A cost comparison of off-pump CABG versus on-pump CABG at one-year: The Canadian off-pump CABG registry

Low-Cost Innovations in Global Cardiac Surgery

Cardiovascular diseases are the leading cause of morbidity and mortality worldwide, costing the lives of 18 million people annually, with up to one-third being attributable to cardiac surgical conditions. Approximately 6 billion people do not have access to safe, timely, and affordable cardiac surgery, predominantly affecting populations living in low-middle income countries. Cardiac surgical care is costly, resulting in few centers in variable-resource contexts operating continuously or with the resources observed in higher-resource environments. As a result, innovations may be formally developed or informally adopted to bypass resource constraints and ensure care delivery. Innovations have been observed across the cardiac surgical care continuum and across settings, potentially benefiting both high-income countries, where growing health care costs are becoming unsustainable, and low- and middle-income countries, where competing health agendas may limit investments into cardiac surgery. This narrative review attempts to address the costs associated with cardiac surgery, placing an emphasis on frugal innovations in the perioperative and postoperative care spectrum.

Off-pump coronary artery bypass grafting in India

Off-pump Coronary Artery Bypass Grafting (OPCAB) is the latest innovation in cardiac surgery. However OPCAB is not adopted universally. Even there have been suggestions of abandoning OPCAB in a special report. In India, OPCAB has been successfully adopted across the board. There are various evidences which favor OPCAB and are discussed in this review. The purpose of this review is to put forward the perspective of the OPCAB surgeons of our country and critically look at the suggestion of abandoning OPCAB.

Early mortality from off-pump and on-pump coronary bypass surgery in Canada: a comparison of the STS and the EuroSCORE risk prediction algorithms

OBJECTIVE

Early mortality from off-pump and on-pump coronary artery bypass graft (CABG) surgery was assessed and compared with two widely used risk algorithms for CABG: The Society of Thoracic Surgeons (STS) and the European System for Cardiac Operative Risk Evaluation (EuroSCORE).

METHOD

From March 12, 2001, to December 31, 2002, 1657 consecutive patients were treated with off-pump CABG and 1693 consecutive patients were treated with on-pump CABG. The predicted risk of mortality scores for the STS and EuroSCORE models were calculated. The predictive accuracy for early mortality was assessed by comparing the observed and expected mortalities for equal-sized quantiles of risk using the Hosmer-Lemeshow goodness-of-fit test. The discriminatory power of the models was evaluated by calculating the area under the receiver operating characteristic (ROC) curves.

RESULTS

The observed postoperative mortality was 1.8% (95% CI 1.3% to 2.4%) for off-pump CABG and 1.5% (95% CI 1.1% to 2.1%) for on-pump CABG. For both on-pump and off-pump CABG surgery, the Hosmer-Lemeshow goodness-of-fit test indicated good accuracy. The area under the ROC curve was 0.81 (95% CI 0.73 to 0.90) for the STS and 0.79 (95% CI 0.71 to 0.88) for EuroSCORE in off-pump CABG (P=0.567). The area under the ROC curve was 0.82 (95% CI 0.73 to 0.91) for STS and 0.81 (95% CI 0.71 to 0.90) for EuroSCORE in on-pump CABG (P=0.616). The STS-predicted risk of stroke, prolonged ventilation and renal failure were similar to the observed data, with relatively good discriminatory powers for both off-pump and on-pump CABG.

CONCLUSION

Both the STS and EuroSCORE risk algorithms are good predictors of early mortality from off-pump or on-pump CABG surgery. However, the generalizability of these results in the Canadian context would require a broader sampling of Canadian centres, including ones that provide both on-pump and off-pump CABG.