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Eur J Cardiothorac Surg 2002;21:193-198
© 2002 Elsevier Science NL

Off pump coronary artery bypass grafting in EuroSCORE high and low risk patients

M. Riha, M. Danzmayr, G. Nagele, L. Mueller, D. Hoefer, H. Ott, G. Laufer, J. Bonatti*

Department of Cardiac Surgery, Innsbruck University Hospital, Anichstrasse 35, A-6020 Innsbruck, Austria

Received 12 September 2001; received in revised form 2 November 2001; accepted 16 November 2001.

* Corresponding author. Tel.: +43-512-504-3806; fax: +43-512-504-5953
e-mail: johannes.o.bonatti{at}uibk.ac.at


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 References
 
Objective: Off pump coronary artery bypass grafting (OPCAB) is claimed to reduce the operative morbidity and mortality in high risk patients. It was the aim of the study to compare the outcome of OPCAB patients classified as high- and low risk according to the EuroSCORE. Methods: Medical records of patients undergoing off pump coronary artery bypass grafting (n=126) at our institution between 1998 and 2001 were retrospectively reviewed. We classified them into two subgroups: low risk (EuroSCORE<=5, n=72, male 58 (81%), female 14 (19%), age 61 (37–78) years) and high risk (EuroSCORE >5, n=54, male 32 (59%), female 22 (41%), age 73 (42–83) years). Results: EuroSCORE high risk patients showed significantly higher rates of blood transfusion (70 vs 31%; P<0.0001), intraaortic balloon pump insertion (16 vs 3%; P=0.013), atrial fibrillation (43 vs 22%; P=0.014), and renal failure (13 vs 3%; P=0.028). ICU length of stay was significantly longer in the high risk group (25 vs 22 h; P=0.002). There was also a higher perioperative mortality in the high risk group (9 vs 0%; P=0.008). Conclusion: From these data we conclude that using off pump coronary artery bypass grafting results as predicted by the EuroSCORE can be achieved. OPCAB is safe for low risk patients. Major complications seem to occur preferentially in the high risk group.

Key Words: Coronary artery bypass grafting • Risk • EuroSCORE


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 References
 
Cardiopulmonary bypass (CPB) and cardioplegic cardiac arrest have become the mainstays of coronary artery bypass grafting (CABG) in the last three decades. The major benefits, bloodless and accessible coronary artery sites for anastomosis, have made this procedure safe and common [1]. Nevertheless cardiopulmonary bypass has long been claimed to be responsible for systemic inflammation and multiple organ dysfunction after coronary artery bypass grafting [2].

In order to minimize these complications off-pump coronary artery bypass grafting has achieved acceptance in coronary artery revascularization. With the increasing numbers of CABG without CPB, recent improvements in retractor-stabilizier systems and techniques of exposure of all surfaces of the heart have been developed [3]. Likewise multivessel OPCAB is currently feasible in many patients.

Decreased operative mortality [4], postoperative morbidity [4,5], shorter ICU [4] and hospital stay [6] and reduced cost [4,6] are often cited arguments which favor OPCAB [5–7]. Therefore OPCAB is thought to be beneficial for high risk patients. Few data are available in the literature that report different outcome of low- and high-risk patients [7–9] undergoing off-pump coronary artery bypass surgery. In this study we compared OPCAB results in patients classified as high and low risk according to the EuroSCORE.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 References
 
From March 1998 to June 2001, 126 patients underwent coronary artery bypass grafting without cardiopulmonary bypass at the Cardiac Surgery Department of Innsbruck University Hospital. Based on preoperative demographics patients were divided into two subgroups according to the EuroSCORE: low risk patients (group I, n=72, EuroSCORE<=5) and high risk patients (group II, n=54, EuroSCORE >5). The median EuroSCORE was 3 (0–5) in group I and 8 (6–17) in group II. The median age in group I was 61 (37–78) years, and 73 (42–83) years in group II, (P<0.0001). Corresponding to EuroSCORE criteria there was a significantly higher rate of female patients, hypertensive patients, and patients with cerebral vascular disease or peripheral vascular disease in group II. Further patient demographics and comorbidities are listed in Table 1.


