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Ann Thorac Surg 2001;72:776-781
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Influence of diabetes on mortality and morbidity: off-pump coronary artery bypass grafting versus coronary artery bypass grafting with cardiopulmonary bypass

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

Address reprints requests to Dr Magee, 7777 Forest Lane, Suite A323, Dallas, TX 75230
e-mail: mmagee{at}csant.com

Presented at the Forty-seventh Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 9–11, 2000.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
Background. Myocardial revascularization in diabetic patients is challenging with no established optimum treatment strategy. We reviewed our coronary artery bypass grafting experience to determine the impact of eliminating cardiopulmonary bypass on outcomes in diabetic patients relative to nondiabetic patients.

Methods. From January 1995 through December 1999, 9,965 patients, of whom 2,891 (29%) had diabetes, underwent isolated coronary artery bypass grafting. Diabetic and nondiabetic patients were further divided into groups on the basis of cardiopulmonary bypass use. Twelve percent (346 of 2,891) of diabetic patients and 12% (829 of 7,074) of nondiabetic patients underwent coronary artery bypass grafting without cardiopulmonary bypass; the remainder had coronary artery bypass grafting with cardiopulmonary bypass. Nineteen preoperative variables were compared among treatment groups by univariate analysis.

Results. Patients undergoing coronary artery bypass grafting without cardiopulmonary bypass compared with those having coronary artery bypass grafting with cardiopulmonary bypass had higher mean predicted mortalities (diabetic, 3.96% versus 3.72%, p = 0.83; nondiabetic, 3.03% versus 2.86%, p = 0.79). In nondiabetic patients, coronary artery bypass grafting without cardiopulmonary bypass provides an actual and risk-adjusted survival advantage over coronary artery bypass grafting with cardiopulmonary bypass (1.81% versus 3.44%, p = 0.0127; risk-adjusted mortality, 1.79% versus 3.61%, p = 0.007). This survival benefit of coronary artery bypass grafting without cardiopulmonary bypass was not seen in diabetic patients (2.89% versus 3.69%, p = 0.452; risk-adjusted mortality, 2.19% versus 2.98%, p = 0.42). Diabetic patients undergoing coronary artery bypass grafting without cardiopulmonary bypass had fewer complications, including decreased blood product use (34.39% versus 58.4%, p = 0.001), and reduced incidence of prolonged ventilation (6.94% versus 12.10%, p = 0.005), atrial fibrillation (15.90% versus 23.26%, p = 0.002), and renal failure requiring dialysis (0.87% versus 2.75%, p = 0.036).

Conclusions. The survival advantage in nondiabetic patients treated with coronary artery bypass grafting without cardiopulmonary bypass is not apparent in diabetic patients. Coronary artery bypass grafting without cardiopulmonary bypass in diabetic patients is nevertheless associated with a significant reduction in morbidity.

	Introduction

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Diabetes mellitus is an established risk factor for the development of coronary artery disease. Coronary artery disease is not only more prevalent in diabetic patients compared with nondiabetic patients, but also tends to be more extensive, involving multiple vessels, and rapidly progressive [1–6]. Accordingly, diabetic patients represent a large proportion of patients requiring myocardial revascularization. Unfortunately, diabetes is also a significant risk factor for adverse early and late outcomes after percutaneous and surgical revascularization [7–10]. Diabetes is associated with higher restenosis rates after angioplasty and stent placement [11–13]. Although diabetic patients typically do worse with any management approach than nondiabetic patients, studies comparing treatment options in diabetic patients have been conflicting. The Bypass Angioplasty Revascularization Investigation trial reported a survival benefit in diabetic patients treated with coronary artery bypass grafting (CABG) compared with percutaneous transluminal coronary angioplasty, whereas other studies failed to show a significant difference [6, 14–16]. The reported effects of eliminating cardiopulmonary bypass (CPB) on morbidity and mortality in patients undergoing CABG are mostly favorable, although some have been conflicting or inconclusive [17–20]. The greatest benefit derived from eliminating CPB in CABG most likely exists in a selected risk subset of patients [21–24]. With diabetic patients representing a particularly challenging group with no optimum treatment strategy established, the opportunity to improve outcomes with a contemporary therapeutic approach is evident. Therefore, we reviewed our CABG experience to determine the impact of CPB on outcomes in diabetic patients relative to nondiabetic patients.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
Patients
A retrospective review of prospective data collected in our customized Society of Thoracic Surgeons (STS) computerized cardiac surgery group practice database identified 9,965 patients who underwent isolated CABG from January 1995 through December 1999, of whom 2,891 (29%) were diabetic and 7,074 (73%) were nondiabetic. Twelve percent (346 of 2,891) of diabetic patients and 12% (829 of 7,074) of nondiabetic patients underwent CABG without CPB (off-pump CABG; OPCABG). The remaining 88% in each group had conventional CABG using CPB (CABG-CPB). Among the total diabetic population, 35.51% were being treated with insulin. Insulin-requiring diabetic patients constituted 39.83% of the diabetic OPCABG group and 34.93% of the diabetic CABG-CPB group.

