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Type of Intervention and Predicting Late Decline

Type of Intervention and Predicting Late Decline JAMA Cognitive and Cardiac Outcomes 5 Years After Off-Pump vs On-Pump Coronary Artery Bypass Graft Surgery Diederik van Dijk, MD, PhD; Monique Spoor, MS; Ron Hijman, PhD; Hendrik M. Nathoe, MD, PhD; Cornelius Borst, MD, PhD; Erik W. L. Jansen, MD, PhD; Diederick E. Grobbee, MD, PhD; Peter P. T. de Jaegere, MD, PhD; Cor J. Kalkman, MD, PhD; for the Octopus Study Group Context Conventional coronary artery bypass graft surgery with use of cardiopulmonary bypass (on-pump CABG) is associated with excellent long-term cardiac outcomes but also with a high incidence of cognitive decline. The effect of avoiding cardiopulmonary bypass (off-pump CABG) on long-term cognitive and cardiac outcomes is unknown. Objective To compare the effect of off-pump CABG and on-pump CABG surgery on long-term cognitive and cardiac outcomes. Design, Setting, and Participants The Octopus Study, a multicenter randomized controlled trial conducted in the Netherlands, which enrolled 281 low-risk CABG patients between 1998 and 2000. Five years after their surgery, surviving patients were invited for a follow-up assessment. Intervention Patients were randomly assigned to receive either off-pump (n = 142) or on-pump (n = 139) CABG surgery. Main Outcome Measure The primary measure was cognitive status 5 years after surgery, which was determined by a psychologist blinded to treatment allocation who administered 10 standardized validated neuropsychological tests. Secondary measures were occurrence of cardiovascular events (all-cause mortality, stroke, myocardial infarction, and coronary reintervention), anginal status, and quality of life. Results After 5 years, 130 patients were alive in each group. Cognitive outcomes could be determined in 123 and 117 patients in the off-pump and on-pump groups, respectively. When using a standard definition of cognitive decline (20% decline in performance in 20% of the neuropsychological test variables), 62 (50.4%) of 123 in the off-pump group and 59 (50.4%) of 117 in the on-pump group had cognitive decline (absolute difference, 0%; 95% confidence interval [CI], −12.7% to 12.6%; P > .99). When a more conservative definition of cognitive decline was used, 41 (33.3%) in the off-pump group and 41 (35.0%) in the on-pump group had cognitive decline (absolute difference, −1.7%; 95% CI, −13.7% to 10.3%; P = .79). Thirty off-pump patients (21.1%) and 25 on-pump patients (18.0%) experienced a cardiovascular event (absolute difference, 3.1%; 95% CI, −6.1% to 12.4%; P = .55). No differences were observed in anginal status or quality of life. Conclusion In low-risk patients undergoing CABG surgery, avoiding the use of cardiopulmonary bypass had no effect on 5-year cognitive or cardiac outcomes. Trial Registration isrctn.org Identifier: ISRCTN69438133 JAMA. 2007;297(7):701-708 Several studies have demonstrated the occurrence of “late” cognitive decline approximately 5 years after CABG surgery. However, because most of these studies did not include a control group, a causal link to the use of cardiopulmonary bypass has not been established. The study by van Dijk and colleagues examines the etiology of the late decline by comparing cognitive outcomes 5 years after randomization to either conventional on-pump or off-pump surgery. Regardless of the choice of methods to define cognitive decline, they found a comparable incidence of late decline at 5 years in their 2 study groups. It thus confirms findings from previous randomized studies that have not found reduced incidence of cognitive decline with off-pump surgery during weeks to months after surgery, but this is the first prospective randomized study comparing cognitive outcomes 5 years after on- or off-pump surgery. Their findings are important because they suggest that factors other than the use of cardiopulmonary bypass are responsible for the late cognitive decline. The authors suggest that normal aging and test-retest variability may account for some of the late cognitive decline. We have previously suggested that normal aging in the context of vascular disease of the brain may be important determinants of late decline and agree that the findings by van Dijk et al emphasize that patient characteristics may be more important for predicting degree of late decline than type of intervention. Back to top Article Information Correspondence: Dr Baumgartner, Department of Surgery–Cardiac, Johns Hopkins University, 600 N Wolfe St, Blalock 618, Baltimore, MD 21287 (wbaumgar@jhmi.edu). Financial Disclosure: None reported. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Type of Intervention and Predicting Late Decline

