Does off-pump total arterial revascularization without aortic manipulation influence neurological outcome? A study of 226 consecutive, unselected cases.

BACKGROUND

Off-pump coronary artery bypass (OPCAB) is increasingly reported to have better post-operative outcomes than on-pump coronary artery bypass (ONCAB). Most series report OPCAB in selected cases and therefore the results of such studies are affected by selection bias. We report our series of consecutive, unselected OPCAB cases representing an entire coronary revascularization practice and its effect on neurological outcome.

METHODS

Between January and December 2000, 226 consecutive OPCAB cases were performed. These were compared with 258 consecutive ONCAB cases performed by same surgeons historically. There were no significant differences in major demographic characteristics between the two groups. Postoperative outcomes including operation time, ventilation time, inotrope requirement, focal strokes, peak CKMB, length of hospital stay and mortality formed the basis of this study. All OPCAB patients had a median sternotomy approach. Left and right internal mammary arteries and radial arteries were used in varying combinations using composite and sequential grafting techniques to achieve revascularization and completely avoid aortic manipulation. ONCAB cases were performed employing conventional cardiopulmonary bypass techniques and using the left internal mammary artery and saphenous vein grafts as appropriate.

RESULTS

OPCAB cases had significantly lower peak CKMB levels, operative time, length of hospital stay and number of grafts. There was a significantly lower incidence of permanent focal neurological events in OPCAB patients (0.4%, n = 1) compared to the ONCAB group (3.9%, n = 10, p = 0.012).

CONCLUSION

This study documents the safety of off pump total arterial revascularization without aortic manipulation as the routine technique for coronary bypass surgery. It also demonstrates a significant reduction in the incidence of focal strokes. We conclude that avoidance of both cardiopulmonary bypass and aortic manipulation are important factors in reducing the occurrence of neurological deficits.