César, Luı́z Antonio Machado

Background— Coronary artery bypass graft surgery with cardiopulmonary bypass is a safe, routine procedure. Nevertheless, significant morbidity remains, mostly because of the body’s response to the nonphysiological nature of cardiopulmonary bypass. Few data are available on the effects of off-pump coronary artery bypass graft surgery (OPCAB) on cardiac events and long-term clinical outcomes. Methods and Results— In a single-center randomized trial, 308 patients undergoing coronary artery bypass graft surgery were randomly assigned: 155 to OPCAB and 153 to on-pump CAB (ONCAB). Primary composite end points were death, myocardial infarction, further revascularization (surgery or angioplasty), or stroke. After 5-year follow-up, the primary composite end point was not different between groups (hazard ratio 0.71, 95% CI 0.41 to 1.22; P =0.21). A statistical difference was found between OPCAB and ONCAB groups in the duration of surgery (240±65 versus 300±87.5 minutes; P <0.001), in the length of ICU stay (19.5±17.8 versus 43±17.0 hours; P <0.001), time to extubation (4.6±6.8 versus 9.3±5.7 hours; P <0.001), hospital stay (6±2 versus 9±2 days; P <0.001), higher incidence of atrial fibrillation (35 versus 4% of patients; P <0.001), and blood requirements (31 versus 61% of patients; P <0.001), respectively. The number of grafts per patient was higher in the ONCAB than the OPCAB group (2.97 versus 2.49 grafts/patient; P <0.001). Conclusions— No difference was found between groups in the primary composite end point at 5-years follow-up. Although OPCAB surgery was related to a lower number of grafts and higher episodes of atrial fibrillation, it had no significant implications related to long-term outcomes. Clinical Trial Registration— URL: http://www.controlled-trials.com. Unique identifier: ISRCTN66068876.

Background— Prior comparisons of costs following CABG and PTCA have demonstrated higher initial costs after CABG but following PTCA, recurrent symptoms and repeat revascularization result in increased late costs and over time their costs equilibrate. The MASS II trial provides an opportunity to compare the costs of CABG and PTCA in addition to a strategy of medical therapy. Methods— We studied the 611 patients of MASS II [Medical (203), Angioplasty (205), or Surgery (203) Study], a randomized study to compare treatments for multivessel CAD and preserved left ventricle function. The costs were: CABG US$ 10 650.00; PTCA US$ 6400.00; new AMI hospitalization AMI U$ 2550; angiography not followed-up of PTCA US$ 1900.00; and medication US$ 1200.00 for medical, and US$ 1000.00 for the other groups. We did adjustment for average event-free time, and angina-free proportion. The statistical analysis carried out was chi-square, t test, and analysis of variance. Results— After 1 year, 49% Medical, 79% PTCA, and 88% CABG became angina-free; P <0.0001. There were 26 coronary angiograms (5 medical, 17 PTCA, and 4 CABG), 23 AMI (8 medical, 17 PTCA, and 6 CABG; P =0.03); PTCA was performed in 7 Medical, 17 PTCA, and 1 CABG, ( P =0.0003), CABG was performed in 15 Medical, 8 PTCA, and zero CABG; P =0.002. The event-free and event and angina-free-costs in the first year were US$ 2453.50 and US$5006.32 for Medical; US$ 10348,43; and US$ 13 099.31 for PTCA; and US$ 12 404.21 and US$ 14 095.09 for CABG group. An increase from expected costs of 317%, 77%, and 21%, respectively. Conclusion— PTCA effective costs were similar to CAGB costs, Medical treatment presented the lowest cost, and however, the greatest increment, and CABG presented the most stable costs.