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Ann Thorac Surg 2003;76:1138-1143
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Conversion in Off-Pump coronary artery bypass grafting: an analysis of predictors and outcomes

^a Cardiopulmonary Research Science and Technology Institute, USA and Medical City Dallas Hospital, Dallas, Texas, USA

^* Address reprint requests to Dr Edgerton, 7777 Forest Lane, Suite A323, Dallas, TX 75230, USA
e-mail: edgertonjr{at}aol.com

Presented at the Forty-ninth Annual Meeting of the Southern Thoracic Surgical Association, Miami Beach, FL, Nov 7–9, 2002.

	Abstract

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BACKGROUND: The incidence, predictive factors, and outcomes related to conversion from off-pump coronary artery bypass (OPCAB) to on-pump coronary artery bypass grafting (ONCAB) have not been well defined. We sought to determine the incidence of conversion, predictive factors, and any associated adverse consequences.

METHODS: From January 2000 through June 2002, 1,644 patients underwent nonemergent OPCAB with 61 patients requiring conversion from OPCAB to ONCAB. These groups were retrospectively compared by univariate and multivariate regression analysis. The converted group was then computer matched 1:3, to a cohort of ONCAB patients to determine differences in outcomes.

RESULTS: The overall conversion rate was 3.71%. Converted patients compared with a computer-matched ONCAB patients had a higher incidence of operative mortality (18.0% versus 2.7%, p < 0.001). Urgently converted patients had a higher incidence of postoperative cardiac arrest (25% versus 1.1%, p < 0.001), multisystem organ failure (10.7% versus 0.6%, p < 0.001), vascular complications (7.1% versus 1.1%, p = 0.03), and perioperative myocardial infarction (10.7% versus 1.1%, p = 0.02). Predictive factors for conversion were surgeon early in OPCAB experience (odds ratio [OR] 4.4), previous CABG (OR 2.8), and congestive heart failure (OR 2.0). The need for urgent-emergent conversion was highly predictive for operative mortality (OR 7.3) compared with elective conversion.

CONCLUSIONS: Patients undergoing urgent-emergent but not elective conversion from OPCAB to ONCAB had a significantly higher risk of mortality and morbidity compared with patients whose procedure was initially ONCAB. Variables predictive of conversion included previous CABG, congestive heart failure, and surgeons early in OPCAB experience.

	Introduction

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Increasingly surgeons are using off-pump techniques for coronary artery bypass grafting (CABG) in an effort to eliminate the morbidity associated with cardiopulmonary bypass (CPB). However occasionally during a beating heart operation the patient must be placed on CPB in order to safely complete the operation. Common reasons mandating conversion from an off-pump to an on-pump procedure include hemodynamic instability, failure to adequately expose the target vessel, deep intramyocardial course of the target vessel, and global ventricular ischemia [1–3]. The reported incidence of conversion to CPB ranges from a low of 1.1% [4] to a high of 16.3% [2]. Patients who require conversion may experience a higher rate of morbidity or mortality.

Several studies do indicate that patients converted to CPB may have a higher mortality rate [5, 6] than those whose operation was successfully completed off-pump while others suggest no increase in mortality [7, 8]. Converted patients have also been shown to have a higher complication rate [9]. As further evidence that this group of converted patients may follow a different clinical course Sinclair and colleagues [5] found that converted patients had a significantly increased hospital cost and length of stay.

A retrospective review of isolated CABG procedures was performed to determine if patients (the "conversion" group) who have their CABG operation initiated off- pump (OPCAB) and are subsequently converted to on- pump (ONCAB) during the procedure have a higher morbidity and mortality than if their operation had been initiated as ONCAB without an aborted OPCAB attempt. We also sought to determine whether there are preoperative factors predictive of the need to convert.

	Material and methods

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Patients
Data on a total of 4,689 patients were exported from our Society of Thoracic Surgeons (STS) approved database. These data represented the population of all isolated CABG patients operated on by our group of 22 surgeons from January 1, 2000, to June 30, 2002. Patients whose status was listed as "emergent" or "salvage", who were in cardiogenic shock, or who were being resuscitated were not included in the study, reasoning that they could only be done on-pump. This excluded a total of 151 patients representing 3.2% of the study population. The analysis examined data from a total of 4,538 study patients consisting of 61 conversions (1.34%), 1,583 OPCAB patients (34.9%), and 2,894 ONCAB patients (63.8%). Data on the conversions were obtained from operative records and surgeon interviews.

