Trends in use of off-pump coronary artery bypass grafting: results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database.

Selected in The Journal of Thoracic and Cardiovascular Surgery by S. Head

References

Authors

Faisal G. Bakaeen, A. Laurie W. Shroyer, James S. Gammie, Joseph F. Sabik, Lorraine D. Cornwell, Joseph S. Coselli, Todd K. Rosengart, Sean M. O’Brien, Amelia Wallace, David M. Shahian, Frederick L. Grover, John D. Puskas

Reference

J Thorac Cardiovasc Surg 2014;148:856-64

Published

September 2014

Link

Access abstract

My Comment

Background

Off-pump coronary artery bypass grafting (CABG) was introduced in the early 1990s and gained popularity over the next decade as a potential means of avoiding several of the complications and adverse effects of cardiopulmonary bypass. However, although some studies have associated off-pump CABG with favourable outcomes, other have not found a significant benefit to off-pump CABG.

Given the inconsistency in the literature as to the relative benefits of off-pump and on-pump CABG, it would be of interest to know the extent to which off-pump CABG has been widely accepted by cardiac surgery practices in the US and the degree to which the use of off-pump CABG has changed over time.

Results

  • Records of 2,137,841 patients that underwent primary isolated CABG through 1/1/1997 – 30/9/2012 at hospitals participating in the Society of Thoracic Surgeons (STS) Database.
  • The rate of off-pump CABG peaked at 23% in 2002, and declined to 17% in 2012.
  • Of 967 centers that submitted data for 2008-2012, by the end of the study period (2011/2012), 84% of centers performed <50 off-pump cases per year. Moreover, 86% of surgeons performed <20 off-pump cases per year, and 35% of surgeons performed no off-pump cases. The median number of off-pump cases per year was 6.3 per center and 1.7 per surgeon.
  • Comparing high-volume (n > 200 per year) with intermediate-volume (n = 50-200 per year) and low-volume (n < 50 per year) centers, the conversion rate of off-pump to on-pump procedures was 3.6% vs 6.0% vs 7.3% (P<0.0001).
  • High-volume surgeons (n > 100 per year) versus intermediate-volume (n = 20-100 per year) and low-volume (n < 20 per year) surgeons had the lowest rates of conversion (2.6% vs 6.3% vs 8.4%; P<0.0001).

My comments

The current study adds important data to the debate of off-pump versus on-pump CABG. The authors have managed to review a staggering number of 2,137,841 CABG cases. With regard to outcomes, unfortunately, only the rate of conversions was explored. Moreover, it should be acknowledged that the conversion rates have not been adjusted for differences in baseline characteristics between patients treated in high-, intermediate-, or low-volume centers or surgeons.

These data are useful to establish recommendations for centralization of care to centers with more experience, the appropriate infrastructure and resources.

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