Does on-pump/beating-heart coronary artery bypass grafting offer better outcome in end-stage coronary artery disease patients?

Objectives: The purpose of our study was to evaluate in a cohort of end-sta ge coronary artery disease (ESCAD) patients the effects of on-pump/beating- heart versus conventional coronary artery bypass grafting (CABG) requiring cardioplegic arrest. We report early and midterm survival, morbidity, and i mprovement of left ventricular (LV) function. Methods: Between January 1992 and October 1999, 107 (Group I) ESCAD patients underwent on-pump/beating-h eart surgery and 191 (Group II) ESCAD patients underwent conventional CABG requiring cardioplegic arrest. Mean age in Group I was 65.8 +/- 6.5 years ( 58-79 years); New York Heart Association (NYHA) and Canadian Cardiovascular Society (CCS) classifications were 3.2 +/- 0.4 and 3.3 +/- 0.5, respective ly. LV ejection fraction (LVEF) was 24.8% +/- 4%, LV end diastolic pressure (LVEDP) was 28.2 +/- 3.8 mmHg, and LV end diastolic diameter (LVEDD) was 6 9.6 +/- 4.6 mm. Mean age in Group II was 64.1 +/- 5 years (57-76 years), NY HA class was 3 +/- 0.6, CCS class was 3.4 +/- 0.4, LVEF was 26.2% +/- 4.3%, LVEDP was 27.2 +/- 3.4 mmHg, and LVED was 68 +/- 4.2 mm. Results: Preopera tively, Group I patients versus Group II patients had a markedly depressed LV function (LVEF, p = 0.006; LVEDP, p = 0.02; LVEDD, p = 0.003; and NYHA c lass, p, = 0.002), older age (p, = 0.012), and higher incidences of multipl e acute myocardial infarction (AMI; p = 0.004), cardiovascular disease (CVD ; p = 0.008), and chronic renal failure (CRH, p = 0.002). Cardiopulmonary b ypass (CPB) time was longer in Group II patients (p = 0.028). The mean dist al anastomosis per patient was similar between groups (p = NS). Operative m ortality between Groups I and II was 7 (6.5%) and 19 (10%), respectively (p = NS). Perioperative AMI (p = 0.034), low cardiac output syndrome (LCOS; p , = 0.011), necessity for ultrafiltration (p = 0.017), and bleeding (p = 0. 012) were higher in Group II. Improvement of LV function within 3 months af ter the surgical procedure was markedly higher in Group II, demonstrated by increased LVEF (p = 0.035), lower LVEDP (P = 0.027), and LVEDD (P = 0.001) versus the preoperative data in Group Il. The actuarial survivals at 1, 3, and 5 years were 95%, 86%, and 73% in Group I and 95%, 84%, and 72% in Gro up II (p = NS). Conclusions: ESCAD patients with bypassable vessels to two or more regions of reversible ischemia can undergo safe CABG with acceptabl e hospital survival and mortality and morbidity. In higher risk ESCAD patie nts, who may poorly tolerate cardioplegic arrest, on-pump/beating-heart CAB G may be an acceptable alternative associated with lower postoperative mort ality and morbidity. Such a technique offers better myocardial and renal pr otection associated with lower postoperative complications.