Abstract
Patients aged ≥80 years are at high risk of adverse events after coronary artery bypass grafting. This study was performed to evaluate whether off-pump coronary artery bypass surgery (OPCAB) is superior to conventional surgery (CCAB) in these high-risk patients. The outcome of 185 patients aged ≥80 years who underwent OPCAB or CCAB at our institution was reviewed and a meta-analysis on this issue was performed. Similar immediate postoperative results were observed after OPCAB and CCAB at our institution, despite significantly different operative risk (mean logistic EuroSCORE, OPCAB 20.3% vs CCAB 13.4%, P = 0.003). Among 56 propensity score matched pairs a trend toward lower postoperative stroke (0%, 95% CI 0–0 vs 3.6%, 95% CI 0–10.0, P = 0.50) was observed after OPCAB. No significant differences were observed in the other outcome end points. Five-year survival was 81.0% after OPCAB and 78.1% after CCAB (P = 0.239). Pooled analysis of eight studies including 3416 patients showed a significantly higher risk of postoperative stroke after CCAB (pooled rates: 4.2%, 95% confidence interval (95% CI) 2.4–7.1 vs 1.5%, 95% CI 0.9–2.5, risk ratio (RR) 2.15, 95% CI 1.17–3.96, P = 0.01). A trend toward higher immediate postoperative mortality was observed after CCAB (15 studies including 4409 patients, pooled rates: 6.5%, 95% CI 5.2–8.0 vs 5.6%, 95% CI 4.2–7.4, RR 1.29, 95% CI 0.86–1.93, P = 0.21). Generic inverse variance analysis showed similar intermediate survival after CCAB and OPCAB (RR 1.31, 95% CI 0.85–2.01, P = 0.22). At 2 years, survival was 82.8% (95% CI 76.4–89.2) after CCAB and 88.3% (95% CI 82.9–93.7) after OPCAB. Current results indicate that OPCAB compared with CCAB in patients aged ≥80 years is associated with significantly lower postoperative stroke and with a trend toward better early survival. However, suboptimal quality of the available studies, particularly the lack of comparability of the study groups, prevents conclusive results on this controversial issue.
Similar content being viewed by others
References
Shirasawa K, Hwang MW, Sasaki Y, Takeda S, Inenaga-Kitaura K, Kitaura Y, Kawai C (2011) Survival and changes in physical ability after coronary revascularization for octa-nonagenerian patients with acute coronary syndrome. Heart Vessels 26:385–391
Nissinen J, Wistbacka JO, Loponen P, Korpilahti K, Teittinen K, Virkkilä M, Tarkka M, Biancari F (2010) Coronary artery bypass surgery in octogenarians: long-term outcome can be better than expected. Ann Thorac Surg 89:1119–1124
Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R (1999) European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 16:9–13
Biancari F, Yli-Pyky S (2011) Meta-analysis on the use of the Heartstring anastomotic device to prevent stroke in patients undergoing off-pump coronary artery bypass grafting. Eur J Cardiothorac Surg 40:1236–1240
Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB (2000) Meta-analysis of observational studies in epidemiology. A proposal for reporting. JAMA 283:2008–2012
Austin PC (2011) Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies. Pharm Stat 10:150–161
Higgins JPT, Altman DG, on behalf of the Cochrane Statistical Methods Group and the Cochrane Bias Methods Group (Eds) (2008) Chapter 8: assessing risk of bias in included studies. In: Higgins JPT, Green S (eds) Cochrane handbook for systematic reviews of interventions version 5.0.0 (updated September 2008). The Cochrane Collaboration
Wallace BC, Schmid CH, Lau J, Trikalinos TA (2009) Meta-analyst: software for meta-analysis of binary, continuous and diagnostic data. BMC Med Res Methodol 9:80
Tierney JF, Stewart LA, Ghersi D, Burdett S, Sydes MR (2007) Practical methods for incorporating summary time-to-event data into meta-analysis. Trials 8:16
