Propensity case-matched analysis of off-pump coronary artery bypass grafting in patients with atheromatous aortic disease

Objective: Atheromatous aortic disease is a risk factor for excessive mortality and stroke in patients undergoing coronary artery bypass grafting. Outcomes of off-pump coronary artery bypass grafting and coronary artery bypass grafting with cardiopulmonary bypass in patients with severe atheromatous aortic disease were compared by propensity case-match methods. Methods: Routine intraoperative transesophageal echocardiography identified 985 patients undergoing isolated coronary artery bypass grafting with severe atheromatous disease in the aortic arch or ascending aorta. Off-pump coronary artery bypass grafting was performed in 281 patients (28.5%). Propensity matched-pairs analysis was used to match patients undergoing off-pump coronary artery bypass grafting (n = 245) with patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. Results: Univariate analysis revealed decreased hospital mortality (16/245, 6.5% vs 28/245, 11.4%; P = .058) and stroke prevalence (4/245, 1.6% vs 14/245, 5.7%; P = .03) in off-pump coronary artery bypass grafting compared with coronary artery bypass grafting with cardiopulmonary bypass. Freedom from any postoperative complication was higher in off-pump coronary artery bypass grafting compared with coronary artery bypass grafting with cardiopulmonary bypass (226/245, 92.2% vs 196/245, 80.0%; P < .001). Multivariable analysis of preoperative risk factors showed that increased hospital mortality was associated with coronary artery bypass grafting with cardiopulmonary bypass (odds ratio = 2.7; P = .01), fewer grafts (P = .05), acute myocardial infarction (odds ratio = 11.5; P < .001), chronic obstructive pulmonary disease (odds ratio = 2.4; P = .03), previous cardiac surgery (odds ratio = 10.2, P = .05), and peripheral vascular disease (odds ratio = 2.1; P = .05). Cardiopulmonary bypass was the only independent risk factor for stroke (odds ratio = 3.6, P = .03). At 36 months' follow-up, comparable survival was observed in the off-pump coronary artery bypass grafting and coronary artery bypass grafting with cardiopulmonary bypass groups (74% vs 72%). Multivariable analysis revealed that renal disease (P < .001), advanced age (P < .001), previous myocardial infarction (P = .03), and lower number of grafts (P = .02) were independent risks for late mortality. Conclusions: Patients with severe atherosclerotic aortic disease who undergo off-pump coronary artery bypass grafting have a significantly lower prevalence of hospital mortality, perioperative stroke, and overall complications than matched patients who underwent coronary artery bypass grafting with cardiopulmonary bypass. Routine intraoperative transesophageal echocardiography identifies severe atheromatous aortic disease and directs the choice of surgical technique.