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  		Table 1. Patients demographics and comorbiditiesa

 
2.1. Operative technique
A median sternotomy was used in all cases. Internal mammary artery and saphenous vein or radial artery grafts were harvested using standard techniques. Intravenous heparin (200 IU/kg) was given to maintain activated clotting times above 200 s.

Stabilization of the anastomotic region during revascularization procedures was accomplished with the assistance of either the OctopusTM (Medtronic, Minneapolis, MN), the USSCTM, the CTS IITM (Cardiothoracic Systems, Cupertino, CA), or the CorvascTM (Coroneo) retractor/stabilizer system. Additional exposure and stabilization were accomplished using deep pericardial LIMA loops or SPOONER slings. The target coronary arteries were occluded with a silicone elastomer vessel loop. A mister blower for improved visualization of the anastomotic region was used selectively. In case of excessive retrograde bleeding or ischemia after occlusion of the coronary target vessel intraluminal coronary shunts were inserted. Occluded coronary arteries were usually revascularized before stenosed ones, technically difficult anastomoses were performed before easier ones. Proximal anastomoses were carried out before or after performance of distal ones at the surgeons preference. Distal anastomoses were constructed with a continuous running 7-0 or 8-0 Prolene monofilament suture. Proximal anastomoses were sewn to the aorta under partial occlusion clamp with 5-0 or 6-0 Prolene running suture. At the surgeon's preference systemic blood pressure was lowered before placement of the side biting clamps using intravenous antihypertensive substances or digital inflow occlusion. After all anastomoses were completed, heparin was neutralized with protamine sulfate.

2.2. Definitions of outcome parameters
Postoperative low cardiac output syndrome (LCOS) was defined as a cardiac index lower than 2.0 l/min per m2 and the postoperative need for positive inotropic agents. Renal failure was defined as prolonged oliguria or anuria requiring forced diuresis or hemofiltration. Multi organ failure was defined as severe dysfunction of two or more organ systems. Myocardial infarction was defined as the occurrence of a new Q-wave on the ECG and/or a CK-MB elevation above 50 UI/l.

2.3. Statistical analysis
Data collection and statistical analysis were performed with MS Excel for Windows and SPSS for Windows. Continuous variables are presented as median and range, categorical variables were compared using the chi square test or Fisher's exact test where appropriate, continuous variables were compared by the non-parametric Mann–Whitney U-test. Freedom from angina and cumulative survival were calculated using life table analysis and for comparisons between groups the Wilcoxon test was applied. Statistical significance was assumed at P<0.05.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 References
 
3.1. Intraoperative results
A total of 13 (18%) patients in the low risk group and 22 (41%) patients in the high risk group were incompletely revascularized. The median number of anastomoses performed was 1.8 per patient in group I and 2.3 per patient in group II (P<0.005). There was no significant difference observed in the application of intraluminal shunts (19% in the low risk group versus 20% in the high risk group). Table 2 shows the frequency distribution of grafts per patient in groups I and II. The number of arterial conduits was similar in both groups. A total of 23 patients (43%) in the high risk group received a saphenous vein bypass to the circumflex system compared to nine patients (13%) in the low risk group (P<0.001). Differences in the distribution of grafts are also shown in Table 2.


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  		Table 2. Intraoperative resultsa

 
3.2. Postoperative results
There tended to be fewer complications in the low risk group. Blood product use within the first 24 h was significantly different between the groups: 22 patients (31%) in group I versus 38 patients (70%) in group II received packed red blood cells (P<0.001). The use of an intraoperative or postoperative intraaortic balloon pump was significantly lower in group I (P=0.013). The incidence of postoperative atrial fibrillation also was significantly different (22% vs 43%, P=0.014) and renal failure requiring hemofiltration occurred in 3% versus 13% (P=0.028). In both groups no neurologic deficit occurred. We found a significant difference between the two groups in the length of stay in the intensive care unit 22 (12–432) versus 25 h (15–1248) (P=0.002). No patient of group I died whereas five perioperative deaths occurred in group II giving an operative mortality of 9% (P=0.008). Further postoperative differences between the groups are listed in the Table 3.


