than 48 hours (OPCAB 1/60, 1.6%, vs CAB 20/169, 11.8%, p = 0.02) were significantly lower in the OPCAB group. Although rates for return to the operating room for bleeding (OPCAB 0/60, 0%, vs CAB 6/169, 3.6%), dialysis-dependent renal failure (OPCAB 0/60, 0%, vs CAB 3/169, 1.8%), and new atrial fibrillation (OPCAB 14/60, 23.3%, vs CAB 52/169, 30.8%) tended to be lower in the OPCAB group, these did not reach statistical significance. Fewer patients in the OPCAB group required blood transfusions (OPCAB 20/60, 33.3%, vs CAB 119/169, 70.4%, p < 0.001).


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  		Table 3. Outcome Data

 
The average postoperative length of stay was shorter in the OPCAB than in the CAB group (OPCAB 6.3 days vs CAB 9.2 days, p < 0.001). This translated into lower direct variable hospital cost for those patients in the OPCAB group (OPCAB $9,363 vs CAB $12,312, p < 0.001). Of the hospital survivors, 68% in the CAB group could be discharged home, a percentage similar to that in the OPCAB group (70%). Most of the remainder of patients could be transferred to a short-term inpatient rehabilitation program if further strengthening was required or if social circumstances demanded it. Six patients in the CAB group required transfer to a rehabilitation hospital for long-term inpatient rehabilitation.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Acknowledgments
 References
 
As the population ages and improved medical care improves life expectancy, more patients will live long enough to develop coronary artery disease and will therefore be considered for surgical revascularization [1, 2]. Multivariate analysis has shown that advanced age is an independent risk factor for higher perioperative mortality, morbidity, and prolonged hospital stay [1–3]. Specific age-related factors leading to increased perioperative risk were recently reviewed by Oskvig [8]. Specific cardiac risks include aortic calcification, stiff vessels, diminished cardiovascular response to exercise, and intolerance of anemia. Additional age-related changes affect performance and physiologic reserve of the pulmonary, renal, and nervous systems.

The definition of "elderly" is central to the evaluation of increased risk to patients of advanced age. In the past, studies have defined elderly patients as older than 65, 70, 75, and, most recently, 80 years of age. Defining the population precisely is important, as studies have shown incremental risk related to advanced age [1, 3–4, 9]. We have chosen 80 years of age to define a patient population that is truly at high risk for perioperative morbidity and mortality.

As experience with off-pump coronary artery bypass grows, patients at high risk for perioperative morbidity and mortality are being considered for operation. Several recent studies have shown improved outcomes in high-risk patients after off-pump coronary artery bypass, particularly in patients with preoperative respiratory, insufficiency, renal insufficiency, and previous stroke [7, 10–16]. With improved outcomes, patients who were once considered to be at prohibitively high risk for coronary artery bypass may now be candidates for surgical revascularization, with its attendant benefits. Patients at high risk may be able to undergo coronary artery bypass with more acceptable risk. The current study supports this concept. Off-pump coronary artery bypass may offer patients at low risk a better option if morbidity, mortality, and graft patency are equivalent to those of an on-pump approach and if neurocognitive deficits observed after on-pump coronary artery bypass can be avoided. Evidence has suggested that an off-pump approach may limit subtle neurocognitive changes observed after on-pump coronary artery bypass that are related to aortic manipulation and microemboli created by extracorporeal circulation [17–20].

With improvements in aids to provide stabilization, exposure, and visualization, concerns about completeness of revascularization have become less important after off-pump coronary artery bypass. Many studies, including ours, report fewer grafts performed in patients off-pump compared to those who undergo operation on pump [2, 5, 10, 12]. The number of grafts performed in the OPCAB group, as well as the percentage of patients receiving lateral wall grafts, was comparable to published reports [2, 6]. Although many studies have included more limited MIDCAB approaches with multivessel transsternal OPCAB in their analysis, our study controlled for this variable and still found a difference in the number of grafts per patient. In our study, this difference may reflect a difference in surgeon preference, as a single surgeon performed all off-pump operations, whereas multiple surgeons performed the on-pump operations, with some surgeons tending to graft more vessels. There were also likely more patients with single-vessel and double-vessel disease in the off-pump group, although this did not translate into a reduction in the predicted STS risk, which was higher in the OPCAB group in our study. Improved outcomes in off-pump patients in all of these studies with no change in perioperative cardiac events may also suggest that the number of grafts performed is less important clinically than accomplishing complete revascularization [21].

Reduced blood use appears to be a consistent benefit of an off-pump approach. Multiple studies have shown decreased bleeding tendencies with less transfusion requirements, even in an era in which antiplatelet agents including IIb/IIIa inhibitors are a routine part of preoperative care [5, 7, 13, 14, 22]. Less coagulaopathy, with elimination of dilutional anemia created by the pump prime, has meant less anemia and fewer transfusions in patients undergoing operations off-pump. This is particularly important in patients of advanced age, who tolerate anemia poorly. Our preference has been toward a more liberal transfusion policy in elderly patients. Whether this has contributed to improved outcomes related to better oxygen-carrying capacity and renal perfusion and therefore fewer pulmonary and renal complications is not directly addressed by this study.

This study is limited by the usual limitations of a retrospective analysis. Although few larger studies exist, small patient numbers could limit the power of its conclusions. We have excluded MIDCAB operations and emergency operations in an attempt to more accurately study elective, multivessel surgical revascularization using these two approaches. This also limits study size. Surgeon preference may have affected various factors, as has already been discussed. A single surgeon, who also operated on 6 patients in the on-pump group, performed all off-pump cases. The inclusion of these cases in the on-pump group did not statistically affect outcomes in this group of patients. We have made no attempt to study graft patency, which is an extremely important component of the safety and efficacy of coronary artery bypass for any patient population. Puskas and colleagues showed that early graft patency rates equal to or exceeds published data for on-pump procedures [7]. If a difference in long-term patency rates exists between on-pump and off-pump approaches because of a technical difference in graft construction, it should be evident in early and midterm results As experience with off-pump procedures grows, larger studies and prospective randomized studies should better define the benefits of an off-pump approach.

In conclusion, elderly patients are at increased risk for mortality and morbidity after coronary artery bypass. This study demonstrates that coronary artery bypass grafting can be performed safely on patients 80 years of age and older without the use of cardiopulmonary bypass. With this approach, elderly patients in our study had fewer complications, reduced postoperative stay, and lower hospital cost. Off-pump coronary artery bypass may be the operation of choice for octogenarians requiring surgical myocardial revascularization.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
References
 
The authors acknowledge Barbara Patterson, RN, for assistance with data retrieval, and Laura Lee, RN, for assistance in the preparation of this manuscript.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 

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