Archives of Surgery , Volume 142 (7) – Jul 1, 2007

Type of Intervention and Predicting Late Decline

Abstract

JAMA Cognitive and Cardiac Outcomes 5 Years After Off-Pump vs On-Pump Coronary Artery Bypass Graft Surgery Diederik van Dijk, MD, PhD; Monique Spoor, MS; Ron Hijman, PhD; Hendrik M. Nathoe, MD, PhD; Cornelius Borst, MD, PhD; Erik W. L. Jansen, MD, PhD; Diederick E. Grobbee, MD, PhD; Peter P. T. de Jaegere, MD, PhD; Cor J. Kalkman, MD, PhD; for the Octopus Study Group Context Conventional coronary artery bypass graft surgery with use of cardiopulmonary bypass (on-pump CABG) is associated with...
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Publisher
American Medical Association
Copyright
Copyright © 2007 American Medical Association. All Rights Reserved.
ISSN
0004-0010
DOI
10.1001/archsurg.142.7.595
Publisher site
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Abstract

JAMA Cognitive and Cardiac Outcomes 5 Years After Off-Pump vs On-Pump Coronary Artery Bypass Graft Surgery Diederik van Dijk, MD, PhD; Monique Spoor, MS; Ron Hijman, PhD; Hendrik M. Nathoe, MD, PhD; Cornelius Borst, MD, PhD; Erik W. L. Jansen, MD, PhD; Diederick E. Grobbee, MD, PhD; Peter P. T. de Jaegere, MD, PhD; Cor J. Kalkman, MD, PhD; for the Octopus Study Group Context Conventional coronary artery bypass graft surgery with use of cardiopulmonary bypass (on-pump CABG) is associated with excellent long-term cardiac outcomes but also with a high incidence of cognitive decline. The effect of avoiding cardiopulmonary bypass (off-pump CABG) on long-term cognitive and cardiac outcomes is unknown. Objective To compare the effect of off-pump CABG and on-pump CABG surgery on long-term cognitive and cardiac outcomes. Design, Setting, and Participants The Octopus Study, a multicenter randomized controlled trial conducted in the Netherlands, which enrolled 281 low-risk CABG patients between 1998 and 2000. Five years after their surgery, surviving patients were invited for a follow-up assessment. Intervention Patients were randomly assigned to receive either off-pump (n = 142) or on-pump (n = 139) CABG surgery. Main Outcome Measure The primary measure was cognitive status 5 years after surgery, which was determined by a psychologist blinded to treatment allocation who administered 10 standardized validated neuropsychological tests. Secondary measures were occurrence of cardiovascular events (all-cause mortality, stroke, myocardial infarction, and coronary reintervention), anginal status, and quality of life. Results After 5 years, 130 patients were alive in each group. Cognitive outcomes could be determined in 123 and 117 patients in the off-pump and on-pump groups, respectively. When using a standard definition of cognitive decline (20% decline in performance in 20% of the neuropsychological test variables), 62 (50.4%) of 123 in the off-pump group and 59 (50.4%) of 117 in the on-pump group had cognitive decline (absolute difference, 0%; 95% confidence interval [CI], −12.7% to 12.6%; P > .99). When a more conservative definition of cognitive decline was used, 41 (33.3%) in the off-pump group and 41 (35.0%) in the on-pump group had cognitive decline (absolute difference, −1.7%; 95% CI, −13.7% to 10.3%; P = .79). Thirty off-pump patients (21.1%) and 25 on-pump patients (18.0%) experienced a cardiovascular event (absolute difference, 3.1%; 95% CI, −6.1% to 12.4%; P = .55). No differences were observed in anginal status or quality of life. Conclusion In low-risk patients undergoing CABG surgery, avoiding the use of cardiopulmonary bypass had no effect on 5-year cognitive or cardiac outcomes. Trial Registration isrctn.org Identifier: ISRCTN69438133 JAMA. 2007;297(7):701-708 Several studies have demonstrated the occurrence of “late” cognitive decline approximately 5 years after CABG surgery. However, because most of these studies did not include a control group, a causal link to the use of cardiopulmonary bypass has not been established. The study by van Dijk and colleagues examines the etiology of the late decline by comparing cognitive outcomes 5 years after randomization to either conventional on-pump or off-pump surgery. Regardless of the choice of methods to define cognitive decline, they found a comparable incidence of late decline at 5 years in their 2 study groups. It thus confirms findings from previous randomized studies that have not found reduced incidence of cognitive decline with off-pump surgery during weeks to months after surgery, but this is the first prospective randomized study comparing cognitive outcomes 5 years after on- or off-pump surgery. Their findings are important because they suggest that factors other than the use of cardiopulmonary bypass are responsible for the late cognitive decline. The authors suggest that normal aging and test-retest variability may account for some of the late cognitive decline. We have previously suggested that normal aging in the context of vascular disease of the brain may be important determinants of late decline and agree that the findings by van Dijk et al emphasize that patient characteristics may be more important for predicting degree of late decline than type of intervention. Back to top Article Information Correspondence: Dr Baumgartner, Department of Surgery–Cardiac, Johns Hopkins University, 600 N Wolfe St, Blalock 618, Baltimore, MD 21287 (wbaumgar@jhmi.edu). Financial Disclosure: None reported.

Journal

Archives of SurgeryAmerican Medical Association

Published: Jul 1, 2007

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