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Analysis Of 30-day Outcomes Of Off- And On-pump Coronary Artery Bypass Grafting - A Propensity Matched Study
Lokeswara R. Sajja1, Gopichand Mannam1, Venkata Ramachandra R. Pusapati1, Ramesh Gudapati1, Raghava R. Penumatsa2, Jyothsna Guttikonda1, Nadamuni N. Adusumalli3.
1Star Hospitals, Hyderabad, India, 2Care Hospital, Hyderabad, India, 3National Institute of Nutrition, Hyderabad, India.

OBJECTIVE: The relative benefits and risks of performing coronary artery bypass grafting (CABG) with the aid of cardiopulmonary bypass (on-pump CABG) and without aid of cardiopulmonary bypass (OPCAB) continue to be contentious issue in coronary surgery. The objective of study is to compare 30-day outcomes (primary and secondary) for on-pump CABG versus OPCAB procedures and subgroup analyses in patients with diabetes, left ventricular (LV) dysfunction and chronic kidney disease (CKD) in a propensity matched population.
METHODS: A retrospective study was conducted on 30-day outcomes of CABG in a cohort of 11,697 consecutive patients operated by a team of surgeons during a period of 20 years (January 1997 through July 2016). Among these, 6,572 patients underwent OPCAB and 5,725 patients underwent on-pump CABG. Among these 4,433 pairs were matched by propensity score. Subgroup analysis was performed in 1445 pairs of diabetics , 898 pairs with CKD and 179 pairs of patients with LV dysfunction (EF<40% ) to analyze the clinical outcomes of both procedures. Preoperative characteristics and postoperative outcomes were compared using Chi square test.
RESULTS: 30-day mortality was higher in on-pump group (1.15% vs 0.41% p<0.0001). Higher incidence of cerebro vascular accident in OPCAB (p=0.019). There was no significant difference in myocardial infarction (MI) (p=0.57)) and acute kidney injury requiring renal replacement therapy (RRT) (p= 0.37). The number of grafts per patient were less in OPCAB (p=<0.001). There was no difference in incidence of atrial fibrillation (p=0.38) and deep sternal wound infection (DSWI) (p=0.67). In subgroup analysis, diabetics undergoing OPCAB required inotropic usage more frequently (p=<0.0001) and re-exploration (p=0.035) and DSWI (p=0.01) more in on-pump group. In patients with preoperative CKD, there was a higher incidence of mortality (p=0.05), postoperative MI (p=<0.0001), postoperative AKI requiring RRT (p=0.04) and usage of intra-aortic balloon pump (p=0.05). No difference in outcomes between the groups in patients with LV dysfunction.
CONCLUSIONS: On-pump CABG was associated with higher incidence of 30-day mortality and OPCAB with higher postoperative CVA. The number of grafts was fewer in OPCAB. In subgroup analysis, on -pump group showed higher incidence of DSWI in diabetics and more adverse events in CKD.

Analysis of 30-day outcomes of off-pump and on-pump CABG in propensity score matched population
VariableYes
NO
Off-pump CABG (n=4433)On -pump CABG (n=4433)P value
MortalityYes
No
18 (0.41)
4415 (99.59)
51 (1.15)
4382(98.85)
<0.0001
Post operative MIYes
No
160(3.61)
4273(96.39)
170(3.83)
4263(96.17)
0.57
Postoperative CVAYes
No
47(1.06)
4386( 98.94)
27(0.61)
4406(99.39)
0.01
Post operative AKI requiring renal replacement therapyYes
No
37(0.83)
4396(99.17)
45(1.02)
4388(98.98)
0.37
IABP usageYes
No
58(1.31)
4375(98.69)
71(1.60)
4362(98.40)
0.24
Number of grafts3.470.833.510.78<0.0001
Postoperative AFYes
No
289(6.52)
4144(93.48)
269(6.07)
4164(93.93)
0.38
Post operative AKIYes
No
340(7.67)
4093(92.33)
308(6.95)
4125(93.05)
0.19
Deep sternal wound infectionYes
No
44(0.99)
4389(99.01)
48(1.08)
4385 (98.92)
0.67


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Endorsed by:
The Society of Thoracic Surgeons


Co-sponsored by:
Association of Physician Assistants in Cardiovascular Surgery (APACVS) The International Society for Minimally Invasive Cardiothoracic Surgery Japanese Association for Coronary Artery Surgery
Brazilian Society of Cardiovascular Surgery Fu-Wai Hospital of Beijing Indian Association of Cardiovascular-Thoracic Surgeons
Society for Cardiothoracic Surgery in Great Britain & Ireland