Graft Patency After Off-Pump CABG Is Inferior | Journal Scan

Study Questions:

Is there a difference in graft patency after on-pump and off-pump coronary artery bypass surgery (CABG) when performed using the same heparinization protocol?

Methods:

The DOORS study investigators randomized 900 patients >70 years of age to receive either on-pump or off-pump CABG in a multicenter trial. Heparin was given to achieve an activated clotting time of 400 seconds before arteriotomy in both groups. After the procedure, protamine sulfate was given to revert the activated clotting time to <120 seconds. Coronary angiography was performed 6 months after the operation, and graft patency was assessed by independent blinded observers.

Results:

There was no difference in 6-month mortality (4.7% vs. 4.2%). Angiographic follow-up was available for 481 patients. There was a statistically lower patency in the off-pump group (9% stenotic grafts and 12% occluded grafts) compared with the on-pump group (5% stenotic and 9% occluded, p = 0.01). The proportion of open left internal mammary artery grafts was 95% in both groups. Perioperative use of intracoronary shunts did not increase the risk of stenosis of the coronary artery distal to the anastomosis.

Conclusions:

Despite comparable heparinization, graft patency after off-pump surgery was inferior to that after on-pump surgery.

Perspective:

Off-pump CABG has many theoretical advantages, but has not been associated with a reduction in stroke or mortality compared with on-pump CABG (Moller, et al. Cochrane Database System Rev 2012;3:CD007224). This study adds to the data suggesting that off-pump CABG is associated with a lower number of bypass grafts and inferior graft patency. Based on these and other data, conventional CABG should remain the preferred technique, and off-pump CABG should only be reserved for clinical scenarios in which on-pump CABG is contraindicated.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Constriction, Pathologic, Coronary Angiography, Coronary Artery Bypass, Coronary Artery Bypass, Off-Pump, Heparin, Mammary Arteries, Protamines, Cardiac Surgical Procedures


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