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  		Table 3. Postoperative resultsa

 
3.3. Follow up
Cumulative intermediate term survival is shown in Fig. 1 . High risk patients showed a significantly lower survival at 1 and 2 years postoperatively in comparison to the low risk patients. As depicted in Figs. 2 and 3 freedom from angina and freedom from major adverse cardiac and cerebral events (MACCE) were also significantly lower in EuroSCORE high risk patients.



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  		Fig. 1. Life-table analysis estimate for survival after OPCAB in low risk patients versus high risk patients. High risk patients showed a significantly lower survival at 1 and 2 years postoperatively in comparison to the low risk patients. Patients at risk are shown in italic numbers.

 


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  		Fig. 2. Life-table analysis estimate for freedom from angina in low risk patients versus high risk patients. High risk patients showed significantly lower freedom from angina at 1 and 2 years postoperatively in comparison to the low risk patients. Patients at risk are shown in italic numbers.

 


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  		Fig. 3. Life-table analysis estimate for freedom from major adverse cardiac and cerebral events (MACCE) after OPCAB in low risk patients versus high risk patients. High risk patients showed a significantly lower freedom from MACCE at 1 and 2 years postoperatively in comparison to the low risk patients. Patients at risk are shown in italic numbers.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
References
 
The EuroSCORE was constructed to design a risk stratification system to help in the assessment of quality of cardiac surgical care [7]. The purpose of our study was to compare perioperative morbidity and mortality and the follow up events in low- and high-risk patients according to the EuroSCORE undergoing OPCAB procedure.

A study by Sergeant and coworkers recently investigated relationships between mortality and the EuroSCORE [8]. Using refined statistical techniques Sergeant was able to demonstrate that with increasing risk according to the EuroSCORE the difference between predicted and observed mortality also increases. This shows a potential beneficial effect of OPCAB in high risk patients [8]. The reported mortality of 6.7% in these patients, however, still needs to be regarded as considerable. The observed mortality in our high risk patients was 9.2% and therefore only slightly lower than predicted by the EuroSCORE [7,8].

4.1. Blood transfusion
Coronary artery bypass grafting without CPB has been reported to be beneficial in reducing blood product use [1,4]. Our relatively high blood transfusion rate of 70 and 31% can be explained by blood transfusion triggers in relatively high ranges (serum hemoglobin of 10 g/l) for coronary surgery patients at our ICU. By comparison much lower rates of blood product use in the range of 6.7–34.9% are reported for OPCAB patients [1,4,10–14]. Blood transfusion requirements were significantly higher in our high risk patients. Data on such a difference are to our knowledge not documented in the literature.

4.2. Low cardiac output
There was a trend that LCOS occurred more often in patients with a EuroSCORE >5, but this did not reach statistical significance. An IABP, however, was required at a significantly higher rate of in the high risk group, a fact which most probably reflects poor baseline ventricular performance in these patients.

4.3. Atrial fibrillation
Atrial fibrillation (AF) is known to be a common complication after coronary artery surgery. The incidence has been reported to vary between 3 and 30% [15–17] after open heart surgery. However OPCAB has in some studies been associated with a low rate of AF, but generally off pump CABG has failed to demonstrate a significant reduction in atrial fibrillation [15]. The overall incidence of AF in our study population was 31%. As older age, structural changes in the heart and low ejection fraction are known risk factors for atrial fibrillation after CABG [15,16], this problem appeared, as expected, more often in our high risk patients.

