Multivessel off-pump revascularization in patients with significant left main coronary artery stenosis: Early and midterm outcome analysis

Background: The presence of significant left main stenosis (>= 50%) has been considered a relative contraindication to the use of off-pump coronary artery bypass (OPCAB) stemming from well-documented hemodynamic perturbations during the displacement of the heart. We examined our experience with patients with critical left main stenosis (LMS) to assess the safety and feasibility of OPCAB in this subgroup. Methods: Our prospectively updated database was queried to identify all patients with severe left main disease who underwent isolated coronary revascularization between January 1, 1999 and May 31, 2002. This query yielded 234 on-pump and 420 off-pump patients with significant LMS whose clinical information was retrospectively reviewed. Results: The groups were well matched with regard to gender, left ventricular function, surgical priority, and severity of angina. The conventional coronary artery bypass (CABG) group was significantly younger than the OPCAB group and had a higher incidence of a previous myocardial infarction. Patients in the CABG cohort were more likely than OPCAB patients to remain ventilated after 24 hours, require placement of intraoperative or postoperative intraaortic balloon pump, or suffer from postoperative renal failure. There was a decrease in mortality (6.4% vs. 1.9%; p = 0.006) when CPB was eliminated. Intermediate term survival analysis revealed a significant survival benefit in the off-pump group (p = 0.007). Conclusions: Multivessel off-pump revascularization in patients with severe left main disease is a safe and effective alternative to conventional bypass grafting and conveys a survival benefit.