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Off-pump versus on-pump coronary artery bypass grafting for ischaemic heart disease
Christian H Møller1, Luit Penninga, Jørn Wetterslev
1Department of Cardiothoracic Surgery, RT 2152, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.chm@ctu.rh.dk.
Insights
On-pump coronary artery bypass grafting (CABG) shows better long-term survival than off-pump CABG. On-pump CABG remains the standard surgical treatment for ischemic heart disease, though off-pump may be suitable in specific cases.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery Outcomes
- Comparative Effectiveness Research
Background:
- Coronary artery bypass grafting (CABG) is a common procedure for ischemic heart disease.
- Two techniques exist: off-pump CABG (OPCAB) and on-pump CABG (using cardiopulmonary bypass).
- The optimal CABG technique remains a subject of debate.
Purpose of the Study:
- To compare the benefits and harms of OPCAB versus on-pump CABG.
- To evaluate mortality, morbidity, and long-term survival outcomes.
- To provide evidence-based recommendations for surgical practice.
Main Methods:
- Systematic review and meta-analysis of randomized clinical trials (RCTs).
- Comprehensive literature search across multiple databases (CENTRAL, MEDLINE, EMBASE, etc.).
- Statistical analysis using risk ratios and mean differences, with trial sequential analysis to assess reliability.
Main Results:
- Eighty-six RCTs involving 10,716 participants were analyzed.
- OPCAB was associated with increased all-cause mortality compared to on-pump CABG (RR 1.24).
- No significant differences were found in myocardial infarction, stroke, or renal insufficiency; OPCAB had fewer distal anastomoses.
Conclusions:
- On-pump CABG demonstrated better long-term survival and should remain the standard surgical treatment.
- OPCAB did not show significant benefits in mortality, stroke, or myocardial infarction.
- OPCAB may be considered when aortic cannulation or cardiopulmonary bypass is contraindicated.
Background:
Coronary artery bypass grafting (CABG) is performed both without and with cardiopulmonary bypass, referred to as off-pump and on-pump CABG respectively. However, the preferable technique is unclear.
Objectives:
To assess the benefits and harms of off-pump versus on-pump CABG in patients with ischaemic heart disease.
Search Methods:
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 1, 2011), MEDLINE (OVID, 1950 to February 2011), EMBASE (OVID, 1980 to February 2011), Science Citation Index Expanded on ISI Web of Science (1970 to February 2011) and CINAHL (EBSCOhost, 1981 to February 2011) on 2 February 2011. No language restrictions were applied.
Selection Criteria:
Randomised clinical trials of off-pump versus on-pump CABG irrespective of language, publication status and blinding were selected for inclusion.
Data Collection And Analysis:
For statistical analysis of dichotomous data risk ratio (RR) and for continuous data mean difference (MD) with 95% confidence intervals (CI) were used. Trial sequential analysis (TSA) was used for analysis to assess the risk of random error due to sparse data and to multiple updating of accumulating data.
Main Results:
Eighty-six trials (10,716 participants) were included. Ten trials (4,950 participants) were considered to be low risk of bias. Pooled analysis of all trials showed that off-pump CABG increased all-cause mortality compared with on-pump CABG (189/5,180 (3.7%) versus 160/5144 (3.1%); RR 1.24, 95% CI 1.01 to 1.53; P =.04). In the trials at low risk of bias the effect was more pronounced (154/2,485 (6.2%) versus 113/2,465 (4.6%), RR 1.35,95% CI 1.07 to 1.70; P =.01). TSA showed that the risk of random error on the result was unlikely. Off-pump CABG resulted in fewer distal anastomoses (MD -0.28; 95% CI -0.40 to -0.16, P <.00001). No significant differences in myocardial infarction, stroke, renal insufficiency, or coronary re-intervention were observed. Off-pump CABG reduced post-operative atrial fibrillation compared with on-pump CABG, however, in trials at low risk of bias, the estimated effect was not significantly different.
Authors' Conclusions:
Our systematic review did not demonstrate any significant benefit of off-pump compared with on-pump CABG regarding mortality, stroke, or myocardial infarction. In contrast, we observed better long-term survival in the group of patients undergoing on-pump CABG with the use of cardiopulmonary bypass and cardioplegic arrest. Based on the current evidence, on-pump CABG should continue to be the standard surgical treatment. However, off-pump CABG may be acceptable when there are contraindications for cannulation of the aorta and cardiopulmonary bypass. Further randomised clinical trials should address the optimal treatment in such patients.
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