Definitions
Conversion timing
After review of the operative notes on all conversion patients, we classified the timing of the conversion as either early when conversion was done prior to beginning any anastomoses, or late when converted after any anastomosis was begun.

Conversion status
The urgency of the conversion was also assessed. Elective conversions were planned and unhurried. Conversions were urgent or emergent if there was any evidence of hemodynamic instability or severe electrical disturbance such as recurrent ventricular tachycardia or severe ischemia.

Classification
Using the status and timing groups we have defined four groups: elective conversion done early; elective conversion done late; urgent-emergent conversion done early; and urgent-emergent conversion done late

Reason for conversion
Data from the operative records and surgeon interviews were used to categorize the reason for the conversion into three groupings: anatomic (problems obtaining adequate exposure, small vessels, intramyocardial vessels, adhesions or enlarged heart) observed during the procedure; hemodynamic instability upon manipulation of the heart (severe hypotension, mitral regurgitation, bleeding, acute ischemia as detected by ST-segment or wall-motion changes, left ventricular dysfunction); and electrical disturbances during the procedure (ventricular tachycardia or fibrillation, heart block, severe bradycardia).

Surgeon volume
The 22 surgeons in our practice were divided into three groups based on the number of OPCAB cases they had performed prior to the start of the study period. Groupings used were as follows: high-volume surgeons (4), who had each performed more than 100 off-pump procedures; moderate-volume (8) who had each performed 26 to 100, and low-volume surgeons (10) who had each performed 1 to 25 cases.

Risk factors and complications were defined according to STS database definitions.

Statistics
The data were analyzed using SAS 8.2 (SAS Institute, Cary, NC) initially comparing the on-pump patients with the conversion patients to determine the factors that differed significantly between the populations. These factors were entered into a matching program set to produce a 3:1 control:case match for the conversions against the on-pump controls. Matching criteria used were risk of mortality, previous CABG, congestive heart failure (CHF), and the use of intraaortic balloon pump (IABP). That produced a test population that included 183 on-pump patients and 61 converted patients. After matching, the groups were tested for all preoperative risk factors using the chi-square test (Fisher’s exact test) for categorical variables and the t test for continuous variables. There were no statistically significant differences between the two groups for any of the factors including the distribution of age and ejection fractions within the patient groups.

The groups were then analyzed for outcome variables, rates of conversion and mortality, and the dependence of the variables on surgeon volume, conversion timing, and status.

Logistic regression was applied to the data set consisting of the conversions and off-pump patients, testing for the significance of factors that might be predictive of converting the patients. A subsequent analysis was carried out on the conversions to test for operative mortality.

	Results

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The overall conversion rate was 3.71% but the rate varied between groups. Surgeons with a high prior volume of OPCAB cases had a rate of 1.85%, which was statistically lower than the rate for low-volume surgeons (7.13%, p < 0.001) or that recorded for moderate-volume surgeons (4.3%, p = 0.02; Table 1).

Conversion urgency was a significant factor in patient death. Patients converted electively had a mortality rate of 6.1% (2 of 33) whereas it increased to 32.1% (9 of 28) in those undergoing urgent-emergent conversion (p = 0.02).

Large differences in mortality rates were observed comparing the group converted early 3.1% (1 of 32) to those converted late 34.5% (10 of 29), a statistically significant difference with p = 0.002.

In Table 2 we have presented the mortality rate broken into the four patient conversion classifications. Among elective conversions the mortality rate increases from 4.2% for early conversion to 11.1% for late conversion (p = not significant); but among patients requiring urgent-emergent conversion, the rate jumps from 0% for early conversions to 45% for late conversions (p = 0.03).

View larger version (19K): [in this window] [in a new window]   Fig 1. Effect of conversion urgency on mortality compared with on-pump coronary artery bypass (ONCAB). (ns = not significant.)

Table 3 is a breakdown of the mortality data according to the reason for conversion. An increased fraction of deaths occurred among the cases in the electrical disturbance and hemodynamic instability groups.

	Comment

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Several other studies have addressed the incidence of mortality among converted patients, usually comparing the converted patients with patients who were not converted [5–9]. We sought to determine whether patients started off-pump and converted to on-pump fared less well than if their procedure had been initiated as on- pump. For this reason we compared our converted patients with a computer-derived comparable cohort of patients whose procedure was initiated as ONCAB and who had not undergone an initial aborted OPCAB attempt. Our data showed that the mortality rate in the converted group was six times higher than in the comparable group who had their procedure initiated as ONCAB. Similar to Soltoski and associates [9], we found that surgeons with less prior off pump experience were much more likely to convert than were surgeons with more experience (4.4 times more likely for surgeons with minimal experience and 2.4 times more likely for surgeons with moderate experience). However once converted the mortality rate was the same for all surgeons: a finding also made by Soltoski and colleagues. A possible explanation is that once a patient is converted to ONCAB the surgeon’s prior OPCAB experience no longer comes into play, although it may affect the timing of the conversions.

