Perioperative And Intermediate To Long-Term Outcomes Of Off-pump Coronary Artery Bypass Grafting

Objectives1. To assess in-hospital and short-term(30 day) outcomes of Off-pump coronary artery bypass(OPCAB) in our center, to find predictors of major adverse events, and to evaluate performance of EuroSCORE II and STS risk score in estimating perioperative outcomes of OPCAB.2. To shed lights on the relationship between completeness of revascularization and intermediate to long-term outcomes of OPCAB in patients with triple vessel disease.3. To study intermediate to long-term outcomes of OPCAB in patients aged 70 or older and to evaluate safety and effectiveness of OPCAB for the elderly.Methods1. For analysis, isolated OPCAB cases performed by the same surgeon between April 1999 and December 2015 were consecutively selected. The primary endpoints for in-hospital and early outcomes were Major Adverse Cardiac and Cerebrovascular Events (MACCE, a composite of all-cause death, stroke, myocardial infarction and repeated revascularization). The primary endpoints for in-hospital outcomes were surgical revision for bleeding, new-onset atrial flutter or fibrillation, pulmonary complications, pulmonary embolism/deep vein thrombosis and new-onset renal failure, etc. Multivariate analyses were performed for early outcomes and performance of EuroSCORE II and STS risk score in estimation were evaluated.2. Triple vessel cases were selected and those incompletely revascularized were matched 1:1 to completely revascularized cases by propensity score. The primary endpoints for intermediate to long-term outcomes were MACCE, and outcomes were compared between groups with different completeness of revascularization.3. Cases aged 70 years or older were consecutively selected for analysis of in-hospital, early and intermediate to long-term outcomes. The primary endpoints were set as MACCE and graft failure in evaluating safety and effectiveness.Results1. Mean age was 62.11 ±9.48 years, with 82.57% were male. All OPCAB cases were successfully performed through median sternotomy without conversion to CPB or surgical mortality. The mean number of distal anastomosis was 2.53±0.77. Mortality and MACCE rate were 0.528% and 1.85% in hospital while 0.79% and 2.11% within 30-day postoperatively. Cerebral vascular disease was associated with 30-day mortality (OR =4.775). Cardiac shock, peripheral artery disease and estimated glomerular filtrate rate (eGFR) were associated with 30-day MACCE (OR=0.978). Performance of EuroSCORE II in estimating 30-day mortality was assessed, the area under ROC curve was 0.768[0.742, 0.792], p=0.0003.2. After propensity score matching, demographic and clinical characteristics of complete revascularization(CR) group and incomplete revascularization(IR) group were similar. There were no statistical differences of early outcomes between groups, either. The 1-year, 3-year and 5-year freedom from MACCE rate were 94.6%,90.6% and 82.4% in IR group while 97.4%,91.5% and 84.6% for CR, respectively. The 1-year,3-year and 5-year survival were 99.5%,99.5% and 96.4% for IR while 97.9%,94.4% and 90.6% for CR.3. The mortality and MACCE rate for elderly patients were 0.72%,2.90% in hospital and, 1.81%,3.99% at 30-day. The 1-year,3-year,5-year and 8-year survival were 97.6%,95.9%, 92.8% and 77.3%, respectively. The 1-year,3-year,5-year and 8-year freedom from MACCE were 94.8%,89.6%,84.8% and 64.8%. The 1-year,3-year and 5-year graft patency rate were 98.2%,95.7% and 94.4% for LIMA while 96.5%,90.4% and 87.3% for saphenous vein, respectively.Conclusions1. OPCAB can be performed by high volume surgeon and experienced heart teams with excellent safety and low mortality or morbidity. Cerebral vascular disease was predictor for 30-day mortality while cardiac shock, peripheral artery disease and eGFR were predictors for 30-day MACCE. EuroSCORE Ⅱ has satisfactory performance in predicting early mortality of OPCAB cases in our center, but still tends to overrate.2. The completeness of revascularization does not impact surgical safety and early outcomes. The intermediate to long-term freedom from MACCE are similar between two groups.3. The elderly have higher risk of perioperative morbidity, but good intermediate to long-term clinical and angiographical outcomes could be yielded in experienced cardiac centers.