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Outcomes similar with on-pump or off-pump CABG in elderly patients

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Despite the supposed advantage of off-pump coronary artery bypass grafting for elderly patients with ischemic heart disease, a Danish study found no significant difference in outcomes between on-pump and off-pump procedures in this population.

“Both techniques are relatively safe and can be performed with a fairly low rate of major complications in patients with high age and co-morbidities,” conclude the authors of the report in Circulation online April 20.

Dr. Kim Houlind, at Aarhus University Hospital and the University of Southern Denmark, Odense, and colleagues point out that the benefits of off-pump coronary artery bypass (OPCAB) are believed to be most pronounced in elderly patients who are at higher risk of complications after cardiac surgery. However, older patients are underrepresented in clinical trials.

The authors’ randomized trial was therefore designed to compare outcomes of conventional CABG with cardiopulmonary bypass (CCABG) to outcomes of OPCAB in 900 patients over 70 years of age. Their mean EuroScore was over 5, indicating moderate to high risk.

At 30 days after the procedure, the combined endpoint of death, stroke or MI had occurred in 10.2% of the on-pump group compared to 10.7% of the off-pump group – a nonsignificant difference (p=0.82), the investigators report.

The team also found no statistical difference in the individual components of the composite endpoint, although there were trends toward fewer strokes but more MIs in the off-pump arm.

After 6 months, mortality was 4.7% versus 4.2% in the on- and off-pump groups, respectively, (p=0.21), according to the report, and both groups reported significantly improved health-related quality of life.

Dr. Houlind and colleagues note that there has been a lot of discussion about surgeon experience in relation to outcomes of off-pump CABG. In the present study, surgeons were required to have performed twenty-five off-pump operations. Still, they were all more experienced in on-pump surgery, and so “a learning curve may have influenced the results.”

Nonetheless, the authors conclude, “We found no major advantage in using OPCAB in elderly patients with regard to major morbidity or self-assessed, health-related QoL.”

They add, “The present report does not include data on long-term morbidity and mortality. Further follow-up and angiographic control of graft patency are, however, planned and in the process of being performed.”

SOURCE:

On-Pump versus Off-Pump Coronary Artery Bypass Surgery in Elderly Patients: Results from the Danish On-Pump versus Off-Pump Randomization Study (DOORS)

Circulation 2012