Compared with the ONCAB group we did find an increased risk of selected major complications especially among the urgent-emergently converted patients. Not surprisingly the literature indicates that patients converted from off-pump to on-pump had a higher morbidity rate in addition to a higher mortality rate [4, 6, 9]. Each of these studies found a higher incidence of stroke. Although we did not find an increased stroke rate among our converted patients we did find an increase in overall vascular complications as well as cardiac arrest, multisystem organ failure, and coma lasting longer than 24 hours. In the Soltoski study [9] the most frequent complication was perioperative myocardial infarction. We also found an increase in perioperative myocardial infarction but it only achieved significance (p = 0.02) among patients urgently converted. Although the overall rate of complications was not different between the groups, that is probably because the complication rate appears high in each group when counting all possible major and minor complications.

Knowing that patients who are converted have higher morbidity and mortality rates it would be advantageous to be able to predict which patients are at high risk for conversion. We found that surgeons early in their OPCAB experience are more likely to convert—a finding also reported by Soltolski and associates [9]. We also found that the presence of congestive heart failure was predictive of the need to convert. This finding was also reported by Vassiliades and colleagues [1]. Not previously reported is our finding that patients in our practice undergoing reoperative surgery are more likely to be converted. More important is that we demonstrated that patients who were converted late and urgently fared significantly less well than did patients who were converted early—patients converted early did not have a higher mortality rate than patients initiated as ONCAB.

Potential limitations of this study include the combining of data from many surgeons with different experience levels and using varied and individualized revascularization techniques. However we believe that this combination reflects the more general "real world" experience of all cardiac surgeons and thus our findings are not unique to a small, specialized group. Another possible weakness is that this study did not account for surgeons who may have accelerated their use of off-pump techniques during the study interval and changed from having a low volume of experience to being highly experienced. Indeed that was true of several surgeons but we would argue that we captured their learning curve during the study interval. Finally there may be some nonobjective qualitative factors that go into a surgeon’s decision to convert that we were unable to capture and quantify.

Based on a retrospective review of our experience we conclude that surgeons should have a low threshold to electively convert to ONCAB early in the procedure (before any grafts have been initiated) if there are any early indicators of electrical or hemodynamic instability. That would be especially true for surgeons early in their OPCAB experience or when significant risk factors of conversion exist including congestive heart failure and reoperative surgery.

	Discussion

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DR CONSTANTINE MAVROUDIS (Chicago, IL): Obviously some of these off-pump bypass grafts are performed to obtuse marginal coronary arteries with difficult exposure, retracting the heart, and so on. Did your analysis include patients who had a particularly difficult circumflex coronary anatomy and the need for retraction of the heart in order to perform the bypass? Do these patients become unstable because of that?

DR EDGERTON: We did try to control for that and analyzed our patient population to see if patients who had circumflex grafts being done had a higher incidence of conversion. We were not able to find that statistically they did, and what we did find is that there were very few patients who were not having circumflex grafting done in the study.

DR BRYAN F. MEYERS (St. Louis, MO): I enjoyed your presentation and I particularly agree with your third conclusion. I am a thoracic surgeon with experience in lung transplant, and we have a similar problem analyzing the difference in outcomes observed in patients who are forced to go on cardiopulmonary bypass during the conduct of a lung transplant. The magnitude of the negative effect of going on-pump is a difficult problem to sort out because there is bias toward a bad outcome in such patients even before you actually go on-pump. The difficulty I have with your methods in this paper is the vagueness of your description of the methods of the computer matching. I would like to hear more details on how you picked your comparison group. I would suggest, and you may have done this, that the group from Cleveland Clinic led by Dr Blackstone has written a lot about propensity analysis, a tool that accommodates all the different covariates that factor into the decision between conversion and non-conversion in this case. I also suggest that your second conclusion, the lack of a difference in mortality, could easily be a Type II error. Your numbers are small, so you can only say that you haven’t shown higher mortality in elective conversion but I don’t feel you can conclude that there isn’t one.

