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Eur J Cardiothorac Surg 2006;30:126-131
© 2006 Elsevier Science NL

Does off-pump surgery offer benefit in high respiratory risk patients?

A respiratory risk stratified analysis in a propensity-matched cohort

^a Department of Cardiothoracic Surgery, The Cardiothoracic Centre-Liverpool, Thomas Drive, Liverpool L14 3PE, United Kingdom
^b Department of Research and Development, The Cardiothoracic Centre-Liverpool, United Kingdom

Received 24 September 2005; received in revised form 6 March 2006; accepted 17 March 2006.

^_* Corresponding author. Tel.: +44 151 228 1616; fax: +44 151 220 8573. (Email: reddylcs{at}aol.com).

Objective: The role of off-pump surgery in high respiratory risk patients remains unclear. In this study, we aim to evaluate the effect of off-pump surgery on high respiratory risk patients. Methods: To achieve comparative groups, a five digit propensity score matching with 18 pre-operative variables was performed on 4406 consecutive CABG patients operated between January 2000 and September 2003. Respiratory risk stratification was performed with the following variables: (1) FEV₁ < 65% of predicted, (2) patients > 75 years old, (3) history of current smoking, (4) body mass index more than 40 kg/m² and (5) NYHA class IV dyspnoea in combination with current respiratory medication. The presence of two or more variables defined high risk. The primary end point was post-operative ventilation time. We also compared alveolar arterial gradients (A–a gradient) on admission to ITU, 2 and 4 h using Friedman rank time analysis. Results: We matched 1353 off-pump patients with 1353 unique on-pump patients. Respiratory risk stratified selection resulted in 73 off-pump and 55 on-pump high-risk patients. In the off-pump group, four (5.5%) patients had more than two selection criteria, compared to one (1.8%) for on-pump patients (p = 0.29). The off-pump group had more patients with FEV1 < 65% compared to on-pump: 65 (89.0%) versus 40 (72.7%); p = 0.017. The median ventilation time was significantly shorter for off-pump patients (7 h [IQR: 5–14] vs 12 h [IQR: 7–18], p = 0.003). In the off-pump group, three (4.1%) patients had a ventilation time > 48 h compared to eight (14.6%) in the on-pump group, p = 0.037. A–a gradient measurements on admission to ITU were lower in off-pump patients (median: 182.3 [IQR: 126.6–216.2]) compared to on-pump patients (median: 194.7 [IQR 139.7–245.4], p = 0.064). Conclusion: Off-pump surgery offers benefit to high respiratory risk patients by reducing post-operative ventilation time. Off-pump patients also have lower A–a gradients in the early post-operative period but this failed to reach significance.

Key Words: Off pump • CABG • Respiratory risk • Propensity matching • Ventilation • Alveolar arterial gradient

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