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Ann Thorac Surg 2003;76:32-36
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease: impact of strategy on midterm outcome

^a Department of Cardiology and Cardiac Surgery, University "G. D’Annunzio," Chieti, , Italy
^b Division of Cardiac Surgery, "Papardo" Hospital, Messina, Italy

Accepted for publication February 5, 2003.

^* Address reprint requests to Dr Calafiore, Division of Cardiac Surgery, "G. D’Annunzio" University, S. Camillo de’ Lellis Hospital, via C. Forlanini, 50, 66100 Chieti, Italy.
e-mail: calafiore{at}unich.it

	Abstract

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BACKGROUND: In a previous study, we demonstrated that patients with multivessel disease benefit during the first postoperative month from elimination of cardiopulmonary bypass (CPB). We evaluated the midterm results of the same patients excluding the first postoperative month from the analysis.

METHODS: From May 1997 to November 2000, 1,802 patients with multivessel disease survived the first postoperative month; 906 were operated on without (group A) and 896 with (group B) CPB. Follow-up ranged from 23 to 65 months (mean, 42 ± 12 months). Four-year actuarial freedom from the following events was evaluated: death from any cause; cardiac death; acute myocardial infarction (AMI) in any territory; AMI in a grafted area; redo percutaneous transluminal coronary angioplasty (PTCA); redo PTCA in a target vessel; cardiac events (death from a cardiac cause, acute myocardial infarction on grafted vessel, redo PTCA on target vessel); and any event.

RESULTS: No statistical difference was found between groups A and B with regard to freedom from any death (95.3 ± 0.8 vs 95.7 ± 0.7, p = 0.5160); from cardiac death (97.3 ± 0.6 vs 97.5 ± 0.6, p = 0.5345); from AMI (98.4 ± 0.4 vs 98.7 ± 0.4, p = 0.4655); from AMI in a grafted area (98.9 ± 0.4 vs 98.7 ± 0.4, p = 0.9374); from redo PTCA (97.9 ± 0.5 vs 97.7 ± 0.6, p = 0.8485); from redo PTCA in a grafted area (98.7 ± 0.4 vs 98.5 ± 0.5, p = 0.8774); from target cardiac events (95.8 ± 0.7 vs 95.9 ± 0.8, p = 0.6070); and from any event (92.9 ± 0.9 vs 93.4 ± 1.0, p = 0.3721).

CONCLUSIONS: After exclusion of the first postoperative month, myocardial revascularization without CPB has midterm results similar to myocardial revascularization with CPB. In particular, failure of revascularization does not depend on intraoperative strategy.

	Introduction

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In a previous paper [1], we analyzed the early results of myocardial revascularization with and without cardiopulmonary bypass (CPB) in patients with multivessel disease. We concluded that, when CPB was not used according to our patient selection, patients experienced lower mortality, experiened lower incidence of acute myocardial infarction (AMI), and were less complicated.

In the literature, there is little information about the midterm results in this subgroup of patients according to the different surgical strategies [2, 3]. For this reason, in this retrospective study, we evaluated the clinical results of the same patients who were the subjects of our previous report.

	Material and methods

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From May 21, 1997 to November 30, 2000, 1,843 patients underwent isolated myocardial revascularization through median sternotomy for multivessel disease at the Division of Cardiac Surgery of the University of Chieti, Italy. Forty-one patients (2.2%) died during the first 30 days after surgery. The remaining 1,802, who survived the first month, are the object of this study. Of these, 906 were operated on without CPB (group A) and 896 with CPB (group B). Patients who were converted from without to with CPB (n = 43) were included in group A (patients were grouped according to the intention to treat). Patient selection and surgical technique were previously reported [1].

Methodology of the study
End points of this study were the incidence of events that occurred after the first postoperative month: mortality, cardiac mortality, acute myocardial infarction (AMI) in any territory, AMI in a grafted area, redo percutaneous transluminal coronary angioplasty (PTCA) in any territory, redo PTCA in a grafted area, target cardiac events, and any event.

Definition of terms
Mortality included death from any cause. Cardiac mortality included any death for cardiac causes and sudden death. The diagnosis of AMI was performed according to the medical records of the cardiologic intensive care unit where the patients were hospitalized. Non Q-wave AMIs were considered events. Target cardiac events were defined as cardiac death, AMI in a grafted area, and redo PTCA in a grafted area, with patients included only once. Any event was defined as death from any cause, AMI in any territory, and redo or PTCA in any territory, with a patient included only once.

Follow-up
Follow-up ranged from 23 to 65 months (mean, 42 ± 12 months; 44 ± 13 in group A and 40 ± 12 months in group B, p < 0.001). Patients were followed up in our outpatient clinic 3, 6, and 12 months after surgery and thereafter at yearly intervals. The more recent information was obtained by calling the patient or the referring cardiologist. Follow-up was 100% complete.

