National Trend Of On-pump Versus Off-pump Coronary Artery Bypass Grafting In Veterans
Sarah Halbert, Jared Antevil, Gregory Trachiotis.
Veterans Affairs Medical Center, Washington, DC, USA.
BACKGROUND: To evaluate use trends and perioperative outcomes of on- and off-pump coronary artery bypass graft (CABG) in United States (US) Veterans.
METHODS: We retrospectively reviewed 44,960 Veteran Health Administration (VHA) patients who underwent isolated CABG between 2008-2021. Demographics, operative variables, and perioperative outcomes were recorded. Multivariable logistic regression and multivariable generalized linear models were used to analyze the independent association between surgical technique and outcomes of interest. Adjusted hazard ratios (aHR) are reported for long-term outcomes. P <0.05 using two sided tests was considered statistically significant.
RESULTS: 6169/44960 (13.7%) patients underwent isolated off-pump CABG and 38791/44960 (86.3%) patients underwent isolated on-pump CABG. Between 2008 and 2021, there was a significant decrease in the proportion of off-pump procedures: 18.8% between 2008-2012, 11.6% between 2013-2017, and 8.6% from 2018-2021 (X2=712.78, df=2, p<.001). The groups were then propensity matched on age, history of COPD, diabetes, hypertension, smoking history, history of prior cardiac surgery, and left ventricular ejection fraction, resulting in a cohort of 12,130 patients: 5,961 (49.1%) on-pump and 6,169 (50.9%) off-pump. After adjusting for significant covariates, patients who underwent on-pump CABG had increased risk of the following within 30 days: death (aHR=2.60, 95% CI=1.50-4.51, p<.001), stroke (aHR=1.61, 95% CI =1.09-2.38, p=0.016), acute renal failure (aHR=2.31, 95% CI=1.46-3.66, p<.001), atrial fibrillation (aHR=1.39, 95% CI=1.23-1.57, p<.001), intraoperative death (aHR=1.67, 95% CI=1.07-2.59, p=0.023), and prolonged intubation (aHR=1.53, 95% CI=1.27-1.85, p<.001). They also experienced increased length of stay (Beta=0.05, p<.001). On- vs off- pump status did not affect risk of reintubation, perioperative myocardial infarction, or postoperative cardiac arrest requiring CPR.
CONCLUSIONS: Isolated CABG volume is decreasing over time in Veterans. Off-pump technique was independently associated with decreased risk of multiple perioperative outcomes measures, including death, stroke, and acute renal failure. Despite good outcomes, the proportion of off-pump CABG within the VHA has decreased between 2008-2021, suggesting a more selective use as overall volume has decreased. 
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