DR EDGERTON: Computer matching was done by comparing initially the converted patients to the on-pump group and looking for differences. We then selected those five factors that were different between the groups and used those as the factors upon which to match and drew a three-to-one match so that we had 183 computer-matched controls. We then took those two groups and analyzed 23 dichotomous variables and three continuous variables, and confirmed that at least as far as preoperative risk factors were concerned there were no differences between those computer-matched groups. And that is how the computer-matched group was derived.

We are familiar with propensity matching and spoke to several statistician groups and attempted to see if that was an appropriate study for propensity matching and deemed, after considerable consultation, that it was not.

DR REZA S. KHALAFI (Arlington, TX): One of the questions I had was did this have anything to do with the length of time for the perfusionist to get the pump ready, because some of the surgeons do not have perfusionists in the room or do not have the pump ready. Would that have anything to do with your mortality?

DR EDGERTON. No, I don’t believe that the ready availability of perfusionists had anything to do with the mortality. Our perfusionists are in the room, the pump is in the room. In fact our perfusionists are scrubbed in during the procedure handling the misted blower on the off-pump procedures.

We can tell you that as far as mortality is concerned, if we look at mortality—and I didn’t show this slide because of the low case volumes and it was underpowered to draw any statistical conclusion—but the mortality was pretty much split between the experienced groups of the surgeons and there were no statistically significant differences among these groups. And we can see that when we look at surgeon experience and conversion of timing, these were pretty evenly split across the range also.

DR JOHN M. KRATZ (Charleston, SC). I enjoyed your paper. It does open up lots of questions. One thing I am thinking is that this is really a team effort more so than ever between the surgeon and the anesthesiologist, and I wonder if you analyzed for anesthesiologist experience in your study?

DR EDGERTON. An excellent question, thank you for that, Dr Kratz, and we did. Early on we looked at anesthesiologist off-pump experience and tried to correlate it, and we had two difficulties in doing that. We chose our groups for the surgeon experience based on CUSUM analysis that has been done in other studies, and in general the learning curve appears to plateau initially at 25 cases. In our STS database we do not capture anesthesiologist experience. So with 22 surgeons using a variety of anesthesiologists, it was difficult to capture all of their previous off-pump experience.

We did try with a small group that we know well and were able to capture their off-pump experience and we could not draw any conclusions based on the anesthesiologist’s prior off-pump experience. But I agree this is a very important piece of the equation.

	References

Top Abstract Introduction Material and methods Results Comment Discussion References

 

1. Vassiliades T.A., Nielsen J.L., Lonquist J.L. Hemodynamic collapse during off pump coronary artery bypass grafting. Ann Thorac Surg 2002;73:1874-1879.[Abstract/Free Full Text]
2. Novick R.J., Fox S.A., Stitts L.W., et al. Cumulative sum failure analysis of a policy change from on pump to off pump coronary artery bypass grafting. Ann Thorac Surg 2001;72(Suppl):S1016-1021.[Abstract/Free Full Text]
3. Califiore A.M., Mauro M.D., Contini M., et al. Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease: impact of the strategy on early outcome. Ann Thorac Surg 2001;72:456-463.[Abstract/Free Full Text]
4. Califiore A.M., Mauro M.D., Teodori G., et al. Impact of aortic manipulation on incidence of cerebrovascular accidents after surgical myocardial revascularization. Ann Thorac Surg 2002;73:1387-1393.[Abstract/Free Full Text]
5. Sinclair M.C., Wilsker G.A., Morris D.L., Mohan R., Hollenbeak C.S. Coronary artery bypass: the increasing role of off pump surgery in a large community hospital. Heart Surg Forum 2002;5(Suppl 1):130-144.
6. Iaco A.L., Contini M., Teodori G., et al. Off or on bypass: what is the safety threshold?. Ann Thorac Surg 1999;58:1486-1489.
7. Anyanwu A.C., Al-Ruzzeh S.A., George S.J., Patel R., Yacoub M.H., Amrani M. Conversion to off pump coronary bypass without increased morbidity or change in practice. Ann Thorac Surg 2002;73:798-802.[Abstract/Free Full Text]
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9. Soltoski P., Salerno T., Levinsky L., et al. Conversion to cardiopulmonary bypass in off pump coronary artery bypass grafting: its effect on outcome. J Card Surg 1998;13:328-334.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): James R. Edgerton Todd M. Dewey Mitchell J. Magee Syma L. Prince Michael J. Mack Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Edgerton, J. R. Articles by Mack, M. J. Search for Related Content PubMed PubMed Citation Articles by Edgerton, J. R. Articles by Mack, M. J. Related Collections Minimally invasive surgery