Procedure selection was at the discretion of the operating surgeon and varied accordingly. No specified selection criteria were used in determining which CABG procedure, with or without CPB, individual patients would receive, although medical comorbidities considered to increase the risks of CPB were generally used to select patients for OPCABG. The CABG-CPB and OPCABG patients were contemporaneous and not sequential cohorts.

Patient data were collected and analyzed according to the STS National Cardiac Surgery Database guidelines and definitions (http://www.ctsnet.org/doc/4314). Preoperative patient data were obtained relative to cerebrovascular disease, chronic obstructive pulmonary disease, cerebrovascular accident, hypertension, morbid obesity, peripheral vascular disease, renal failure, renal failure on dialysis, sex, current smoking, unstable angina, recent myocardial infarction (MI), arrhythmias, congestive heart failure, left main coronary artery disease, New York Heart Association class IV classification, age, and left ventricular ejection fraction. Postoperative data collected and compared between groups included length of hospital stay from operation to discharge, operative mortality, blood product use, reoperation for bleeding, MI, adult respiratory distress syndrome, prolonged ventilation, renal failure, renal failure requiring dialysis, transient and permanent neurologic dysfunction, infection, and atrial fibrillation.

Statistical analysis
Patients were grouped and compared according to preoperative disease status, diabetic versus nondiabetic, and according to surgical treatment, OPCABG versus CABG-CPB. Preoperative patient characteristics, intraoperative course, and operative outcomes were collected and compared among groups using either the ² test or two-tailed Student’s t test as appropriate. Probability values less than or equal to 0.05 were considered significant.

The predicted risk of operative mortality was calculated for each patient using the STS algorithm, and mean predicted risk scores were calculated for each group for comparison.

	Results

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Preoperative characteristics that were collected and compared among treatment groups and found to be statistically significant for either diabetic patients or nondiabetic patients are shown in Table 1. The diabetic OPCAB patients as a group were older, more often female, and more likely to have renal failure and renal failure requiring dialysis when compared with diabetic CABG-CPB patients. Likewise, the nondiabetic OPCAB patients were older, more often female, and more likely to have renal failure and renal failure requiring dialysis when compared with nondiabetic CABG-CPB patients. In contrast, obesity, left main coronary artery disease, recent MI, and unstable angina were more prevalent in the diabetic CABG-CPB group compared with their OPCAB cohort. Likewise, obesity, left main coronary artery disease, recent MI, and unstable angina as well as hypertension, lung disease, and arrhythmias were more prevalent in the nondiabetic CABG-CPB group compared with their OPCAB cohort. Additional risk factors examined and found to be similar among treatment groups are shown in Table 2. Most notable were the similarities in ventricular function, heart failure, and cerebrovascular disease.

The unadjusted and risk-adjusted mean operative mortality was less in the OPCABG group compared with the CABG-CPB group. This survival benefit of OPCABG was highly significant in the nondiabetic patients (Table 3).

	Comment

Top Abstract Introduction Patients and methods Results Comment Discussion References

During the period of study, diabetic patients as a group selected for OPCABG were older, more often female, and with renal impairment in accordance with higher risk status, but less often obese and less likely to have left main coronary artery disease, recent MI, or unstable angina. These differences in risk factors trended toward a higher overall mean predicted risk for the OPCABG group, although statistically the groups were similar. In nondiabetic patients, identical disparities noted above existed between therapeutic groups, with the addition of less hypertension, chronic obstructive pulmonary disease, and preoperative arrhythmias in the OPCABG group. Again these differences yielded a higher mean predicted risk score in the OPCABG group although the groups were statistically identical.

