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Original Investigation | Association of VA Surgeons

Trends Over Time in the Relative Use and Associated Mortality of On-Pump and Off-Pump Coronary Artery Bypass Grafting in the Veterans Affairs System

Faisal G. Bakaeen, MD1,2,3; Rosemary F. Kelly, MD4; Danny Chu, MD1,2,3; Michael E. Jessen, MD5; Herbert B. Ward, MD4; William L. Holman, MD6
[+] Author Affiliations
1Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
2The Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
3Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, Texas
4Division of Cardiothoracic Surgery, University of Minnesota and Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
5Division of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
6Department of Cardiothoracic Surgery, University of Alabama and Birmingham Veterans Medical Center, Birmingham, Alabama
JAMA Surg. 2013;148(11):1031-1036. doi:10.1001/jamasurg.2013.3580.
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Importance  Numerous studies have compared the results of on-pump and off-pump coronary artery bypass grafting (CABG), but little is known about how either the relative use of these procedures or their associated perioperative mortality have changed with time.

Objective  To examine trends in off- and on-pump CABG use and outcomes over time.

Design  Retrospective analysis of data from the Veterans Affairs Surgical Quality Improvement Program (VASQIP).

Setting  Data were collected from 42 Veterans Affairs cardiac surgery centers.

Participants  All Veterans Affairs patients (n = 65 097) who underwent isolated primary CABG from October 1997 to April 2011.

Interventions  Patients underwent either on-pump (ON) or off-pump (OFF) CABG.

Main Outcomes and Measures  The percentages of ON vs OFF cases as a function of time. We also evaluated trends over time in rates of conversion from OFF to ON CABG, perioperative mortality (30-day or in-hospital), and VASQIP predicted risk of mortality.

Results  The relative use of OFF CABG peaked at 24% in 2003, followed by a slow and mostly consistent decline to stabilize at about 19%. The conversion rate decreased with time and has stayed less than 3.5% since 2007 (P < .001). Perioperative mortality rates decreased over time for both ON and OFF CABG (P < .001) and have stayed less than 2% for the entire cohort since 2006. The mortality associated with converted cases was high regardless of the surgery year and exceeded the VASQIP predicted risk of mortality.

Conclusions and Relevance  There has been a decline in the relative use of OFF CABG in the Veterans Affairs system since 2003. This trend may affect the training of future generations in OFF surgery and influence conversion rates and outcomes.

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Figure 1.
Percentage of Use of Off-Pump Coronary Artery Bypass Grafting
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Figure 2.
Actual Mortality and Predicted Risk of Mortality (PROM) for Off- and On-Pump Coronary Artery Bypass Grafting
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Figure 3.
Intention-to-Treat Analysis

Actual mortality and predicted risk of mortality (PROM) for off- and on-pump coronary artery bypass grafting.

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Figure 4.
Percentage of Unplanned Conversions and All Conversions
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