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The aim of this study was to compare the long-term survival rates of patients undergoing isolated first-time coronary artery bypass grafting (CABG) by off-pump CABG with the long-term survival rates in patients undergoing CABG using cardioplegic cardiopulmonary bypass techniques.All patients undergoing isolated CABG at a single center (Manchester Heart Centre, Manchester, United Kingdom) between 2000 and 2014 were included. Propensity score matching was performed on the basis of on demographic variables. The in-hospital morbidity and long-term all-cause mortality rates for matched patients were compared.A total of 8,055 patients were identified, with a median follow-up of 7.0 years. With patients matched for preoperative patient characteristics, there was no significant difference in long-term survival between cardiopulmonary bypass and off-pump CABG (n = 2,082 each; 11.5 years vs 11.3 years; p = 0.178). In the off-pump CABG group, there were significantly fewer in-hospital cerebrovascular complications (0.5% vs 1.1%; p = 0.017), and mean length of stay was shorter (7.6 days vs 8.1 days; p0.0001). Arterial conduit use was significantly higher in the off-pump group, with more right mammary artery grafts (16.3% vs 4.3%; p0.0001) and sequential grafts (27.1% vs 13.5%; p0.0001). The mean number of grafts was higher in the on-pump group (3.28 ± 0.94 vs 3.10 ± 1.10; p0.0001).Long-term survival after off-pump CABG is not inferior to long-term survival after on-pump CABG despite a lower mean number of grafts. A statistically significant difference in cerebrovascular complications may be related to conduit choice and reduced aortic manipulation.

Cardiac reoperation carries additional risks compared with surgery in patients who are sternotomy-naïve. To identify if preoperative computerized tomography (CT) can reduce this risk, we performed a systematic review of the literature and meta-analysis. Literature search identified 178 studies of which 4 retrospective cohort studies incorporating 900 patients met inclusion criteria. There were no statistically significant differences in the risk of death, re-entry injury, renal failure or perfusion/ischaemic times. CT scan reduced the risk of stroke by 0.42 [95% confidence interval (CI): 0.19-0.93, P = 0.03] and a composite of major complications by 0.65 (95% CI: 0.47-0.88, P = 0.006). The use of preoperative cross-sectional imaging to reduce the risk of complications following cardiac reoperation is advocated.

Objective As a result of recent failures in clinical governance the government has made a commitment to bring individual surgeons9 mortality data into the public domain. We have analysed a database to compare crude mortality after coronary artery bypass surgery with outcomes that were stratified by risk. Design Retrospective analysis of prospectively collected data. Setting All NHS centres in the geographical north west of England that undertake cardiac surgery in adults. Participants All patients undergoing isolated bypass graft surgery for the first time between April 1999 and March 2002. Main outcome measures Surgeon specific postoperative mortality and predicted mortality by EuroSCORE. Results 8572 patients were operated on by 23 surgeons. Overall mortality was 1.7%. Observed mortality between surgeons ranged from 0% to 3.7%; predicted mortality ranged from 2% to 3.7%. Eighty five per cent (7286) of the patients had a EuroSCORE of 5 or less; 49% of the deaths were in this lower risk group. A large proportion of the variability in predicted mortality between surgeons was due to a small but differing number of high risk patients. Conclusions It is possible to collect risk stratified data on all patients undergoing coronary bypass surgery. For most the predicted mortality is low. The small proportion of high risk patients is responsible for most of the differences in predicted mortality between surgeons. Crude comparisons of death rates can be misleading and may encourage surgeons to practise risk averse behaviour. We recommend a comparison of death rates that is stratified by risk and based on low risk cases as the national benchmark for assessing consultant specific performance.

