5 Years Results of 5 Years Results of Off-Pump VS On-Pump Off-Pump VS On-Pump CABGCABG Prospective Non-randomized Comparative Study

Piya Cherntanomwong*, Panuwat Lertsithichai*, Somchai Viengteerawat**, Suchart Chaiyaroj*.

*Cardiothoracic surgery unit, Department of surgery**Department of AnesthesiologyFaculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok,Thailand.

ObjectivesObjectives

To review experience of off pump and on pump CABG at our institute to compare early and long-term results and to determine the differences of OPCAB and conventional CABG.

Prospective, Non-randomized Study (Approved by Ethic Committee, Protocol ID : 06-51-03)

Baseline characteristics were compared

Primary Endpoint

Secondary Endpoint

Follow up to December 2008

The outcomesThe outcomes

Primary endpoints

•Operative mortality

•Bleeding and Blood transfusion

•Myocardial injury•Post operative AF•Other post

operative complications

Secondary endpoints

• Late death•MI • Stroke•PCI•Redo CABG• Sternal wound

infection

Operative technique for Off Pump CABG

Octopus tissue stabilizer

Starfish heart positioner

(Medtronic Inc., Minneapolis, MN)

The intracoronary shunt

Data Analysis

Continuous data were compared between two independent groups using unpaired t-test or Wilcoxon rank sum test as appropriate, and categorical data were compared between groups using the chi-square test.

The long-term probability of survival was estimated using the Kaplan-Meier method. Cox proportional hazards models were used to test the significance of prognostic factors for long-term survival.

All statistical analyses were performed using Stata version 9 (Stata Corp, College Station, TX, USA). Statistical significance was defined as a two-sided p-value of 0.05 or less.

Base-Line Characteristics of the Base-Line Characteristics of the PatientsPatients

Off pump On pump P-value

Number pateints 170 cases 99 cases 71 cases

Sex male 79 ( 80% ) 55 ( 72% ) 0.16 ( NS )

female 20 ( 20% ) 22 ( 28% ) ( NS )

Age 60.873 + 8.46 60.515 + 11.72 0.83 ( NS )

BW 66.474 + 1.046 66.907 + 1.326 0.54 ( NS )

Previous HT 98 ( 100 % ) 77 ( 99%) ( NS )

Previous DM 32 ( 33% ) 36 ( 46%) 0.08 ( NS )

Previous MI 53 ( 55% ) 23 ( 29%) 0.10 ( NS )

Previous CHF 42 ( 43%) 25 ( 32%) 0.13 ( NS )

Previous COPD 83 ( 85%) 52 ( 67%) 0.06 ( NS )

Previous CVA 6 ( 6% ) 9 ( 11%) 0.21 ( NS )

Previous Renal dysfunction 44 ( 46%) 21 ( 27%) 0.15 ( NS )

Previous Renal failure 0 1 (1.4%) ( NS )

Previous Peripheral vascular disease

0 2 (2.8%) ( NS )

Previous AF 5 ( 5%) 3 ( 7%) 0.32 ( NS )

LVEF 42 + 8.8 43 + 12 0.56 ( NS )

Functional class 3 + 1 2.7 + 0.9 0.06 ( NS )

No. Vessel bypass 3.9 + 1.0 3.6 + 0.8 0.07 ( NS )

EuroSCORE (logistic) 4.2% 2.9% 0.05 ( NS )

Off pump On pump P-value

Record ICD mean

12 hr. median/range

145 cc.

100 ( 0 – 1360 ) cc.

201 cc.

140 ( 0 – 1160 ) cc.

< 0.001

PRC mean

median/range

3. u

2 ( 0 – 6 ) u

4. u

2 ( 1 – 13 ) u

0.006

LPPC mean

median/range

1. u

0 ( 0 – 4 ) u

6. u

0 ( 0 – 8 ) u

0.001

FFP mean

median/range

0.5 u

0 ( 0 – 5 ) u

3. u

( 0 – 10 ) u

0.001

Results of using blood transfusion Results of using blood transfusion and bleedingand bleeding

The results of using blood The results of using blood transfusion transfusion (p < 0.05) (p < 0.05)

Average serum CKMB plotted Average serum CKMB plotted against time after operation for on-against time after operation for on-

pump versus off-pump CABGpump versus off-pump CABG

0

20

40

60

80

100

postop

postop 12

postop 36

postop 60

postop 72

on pump

off pump

Complication Off-pump On-pump P-value

Postoperative AF 10 ( 10% ) 19 ( 24% ) 0.013Postoperative Re-operation 1 (1%) 1 (1.4%) NS

Postoperative MI 0 0 NS

Postoperative CVA 1 (1%) 0 NS

Postoperative Renal Failure 0 2 (2.8%) NS

Postoperative Respiratory Failure

0 2 (2.8%) NS

Postoperative Sternum infection 1 (1%) 1 (1.4%) NS

Postoperative Sepsis 0 0 NS

Mortality 1 (1%) 1 (1.4%) NS

Results of Postoperative Results of Postoperative ComplicationsComplications

Results of 5 years Results of 5 years outcomesoutcomes

On pump (n = 71) Off pump (n = 99) p-value

Follow up time (mo)

Mean (SD) 58.2 (15.6) 53.8 (11.0) 0.032

Median (range) 63.7 (13.4 to 73.8) 55.6 (11.5 to 70.1) < 0.001

Cardiac death 0/71 2/99 (2%) 0.511

Noncardiac death 4/71 (6%) 1/99 (1%) 0.162

All death 4/71 (6%) 3/99 (3%) 0.453

MI event 0/71 2/99 (2%) 0.511

PCI event 1/71 1/99

Redo CABG 0/71 0/99

Stroke event 0/71 0/99

Sternal infection 0/71 0/99

5 Years Survival of 5 Years Survival of Off Pump VS On PumpOff Pump VS On Pump

0.00

0.25

0.50

0.75

1.00

Su

rviv

al P

rob

abil

ity

0 20 40 60 80Time since operation (months)

Kaplan-Meier Estimates: On Pump vs. Off Pump

On Pump

Off Pump 96%

95%

170 164 150 65 13

ConclusionConclusion

Our studies have shown that the “Off Pump” CABG in our patient population is associated with lower incidence of post operative AF, lesser myocardial injury, lesser bleeding and blood transfusion with comparable excellent 5 years survival.Off pump may be more benefit than conventional CABG in the patients who has higher risk and poor reserve.

“Dedicated to our Rama-Off Pump Team”