Should more precautions be taken for better outcomes during off-pump coronary artery bypass grafting in left main coronary artery disease?

Background: Patients with significant left main coronary artery (LMCA) stenosis (≥50%) have traditionally been excluded from off-pump coronary artery bypass grafting (OPCABG) due to concerns regarding the heart's ability to tolerate beating-heart grafting. However, recent developments in surgical techniques have prompted reevaluation of this approach. Objective: The objective of this study was to assess the safety and efficacy of OPCABG in patients with LMCA disease. Methods: This observational study was conducted at Khulna City Medical College Hospital between March 2020 and December 2021. A total of 437 patients underwent isolated OPCABG performed by a single cardiac surgeon. Among them, 159 had significant LMCA disease. Clinical outcomes of 100 patients with LMCA stenosis (LMCA group) were compared with 100 propensity score-matched patients without LMCA stenosis (non-LMCA group). All cases were operated on using the off-pump technique. Results: All surgeries were completed without conversion to on-pump. Thirty-day mortality was identical in both groups (1%), and follow-up was completed in 98% of patients. The three-year freedom from all-cause mortality was 97.3% in the LMCA group and 77.7% in the non-LMCA group (p = 0.17). The composite endpoint of myocardial infarction, angina, repeat intervention, or heart failure occurred in 19.6% of LMCA patients and 29.6% of non-LMCA patients (p = 0.98). Conclusions: Off-pump coronary artery bypass grafting is both feasible and safe in patients with critical LMCA stenosis. LMCA disease does not appear to adversely affect short-or mid-term outcomes following OPCABG.