Omar M. Lattouf, Vinod H. Thourani, Patrick D. Kilgo, Robert A. Guyton, John D. Puskas.
Emory University, Atlanta, GA, USA.
OBJECTIVE: Left main coronary artery disease (LMD) in patients undergoing coronary revascularization is known to pose increased risk for peri-operative complications. This study compares off-pump (OPCAB) versus on-pump CABG (ONCAB) strategies with respect to in-hospital death, stroke, myocardial infarction (MI) and major adverse cardiac events (MACE) in coronary revascularization patients with and without LM stenosis.
METHODS: Among 13,108 consecutive isolated CABG patients treated from 1997-2007 in an academic center, 2891 patients (22.1%) were pre-operatively found to have LMD stenosis of ≥50% in a retrospective interrogation of the institutional database. Of 5917 OPCAB patients, 1276 (21.6%) had LMD while among ONCAB patients 1615 of 7191 (22.5%) had LMD. Surgery type, LMD, and their interaction were examined for their impact on operative mortality, stroke, MI and MACE - the composite of death, stroke or myocardial infarction - via multiple logistic regression models and adjusted odds ratios (AOR). A propensity score (PS) covariate used 44 preoperative risk factors to balance baseline characteristics between the OPCAB and ONCAB groups.
RESULTS: Retrospective review of this data indicates that utilization of OPCAB for coronary revascularization in patients with LMD disease has gradually increased from an initial low of 1.3% of LMD disease patients in 1997 to a peak of 80.8% in 2007. OPCAB was associated with reduced incidence of stroke (AOR=0.51, p<.001), and MACE (AOR=0.66, p=.002) while LMD was associated with an increased incidence of MACE (AOR=1.24, p=.038). Importantly, no interactions between surgery type and LMD existed, meaning that the two conditions did not combine in any way to modify an outcome.
CONCLUSIONS: LMD patients are more likely to suffer a MACE event than those without LMD. OPCAB is marginally associated with lesser risk of operative mortality and significantly associated with less stroke and overall MACE as compared to ONCAB. This benefit of OPCAB is similar for patients with and without LMD.Outcome OPCAB AOR
(95%CI)p value LMD AOR (95%CI) p value Interaction? Death 0.69 (0.47,1.01) 0.0577 1.32 (0.99,1.75) 0.0551 No p=0.4615 Stroke 0.51 (0.34,0.75) 0.0008 1.16 (0.85,2.43) 0.3507 No p=0.2086 MI 1.59 (0.85,2.96) 0.1452 1.14 (0.70,1.84) 0.6030 No p=0.2635 MACE 0.66 (0.50,0.86) 0.0021 1.24 (1.01,1.52) 0.0380 No p=0.3989
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