This study did not exclude single-vessel disease. Both diabetic and nondiabetic OPCABG groups had a lower mean number of grafts per patient than their CABG-CPB cohorts (diabetic, 2.3 versus 3.5; nondiabetic, 2.2 versus 3.4, respectively). This is largely a reflection of a much higher proportion of single CABG procedures in the OPCABG groups (diabetic, 0.347 versus 0.014; nondiabetic, 0.391 versus 0.028). The similarity in predicted risk scores among treatment groups, trending toward a higher risk in the OPCABG groups, argues against this having a favorable impact on OPCABG outcomes. Fewer mean grafts per patient may reflect an OPCABG selection bias for patients who require fewer grafts. Alternatively, surgeons performing OPCABG may have a surgeon-specific propensity to perform fewer grafts independent of the selected approach or may be influenced by procedure-related technical challenges to perform fewer grafts. The limitations of this database do not allow for precise anatomic characterization of preoperative coronary artery disease and the corresponding grafts required to achieve complete revascularization. Therefore, no conclusions can be drawn from this data as to the relative completeness of revascularization among groups.

Nondiabetic patients clearly derive a significant benefit from an OPCABG approach reflected in decreased unadjusted and risk-adjusted mortality as well as decreased morbidity, including decreased blood product use, decreased incidence of adult respiratory distress syndrome and prolonged ventilation, and decreased postoperative hospital length of stay.

It is unclear why diabetic patients do not derive the same benefits from OPCABG as nondiabetic patients. There may be factors with higher prevalence in the diabetic population, such as diffuse small vessel coronary artery disease, renal insufficiency, peripheral vascular disease, or other confounding risk variables that affect these findings. The diabetic treatment groups are smaller than the nondiabetic groups and may simply not be large enough to reflect a survival benefit.

Narrowing the analysis to include only treated diabetic patients, either with oral medication or insulin, or further narrowing the comparison to include only insulin-treated diabetic patients resulted in conclusions similar to those drawn from the entire diabetic population. Likewise, adjusting for differences in risk between diabetic treatment groups by comparing mean risk-adjusted mortalities did not alter the conclusion. Diabetic OPCABG patients as a group, compared with CABG-CPB, do benefit from less blood product use, less incidence of prolonged ventilation, less incidence of postoperative renal failure requiring dialysis, and less postoperative atrial fibrillation. This was reflected in a trend toward a decreased postoperative length of hospital stay.

In conclusion, OPCABG provides a significant survival advantage in nondiabetic patients. Off-pump CABG in diabetic patients and nondiabetic patients is associated with a significant reduction in morbidity. Additional studies including larger numbers of diabetic patients or prospective randomization are needed to confirm these conclusions.

	Discussion

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DR JOSEPH C. CLEVELAND (Denver, CO): Doctor Magee, that was beautifully presented and a nice set of data. It is always even nicer when it correlates with our data. We, similar to you, found that there were more diabetics in our on-pump group that were done, and the risk factors that you displayed are almost similar to those we showed earlier this week. In addition, we have gone through our VA database with Dr Grover and have looked at the risk factors that are prevalent in the diabetic population. There are more women, more patients with renal failure requiring dialysis, et cetera, and these subsets have more comorbidities.

I only have one question for you, and that is whether you subgrouped your diabetics into those patients on oral agents versus insulin agents? Historically there are some data that suggest that patients on oral agents do less well with myocardial type events, both with myocardial infarction and with operation. Our laboratory published data some years ago at the basic science level describing differences in the way human cardiac muscle behaves in oral-dependent diabetics versus insulin-dependent diabetics. We subsequently learned that the oral agents worked by inhibiting the potassium ATP channel, which is thought to be an endogenous cardiac protector. If there is a difference between the group that was taking oral agents versus insulin agents, it could be the oral group that could be responsible for your lack of benefit. Otherwise I think this is a beautifully presented talk and very relevant, solid data.

DR MAGEE: Thank you for your comments. We did in fact look at the insulin dependence of the patients, and you can see, as it is broken down in this slide, that the total number of insulin-dependent patients was 35% of the total population. That represented about 40% of the off-pump group and about 35% of the on-pump group, which was not statistically significant. In looking at morbidity and mortality differences, it did not differ at all from the total population.

	References

Top Abstract Introduction Patients and methods Results Comment Discussion References

 

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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): Mitchell J. Magee Todd M. Dewey Tea Acuff James R. Edgerton Michael J. Mack Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Magee, M. J. Articles by Mack, M. J. Search for Related Content PubMed PubMed Citation Articles by Magee, M. J. Articles by Mack, M. J. Related Collections Coronary disease Related Article