Safety and Cost-Effectiveness of MIDCABG in High-Risk CABG Patients Dario F. Del Rizzo, MD, PhD, W. Douglas Boyd, MD, Richard J. Novick, MD, F. Neil McKenzie, MD, Nemish D. Desai, and Alan H. Menkis, MD London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada Background. Myocardial revascularization without car- diopulmonary bypass has been proposed as a potential therapeutic alternative in high-risk patients undergoing coronary artery bypass grafting. To evaluate this possi- bility we compared 15 high-risk (HR) patients in whom minimally invasive direct coronary artery bypass graft- ing was used as the method of revascularization with 41 consecutive patients who underwent conventional coro- nary artery bypass grafting during 1 month. Methods. Patients undergoing myocardial revascular- ization without cardiopulmonary bypass were signifi- cantly older than their low-risk (LR) counterparts (72.2  11.6 versus 63.3  9.7 years, p  0.006). The demographic profile for HR versus LR patients was as follows: female patients, 60.0% versus 26.8%, p  0.02; diabetes, 20.0% versus 24.4%, p  0.7; prior stroke, 33.3% versus 7.4%, p  0.03; chronic obstructive pulmonary disease, 60.0% ver- sus 9.8%, p < 0.0001; peripheral vascular disease, 33.3% versus 12.2%, p  0.03, congestive heart failure, 26.6% versus 9.8%, p  0.09; impaired left ventricular (ejection fraction < 0.40), 40.0% versus 17.0%, p  0.07; urgent operation, 86.6% versus 46.3%, p < 0.0001; and redo operation, 20.0% versus 0%, p  0.003. Results. There were no deaths in the HR group and one death in the LR group. The average intensive care unit stay was 1.1  0.5 days in HR patients versus 1.6  1.6 days in LR individuals (p  0.2), and the average hospital stay was 6.1  1.8 versus 7.3  4.4 days, respectively (p  0.3). We used an acuity risk score index developed by the Adult Cardiac Care Network of Ontario to predict out- come in the HR group. The expected intensive care unit stay in HR patients was 4.1  1.2 days (versus the observed stay of 1.1  0.5 days, p < 0.0001), and the expected hospital stay was 12.5  1.5 days (versus the observed stay of 6.1  1.8 days, p < 0.0001). The expected mortality in the HR group was 6.1% versus 0%, p  0.3. A cost regression model was used to examine predicted versus actual cost (in Canadian dollars) for the HR patient cohort (based on Ontario Ministry of Health funding). The expected cost for the HR cohort would have been $11,997 per patient. In contrast, the average cost for these 15 patients was $5,997 per patient, an estimated cost saving of 50%. Conclusions. Myocardial revascularization without car- diopulmonary bypass appears to be a safe and cost- effective therapeutic modality for HR patients requiring myocardial revascularization. (Ann Thorac Surg 1998;66:1002–7) © 1998 by The Society of Thoracic Surgeons I schemic heart disease is the leading cause of death in the industrialized Western world. Although the prev- alence and mortality rates of ischemic heart disease have declined in the past few decades, it is anticipated that these rates could increase by as much as 40% as the postwar baby boom generation enters the coronary heart disease age range [1]. Already, in a span of two decades, coronary artery bypass grafting (CABG) has become the most common major operative procedure performed in Canada and the United States. The efficacy of the proce- dure has been well established in several international studies; CABG, when compared with medical therapy, not only improves quality of life, but also prolongs life in selected patient subsets [2, 3]. However, the heightened demands for cardiac surgical procedures from an aging North American population are occurring at a time when debt-ridden Western countries are attempting to de- crease spiraling health care costs. As the population ages the proportion of elderly pa- tients undergoing cardiac surgical procedures is rising. Older patients are generally more frail and have dimin- ished physiologic reserve when compared with their younger counterparts. The increased operative risk to the older patient, in association with shrinking health care resources in the current fiscal climate, is a major concern of health care officials and health care providers. A number of reports have demonstrated that advanced age, urgent operation, impaired left ventricular (LV) function, female sex, New York Heart Association (NYHA) class III or IV status, and left main coronary artery stenosis were independent predictors of operative risk for CABG [4, 5]. Even in the current era, redo operations, the need for preoperative intraaortic balloon pump assist, impaired LV function (grade III/IV LV), impaired renal function, and advanced age continue to Presented at “Facts and Myths of Minimally Invasive Cardiac Surgery: Current Trends in Thoracic Surgery IV,” New Orleans, LA, Jan 24, 1998. Address reprint requests to Dr Del Rizzo, Health Sciences Centre, University of Manitoba, 820 Sherbrook St, Suite GH-604, Winnipeg, MB R3A 1R9, Canada (e-mail: ddelrizzo@exchange.hsc.mb.ca). © 1998 by The Society of Thoracic Surgeons 0003-4975/98/$19.00 Published by Elsevier Science Inc PII S0003-4975(98)00660-2