Statistical analysis
Results are expressed as mean value ± SD unless otherwise indicated. Statistical analysis comparing two groups was performed with unpaired two-tailed t testing for the means or ² test for categorical variables. Actuarial curves were obtained with the Kaplan-Meier method. The statistical significance was calculated with the log-rank test. Cox analysis was used to evaluate the independent risk factors for reduced freedom from an analyzed event. Independent variables were expressed as hazard ratio (HR), with the 95% confidence limit (CL); the related p value was also reported. Variables tested by Cox analysis are listed in the appendix. The SPSS software (SPSS Inc, Chicago, IL) was used. Values of p less than or equal to 0.05 were considered significant.

	Results

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Preoperative and perioperative data of the 1,802 patients who survived the first months after surgery are shown in Table 1. Patients in group A were older, with higher ejection fraction (EF), lower incidence of coronary reoperation, and higher incidence of extracoronary vasculopathy. However, incidence of patients with EF less than or equal to 35% was similar in both groups.

During the follow-up, 76 patients (4.2%) died, 45 (2.5%) from cardiac causes (21 AMI, 15 sudden deaths, 8 from heart failure, 1 from right ventricular lesion). An AMI occurred in 26 patients (1.4%), 21 (1.2%) in a grafted area; 32 (1.8%) had a redo or PTCA, 20 (1.1%) in a grafted area; 68 (3.8%) had a cardiac target event (45 cardiac deaths, 3 had AMI in a grafted area, 20 had redo PTCA in a grafted area), and 110 (6.1%) had any event.

Thirty-two patients had a redo (9 in group A and 2 in group B) or a PTCA (8 in group A and 13 in group B), equally distributed in both groups (10 in each one) if the grafted area is considered. Whereas redo and PTCA in a grafted area had a similar incidence in group A (6 and 4, respectively), more patients in group B had a PTCA (8) rather than a redo (2), without any statistical significance. It was due only to technical reasons (lesion not accessible through the native coronary artery in 3 patients due to graft occlusion).

Results in redo patients (88) operated on without (16) or with (72) CPB were similar. In particular, incidence of deaths was 6.3% in group A and 6.9% in group B (p = 1.000), and incidence of cardiac events was 6.3% versus 8.3% (p = 1.000).

Outcome of patients who were converted [43] was also similar to that of patients who were not converted (1759). In particular, incidence of deaths was 4.7% in converted patients versus 4.2% in nonconverted patients (p = 0.703), and incidence of cardiac events was 4.7% versus 4.3% (p = 0.710).

Globally, 193 patients (10.7%) were readmitted in hospitals for different causes, 99 (10.9%) in group A and 94 (10.5%) in group B (p = 0.951).

Four-year actuarial results are shown in Table 2. Freedom from the explored events was similar in both groups.

	Comment

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Long-term results are not available in the recent literature. Gundry and associates [2] reported in 1998 a 7-year follow-up in patients who had myocardial revascularization with (n = 107) or without (n = 112) CPB. In their experience, no mechanical stabilization was used. The authors found that 7-year actual survival was the same (80% vs 79%); however, twice as many patients in the no CPB group required recatheterization (30% vs 16%, p = 0.01) and 20% needed a second reintervention, interventional or surgical. Only 7% of the patients operated on with CPB required reintervention, always interventional. The authors concluded that long-term results were similar in both groups with regard to survival, but the price to pay was a threefold rate of reinterventions. This paper gave us a crucial contribution of the state of the art in the late 1980s, when coronary surgery without CPB was in its infancy. It focused also on an important point that is still true: Are we justified to avoid CPB in the name of a lower early mortality or morbidity if long-term results are not well known?

More recently, a randomized study Angelini and associates [3], 24 months after surgery, did not find any difference between patients operated on without and with CPB in terms of survival and survival free from any cardiac-related event. The same group, analyzing midterm results, did not show any benefit from off-pump in the elderly as well [16].

In our study, the analysis of midterm results showed that 4-year actuarial outcome is similar in patients operated off-pump and on-pump. However, we evaluated midterm results in patients with multivessel disease excluding the first month from surgery to avoid any influence of the early period on midterm outcome.

Freedom from explored events was not different in the two groups. A positive finding was that, unlike the data reported by Gundry and associates [2], the incidence of failure of revascularization, as crude data and as actuarial freedom from redo PTCA, was similar. No difference was evident if freedom from redo PTCA in the grafted area was considered. It is noteworthy that more patients in group A had surgical redos than patients in group B (6 vs 2). However, this aspect was fortuitous and due only to technical factors, as in 3 patients in group A, a graft was occluded and the lesion was not accessible through the native coronary network.

In conclusion, midterm results after myocardial revascularization in multivessel disease, when the first postoperative month is excluded, are not influenced by the use or not of CPB, if patient selection criteria proposed by us are followed [1]. CPB is not a risk factor, or a protective factor, for any of the events investigated by us.

A limitation of this study is that it is not a prospective or randomized study, but a retrospective one. Nevertheless, in our opinion, it can give an idea, even if not conclusive, about the quality of midterm results of myocardial revascularization without CPB.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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