Yokoyama T, Baumgartner FJ, Gheissari A, Capouya ER, Panagiotides GP, Declusin RJ (2000) Off-pump versus on-pump coronary bypass in high-risk subgroups. Ann Thorac Surg 70:1546–1550
Cheng W, Denton TA, Fontana GP, Raissi S, Blanche C, Kass RM, Magliato KE, Mirocha J, Trento A (2002) Off-pump coronary surgery: effect on early mortality and stroke. J Thorac Cardiovasc Surg 124:313–320
Beauford RB, Goldstein DJ, Sardari FF, Karanam R, Luk B, Prendergast TW, Burns PG, Garland P, Chen C, Patafio O, Saunders CR (2003) Multivessel off-pump revascularization in octogenarians: early and midterm outcomes. Ann Thorac Surg 76:12–17
Saleh HZ, Shaw M, Fabri BM, Chalmers JA (2011) Does avoidance of cardiopulmonary bypass confer any benefits in octogenarians undergoing coronary surgery? Interact Cardiovasc Thorac Surg 12:435–439
Nagpal AD, Bhatnagar G, Cutrara CA, Ahmed SM, McKenzie N, Quantz M, Kiaii B, Menkis A, Fox S, Stitt L, Novick RJ (2006) Early outcomes of coronary artery bypass with and without cardiopulmonary bypass in octogenarians. Can J Cardiol 22:849–853
Hoff SJ, Ball SK, Coltharp WH, Glassford DM Jr, Lea JW 4th, Petracek MR (2002) Coronary artery bypass in patients 80 years and over: is off-pump the operation of choice? Ann Thorac Surg 74:S1340–S1343
Demaria RG, Carrier M, Fortier S, Martineau R, Fortier A, Cartier R, Pellerin M, Hébert Y, Bouchard D, Pagé P, Perrault LP (2002) Reduced mortality and strokes with off-pump coronary artery bypass grafting surgery in octogenarians. Circulation 106:I5–I10
Lin CY, Hong GJ, Lee KC, Loh SH, Tsai CS (2003) Off-pump technique in coronary artery bypass grafting in elderly patients. ANZ J Surg 73:473–476
Tugtekin S, Kappert U, Alexiou K, Wilbring M, Nagpal AD, Matschke K (2007) Coronary artery bypass grafting in octogenarians—outcome with and without extracorporeal circulation. Thorac Cardiovasc Surg 55:407–411
Shimokawa T, Minato N, Yamada N, Takeda Y, Hisamatsu Y, Itoh M (2003) Off-pump coronary artery bypass grafting in octogenarians. Jpn J Thorac Cardiovasc Surg 51:86–90
Serrão M, Graça F, Rodrigues R, Abecasis M, Bruges L, Calquinha J, Neves J, Bebocho MJ, Ferreira M, Queiroz e Melo J (2010) Coronary artery bypass grafting in octogenarians: long-term results. Rev Port Cardiol 29:989–998
D’Alfonso A, Mariani MA, Amerini A, Codecasa R, Bellieni L, Proietti A, Grandjean JG (2004) Off-pump coronary surgery improves in-hospital and early outcomes in octogenarians. Ital Heart J 5:197–204
LaPar DJ, Bhamidipati CM, Reece TB, Cleveland JC, Kron IL, Ailawadi G (2011) Is off-pump coronary artery bypass grafting superior to conventional bypass in octogenarians? J Thorac Cardiovasc Surg 141:81–90
Ricci M, Karamanoukian HL, Abraham R, Von Fricken K, D’Ancona G, Choi S, Bergsland J, Salerno TA (2000) Stroke in octogenarians undergoing coronary artery surgery with and without cardiopulmonary bypass. Ann Thorac Surg 69:1471–1475
Hannan EL, Wu C, Smith CR, Higgins RS, Carlson RE, Culliford AT, Gold JP, Jones RH (2007) Off-pump versus on-pump coronary artery bypass graft surgery: differences in short-term outcomes and in long-term mortality and need for subsequent revascularization. Circulation 116:1145–1152
Conflict of interest
This study was not financially supported and the authors do not have any conflicts of interest.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Vasques, F., Rainio, A., Heikkinen, J. et al. Off-pump versus on-pump coronary artery bypass surgery in patients aged 80 years and older: institutional results and meta-analysis. Heart Vessels 28, 46–56 (2013). https://doi.org/10.1007/s00380-011-0200-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00380-011-0200-y