Objective: Non-elective coronary artery surgery (emergent/salvage or urgent) carries an increased risk in most risk-stratification models. Off-pump coronary surgery is increasingly used in non-elective cases. We aimed to investigate the effect of avoiding cardiopulmonary bypass on outcomes following non-elective coronary surgery. Methods: Of the 3771 consecutive coronary artery bypass procedures performed by five surgeons between April 1997 and March 2002, 828 (22%) were non-elective and 417 (50.4%) of these patients had off-pump surgery. Multivariate logistic regression was used to assess the effect of off-pump on in-hospital outcomes, while adjusting for treatment selection bias. Treatment selection bias was controlled for by constructing a propensity score from core patient characteristics, which was the probability of avoiding cardiopulmonary bypass. The C statistic for this model was 0.8. Results: Off-pump patients were more likely to be hypertensive, stable, had less extensive disease and better left ventricular function. The left internal mammary artery was used in 91.8% (n ¼ 383) of off-pump patients compared to 79.3% (n ¼ 326) of on-pump cases (P , 0:001). After adjusting for the propensity score, no difference in in-hospital mortality was observed between off-pump and on-pump (adjusted odds ratio (OR) 0.83 (95% confidence intervals (CI) 0.36‐ 1.93); P ¼ 0:667). Off-pump patients were less likely to require intra-aortic balloon pump support (adjusted OR 0.44 (95% CI 0.21 ‐ 0.96); P ¼ 0:039), less likely to have renal failure (adjusted OR 0.44 (95% CI 0.22‐ 0.90); P ¼ 0:025), and have shorter lengths of stay (adjusted OR 0.51 (95% CI 0.37‐ 0.70); P , 0:001). Other morbidity outcomes were similar in both groups. Conclusions: In this experience, off-pump coronary surgery in non-elective patients is safe with acceptable results. Non-elective off-pump patients have a significantly reduced incidence of renal failure, and shorter post-operative stays compared to on-pump coronary artery bypass surgery. q 2003 Elsevier Science B.V. All rights reserved.

Background: Various risk stratification systems have been developed in coronary artery bypass graft surgery (CABG), based mainly on patients undergoing procedures with cardiopulmonary bypass. Objective: To assess the validity and applicability of the Parsonnet score, the EuroSCORE, the American College of Cardiology/American Heart Association (ACC/AHA) system, and the UK CABG Bayes model in patients undergoing off-pump coronary artery bypass surgery (OPCAB) in the UK. Methods: Data on 2223 patients who underwent OPCAB in eight cardiac surgical centres were collected. Predicted mortality risk scores were calculated using the four systems and compared with observed mortality. Calibration was assessed by the Hosmer–Lemeshow (HL) test. Discrimination was assessed using the receiver operating characteristic (ROC) curve area. Results: 30 of 2223 patients (1.3%) died in hospital. For the Parsonnet score the HL test was significant (p < 0.001) and the receiver operating characteristic curve (ROC) area was 0.74. For the EuroSCORE the HL test was also significant (p = 0.008) and the ROC area was 0.75. For the ACC/AHA system the HL test was non-significant (p = 0.7) and the ROC area was 0.75. For the UK CABG Bayes model the HL test was also non-significant (p = 0.3) and the ROC area was 0.81. Conclusions: The UK CABG Bayes model is reasonably well calibrated and provides good discrimination when applied to OPCAB patients in the UK. Among the other three systems, the ACC/AHA system is well calibrated but its discrimination power was less than for the UK CABG Bayes model. These data suggest that the UK CABG Bayes model could be an appropriate risk stratification system to use for patients undergoing OPCAB in the UK.

Objectives: Gastrointestinal (GI) complications following on-pump coronary artery bypass grafting (CABG) are rare, but carry a high mortality rate. Prolonged cardiopulmonary bypass (CPB) has been associated with a higher incidence of such complications. Little is known about the effect of avoiding CPB on GI complications. Our hypothesis was that off-pump CABG might reduce such complications. Methods: A total of 2327 consecutive cases undergoing isolated CABG between April 1997 and May 2001 were identified from four consultants' practice at the two cardiothoracic centres involved in this study. We performed a multivariable logistic regression analysis to identify the risk factors for development of post-operative GI complications. Potential risk factors considered in the logistic model were age, sex, angina, ejection fraction, peripheral vascular disease, renal dysfunction, redo operations, previous GI complications, priority of surgery and the use of CPB. Results: A total of 1210 cases were performed on CPB, compared to 1117 off-pump. The incidence of GI complications was 1.2% (n = 14) in the on-pump group and 1.6% (n = 18) in the off-pump group (P = 0.347). The incidence of in-hospital mortality, in the patients who had a GI complication, was 28.6% (n = 4) and 22.2% (n = 4), respectively (P = 0.681). The results of the logistic regression analysis showed that renal dysfunction, advancing age and previous history of GI surgery are significant risk factors for GI complications after coronary bypass surgery whether CPB is used or not. Conclusions: Our study suggests that off-pump and on-pump techniques are similar in the rates of GI complications. We suggest that a properly designed randomized control trial is needed to verify our findings.