CLINICAL RESEARCH: CARDIAC SURGERY
Off-Pump Coronary Artery Surgery for Reducing Mortality and Morbidity
Meta-Analysis of Randomized and Observational Studies
Duminda N. Wijeysundera, MD*,*,
W. Scott Beattie, MD, PhD*,
George Djaiani, MD*,
Vivek Rao, MD, PhD ,
Michael A. Borger, MD, PhD,
Keyvan Karkouti, MD, MSc*, and
Robert J. Cusimano, MD
* Department of Anesthesia, Toronto General Hospital, Toronto, Ontario, Canada
Division of Cardiac Surgery, Toronto General Hospital, Toronto, Ontario, Canada
Department of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
Manuscript received February 22, 2005;
revised manuscript received May 15, 2005,
accepted May 31, 2005.
* Reprint requests and correspondence: Dr. Duminda N. Wijeysundera, EN 3-450, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada. (Email: duminda.wijeysundera{at}uhn.on.ca).
OBJECTIVES: The purpose of this study was to assess the effects of off-pump coronary bypass surgery (OPCAB) on mortality and morbidity.
BACKGROUND: Despite its potential for reducing morbidity and mortality, OPCAB’s role in clinical practice remains controversial.
METHODS: A meta-analysis of 37 randomized controlled trials (RCTs) (n=3,449) and 22 risk-adjusted (logistic regression or propensity-score) observational studies (n=293,617) was performed. Two reviewers performed literature searches (MEDLINE, EMBASE, PubMed, reference lists), quality assessment, and data extraction. Treatment effects were calculated as odds ratios (ORs) with 95% confidence intervals (CIs).
RESULTS: In RCTs, OPCAB was associated with reduced atrial fibrillation (OR 0.59; 95% CI 0.46 to 0.77) and trends toward reduced 30-day mortality (OR 0.91 95% CI 0.45 to 1.83), stroke (OR 0.52; 95% CI 0.25 to 1.05), and myocardial infarction (OR 0.79; 95% CI 0.50 to 1.25). Observational studies showed OPCAB to be associated with reduced 30-day mortality (OR 0.72; 95% CI 0.66 to 0.78), stroke (OR 0.62; 95% CI 0.55 to 0.69), infarction (OR 0.66; 95% CI 0.50 to 0.88), and atrial fibrillation (OR 0.78; 95% CI 0.74 to 0.82). At one to two years, OPCAB was associated with trends toward reduced mortality, but also increased repeat revascularization (RCT: OR 1.75, 95% CI 0.78 to 3.94; Observational: OR 1.35, 95% CI 0.76 to 2.39).
CONCLUSIONS: Randomized controlled trials did not find, aside from atrial fibrillation, the statistically significant reductions in short-term mortality and morbidity demonstrated by observational studies. These discrepancies might be due to differing patient-selection and study methodology. Future studies must focus on improving research methodology, recruiting high-risk patients, and collecting long-term data.
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Abbreviations and Acronyms
| | CCAB = conventional coronary artery bypass surgery | | CI = confidence interval | | CPB = cardiopulmonary bypass | | OPCAB = off-pump coronary artery bypass surgery | | OR = odds ratio | | RCT = randomized controlled trial |
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