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A Randomized Trial

Diederik Van Dijk, MD; Erik W. L. Jansen, MD,PhD; Ron Hijman, PhD; Arno P. Nierich, MD,PhD; Jan C. Diephuis, MD; Karel G. M. Moons, PhD; Jaap R. Lahpor, MD,PhD; Cornelius Borst, MD,PhD; Annemieke M. A. Keizer, MSc; Hendrik M. Nathoe, MD; Diederick E. Grobbee, MD,PhD; Peter P. T. De Jaegere, MD,PhD; Cor J. Kalkman, MD,PhD; for the Octopus Study Group

JAMA. 2002;287:1405-1412.

Context  Coronary artery bypass graft (CABG) surgery is associated with a decline in cognitive function, which has largely been attributed to the use of cardiopulmonary bypass (on-pump procedures). Cardiac stabilizers facilitate CABG surgery without use of cardiopulmonary bypass (off-pump procedures) and should reduce the cognitive decline associated with on-pump procedures.

Objective  To compare the effect of CABG surgery with (on-pump) and without (off-pump) cardiopulmonary bypass on cognitive outcome.

Design and Setting  Randomized controlled trial conducted in the Netherlands of CABG surgery patients enrolled from March 1998 through August 2000, with 3- and 12-month follow-up.

Participants and Intervention  Patients scheduled for their first CABG surgery (mean age, 61 years; n = 281) were randomly assigned to off-pump surgery (n = 142) or on-pump surgery (n = 139).

Main Outcome Measures  Cognitive outcome at 3 and 12 months, which was determined by psychologists (blinded for randomization) who administered 10 neuropsychological tests before and after surgery. Quality of life, stroke rate, and all-cause mortality at 3 and 12 months were secondary outcome measures.

Results  Cognitive outcome could be determined at 3 months in 248 patients. Cognitive decline occurred in 21% in the off-pump group and 29% in the on-pump group (relative risk [RR], 0.65; 95% confidence interval [CI], 0.36-1.16; P = .15). The overall standardized change score (ie, improvement of cognitive performance) was 0.19 in the off-pump vs 0.13 in the on-pump group (P = .03). At 12 months, cognitive decline occurred in 30.8% in the off-pump group and 33.6% in the on-pump group (RR, 0.88; 95% CI, 0.52-1.49; P = .69). The overall standardized change score was 0.19 in the off-pump vs 0.12 in the on-pump group (P = .09). No statistically significant differences were observed between the on-pump and off-pump groups in quality of life, stroke rate, or all-cause mortality at 3 and 12 months.

Conclusion  Patients who received their first CABG surgery without cardiopulmonary bypass had improved cognitive outcomes 3 months after the procedure, but the effects were limited and became negligible at 12 months.

Author Affiliations: Departments of Anaesthesiology (Drs Van Dijk, Diephuis, and Kalkman), Cardiothoracic Surgery (Drs Jansen and Lahpor), Psychiatry (Dr Hijman and Ms Keizer), Cardiology (Drs Borst, Nathoe, and De Jaegere), and the Julius Center for Patient Oriented Research (Drs Moons and Grobbee), University Medical Center Utrecht, Utrecht; and Department of Thoracic Anaesthesiology, Isala Clinics, Weezenlanden Hospital, Zwolle (Dr Nierich), the Netherlands.

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Fetnat M. Fouad-Tarazi, Joseph Feldschuh, Suzana M. F. Malheiros, Ayrton R. Massaro, Enio Buffolo, Donald Venes, William T. C. Yuh, Christopher J. Knott-Craig, Monala D. Tilak, Diederik van Dijk, and Cor J. Kalkman
JAMA. 2002;287(23):3077-3079.
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