On-Pump Versus Off-Pump Coronary Artery Bypass Surgery in Elderly Patients: Results From the Danish On-Pump Versus Off-Pump Randomization Study

Aug 23, 2012
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Authors:
Houlind K, Kjeldsen BJ, Madsen SN, et al., on behalf of the DOORS Study Group.
Citation:
Circulation 2012;125:2431-2439.
Summary By:
Debabrata Mukherjee, MD, FACC

Study Questions:

What are the outcomes of conventional coronary artery bypass grafting (CCABG) and off-pump coronary artery bypass (OPCAB) in patients ≥70 years of age?

Methods:

In a multicenter, randomized trial, the investigator assigned 900 patients >70 years of age to CCABG or OPCAB surgery. After 30 days, a blinded endpoint committee assessed whether a combined endpoint of death, stroke, or myocardial infarction had occurred. At baseline and 6 months postoperatively, self-assessed quality of life was measured with the Medical Outcomes Study Short Form-36 and EuroQol-5D questionnaires. A 6-month follow-up of mortality was performed through the Danish National Registry.

Results:

The proportion of patients experiencing the combined endpoint within 30 days was 10.2% for CCABG and 10.7% for OPCAB. Implied risk difference of 0.4% (with a 95% confidence interval, −3.6 to 4.4) showed nonsignificance in a standard test for equality (p = 0.83) and for noninferiority with an inferiority margin of 0.5% (p = 0.49). At the 6-month follow-up, mortality was 4.7% compared with 4.2% (p = 0.75). Both groups showed significant improvement in self-assessed health-related quality of life.

Conclusions:

The authors concluded that both CCABG and OPCAB are safe procedures, with no major differences in intermediate-term outcomes.

Perspective:

The study reports no major advantage in using OPCAB in elderly patients with regard to major morbidity or self-assessed health-related quality of life. However, noninferiority of OPCAB relative to CCABG with regard to the primary composite endpoint was not proven. Overall, both techniques are relatively safe and can be performed with a fairly low rate of major complications in patients with high age and comorbidities. This analysis only elucidates the comparative safety of the operations. The relative efficacy will be dependent on graft patency and will need to be evaluated by a longer period of follow-up.

Keywords: Self-Assessment, Outcome Assessment, Health Care, Risk, Registries, Myocardial Infarction, Follow-Up Studies, Cardiology, Cardiopulmonary Bypass, Coronary Artery Bypass


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