4.4. Ventilation time
There was a 3 h difference in postoperative ventilation and a 3 h difference in ICU stay between high and low risk patients in our study. Corresponding differences have been found by Arom and coworkers [9] with intubation times of 6 h in low risk patients, 10 h in medium risk patients and 21 h in high risk patients.

4.5. Stroke
Several other authors have reported remarkably low stroke rates after OPCAB [17–20]. We regard our 0% stroke rate in the high risk group as an especially satisfying result because a high rate of patients with ascending aortic atherosclerosis was included and because the McSPI stroke risk index [21] would have predicted stroke rates of 1.1% (0.2–4.2%) for low risk patients and of 6% (0.3–30%) for high risk patients. Preventing a stroke during coronary revascularization is still a complex and multifaceted problem. Of increasing importance is the issue of unrecognized aortic atheromatous disease and carotid artery disease in patients presenting for coronary revascularization especially in high risk patients with peripheral vascular disease [22]. We tried to avoid this type of stroke by performance of extraanatomical bypass grafts and T- or Y-grafts. Concerning perioperative stroke in CABG it needs to be kept in mind that for conventional CABG considerable stroke rates are still reported. In a recent collective review of more than 35 000 patients the stroke rate ranged from 0.9 to 3.9% following isolated CABG with a mean stroke rate of 2%. The mortality from stroke in this review was 13–26% [23].

4.6. Renal failure
Our rate of renal failure requiring hemofiltration was 13% in the high risk group. A considerably lower rate was reported in Arom's study [9]. Concerning this high rate of hemofiltration it needs to be mentioned that the thresholds to install hemofiltration was rather low to treat renal failure early and aggressively.

4.7. Intensive care unit stay
High risk patients in our study population stayed significantly longer in the intensive care unit than low risk patients. This was also observed by Arom and coworkers who reported an ICU length of stay of 25 h in their low risk group, of 42 h in their medium risk group, and of 50 h in their high risk group [9].

4.8. Perioperative mortality
In our high risk patients the operative mortality was 9.2%. These results meet about the predicted mortality in the original publication on the EuroSCORE by Nashef and coworkers [7] who calculated a mortality of 11.2% in the high risk group with a EuroSCORE >5. In our low risk group, which corresponds the low and medium risk group in Nashef's paper no perioperative death occurred given a predicted mortality of 0.8% (EuroSCORE 0–2) and 3.0% (EuroSCORE 3–5). We regard this result as an indicator that OPCAB is safe in low risk patients, which is an absolute prerequisite if a new technique is applied. In Sergeant's paper [8], however, perioperative deaths also occurred in patients with EuroSCORE s lower than 6, maybe showing that the technique could in certain cases cause problems in the lower risk population.

4.9. Intermediate term outcome
In our study we noticed significantly worse intermediate term results after OPCAB in EuroSCORE high risk patients. More MACCE and return of angina occurred in this patient group. Explanations for this inferior outcome may be the higher grade of cardiac and non-cardiac morbidity as well as the higher rate of incomplete revascularization in the high risk patients. The most frequent cause of incomplete revascularization were the small size of the target vessel or difficulties achieving complete revascularization when extraanatomical bypass grafts were used for management of an atherosclerotic ascending aorta. Additionally a significantly higher preoperative grade of angina was present in our high risk group. In comparison to our data Arom and coworkers described a 1 year return of angina rate in high risk OPCAB patients of 50% [9]. A total of 42% of these patients required hospitalization for angina events [9].

Overall our study demonstrated that using off pump coronary artery bypass grafting we were able to achieve results slightly better than predicted by the EuroSCORE in high risk patients. Another conclusion that can be drawn from the data was that OPCAB seems to be safe in low risk patients. Major perioperative and intermediate term problems do occur preferentially in high risk patients.


   Footnotes
 
Presented at the joint 15th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 9th Annual Meeting of the European Society of Thoracic Surgeons, Lisbon, Portugal, September 16–19, 2001.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 References
 

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