According to new research, carrying out heart by-pass surgery while the heart is still beating is as effective and cheaper than traditional surgery. Sicker patients can undergo heart by-pass surgery more safely if their heart continue to beat during the operation.

HERE IS THE REPORT FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION (JAMA)

Off-Pump vs Conventional Coronary Artery Bypass Grafting: Early and 1-Year Graft Patency, Cost, and Quality-of-Life Outcomes

A Randomized Trial

Context

Previous trials of off-pump coronary artery bypass (OPCAB) have enrolled selected patients and have not rigorously evaluated long-term graft patency. A preliminary report showed OPCAB achieved improved inhospital outcomes, similar completeness of revascularization, and shorter lengths of stay compared with conventional coronary artery bypass grafting (CABG).

Objective

To assess graft patency, clinical and quality-of-life outcomes, and cost among patients while in the hospital and at 1-year follow-up.

Design, Setting, and Patients

Randomized controlled trial of patients unselected for coronary anatomy, ventricular function, or comorbidities between March 10, 2000, and August 20, 2001, at a US academic center. A total of 200 patients were enrolled; 3 patients were withdrawn after randomization for mitral valve repair or replacement. Follow-up was complete for 197 patients at 30 days; 185 at 1 year.

Interventions

One surgical session consisting of elective OPCAB or CABG with cardiopulmonary bypass.The surgeon had extensive experience performing off-pump surgery; patients were subsequently managed by blinded protocols.

Main Outcome Measures

Coronary angiography documented graft patency prior to hospital discharge and at 1 year; health-related quality of life; and cost of the index and subsequent hospitalization(s).

Results

Graft patency was similar for OPCAB and conventional CABG with cardiopulmonary bypass at 30 days (absolute difference, 1.3%; 95% confidence interval [CI], -0.66% to 3.31%; P = .19) and at 1 year (absolute difference, -2.2%; 95% CI, -6.1% to 1.7%; P = .27). Rates of death, stroke, myocardial infarction, angina, and reintervention were similar at 30 days and 1 year. There were no significant differences in health-related quality of life. Mean total hospitalization cost per patient at hospital discharge was $2272 (95% CI, $755-$3732) less for OPCAB (P = .002) and $1955 (95% CI, -$766 to $4727) less at 1 year (P = .08).

Conclusions

In this randomized single-surgeon trial among unselected patients with angiographic follow-up, OPCAB achieved similar graft patency in the hospital and at 1 year. Cardiac outcomes and health-related quality of life at 30 days and 1 year were similar and patients incurred a lower cost. OPCAB may provide complete revascularization that is durable and cost-effective.

INTRODUCTION

Motivated by morbidity attributable to cardiopulmonary bypass, US surgeons performed approximately 21% of coronary artery bypass operations off-pump in 2002. Nonetheless, concern remains about the technical difficulty of off-pump coronary artery bypass (OPCAB), including the possibility of imprecise anastomoses and incomplete revascularization compromising patient outcomes. Two prospective, randomized studies and all but a few retrospective comparisons have reported significantly fewer grafts in OPCAB. Retrospective studies among selected patients showing significant benefits of OPCAB over conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass for mortality, morbidity, length of stay, and cost have been criticized for potential bias in patient selection and management. Previous randomized studies among selected low-risk patients have reported similar results, but cannot be extrapolated to the general population of CABG patients. The potential clinical and economic advantages of OPCAB in unselected patients and the graft patencies that may be achievable are unknown.

The Surgical Management of Arterial Revascularization Therapies (SMART) trial was designed to compare graft patency, clinical outcomes, health-related quality of life, and costs in unselected patients referred for elective, isolated CABG surgery and randomized to OPCAB or CABG with cardiopulmonary bypass. In a preliminary report, patients receiving OPCAB achieved improved inhospital outcomes, similar completeness of revascularization, and shorter lengths of stay compared with patients receiving CABG with cardiopulmonary bypass. Results for the primary end point, graft patency prior to hospital discharge and at 1 year, are now reported. Secondary end points include clinical and health-related quality-of-life outcomes and costs during 1-year follow-up.

METHODS

Patient Enrollment and Management

In accordance with the Declaration of Helsinki and with the institutional review board approval granted by Emory University, 200 patients provided written informed consent and were enrolled between March 20, 2000, and August 10, 2001. During this period, 465 patients were referred to a single surgeon (J.D.P.) for isolated primary, elective CABG. An attempt was made to enroll 1 patient each operative day to facilitate accurate and complete data acquisition.

Consecutive patients referred each day were screened for eligibility and asked to volunteer until 1 patient had agreed to participate for the following day. Thus, 297 nonconsecutive patients were asked to participate, representing 64% of all referrals. Patients were not excluded for any pattern of coronary artery disease, ventricular dysfunction, or any other comorbidity. Only patients in cardiogenic shock requiring emergency surgery or preoperative intra-aortic balloon pump (inserted at cardiologists’ discretion) were excluded for cardiac reasons. Ninety-seven refused to participate. The 200 elective patients randomized comprised 67% of those screened and 43% of all primary elective coronary referrals during the enrollment period.

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http://jama.ama-assn.org/cgi/content/full/291/15/1841