Off-Pump Coronary Artery Bypass Grafting Does Not Confer Superior Outcomes Among Frail Patients

Background: Off-pump coronary revascularization (OPCAB) has been proposed to benefit patients at greater surgical risk as it avoids the use of extracorporeal circulation. While historically older patients were considered high risk candidates, recent studies implicate frailty as a more comprehensive measure of perioperative fitness. Yet, outcomes of OPCAB among frail patients have not been elucidated. Thus, using a national cohort of frail patients, we assessed the impact of OPCAB, relative to on-pump (ONCAB).Methods: Patients undergoing first-time, elective coronary revascularization were tabulated from the 2010-2020 Nationwide Readmissions Database. Frailty was assessed using the previously-validated Johns Hopkins Adjusted Clinical Groups indicator. Multivariable models were utilized to consider the independent associations between OPCAB and key outcomes.Results: Of ∼26,529 frail patients, 6,322 (23.8%) underwent OPCAB. After risk adjustment and compared to ONCAB, OPCAB was linked with similar odds of in-hospital mortality, but greater likelihood of postoperative cardiac arrest (AOR 1.53, CI 1.13-2.07) and myocardial infarction (AOR 1.44, CI 1.23-1.69). OPCAB was further associated with greater odds of postoperative infection (AOR 1.22, CI 1.02-1.47) but decreased need for blood transfusion (AOR 0.68, CI 0.60-0.77). Additionally, OPCAB faced a +0.86day increase in length of stay (CI +0.21-1.51) but similar costs (β +$1,610, CI -$1,240- +4,460), relative to ONCAB.Conclusions: Although OPCAB was associated with no difference in mortality compared to ONCAB, it was linked with greater likelihood of postoperative cardiac arrest and myocardial infarction. Our findings demonstrate ONCAB remains associated with superior outcomes, even in the growing population of frail patients undergoing coronary revascularization.