On-pump versus off-pump coronary artery bypass surgery: what is the status after ROOBY, DOORS, CORONARY and GOPCABE?

Off-pump coronary artery bypass surgery has been purported to be safer than conventional coronary artery bypass surgery performed using cardiopulmonary bypass. This theory was supported by a number of early series, but failed to be confirmed by a number of small, randomized, controlled trials. Conversely, it has been suggested that revascularization after off-pump surgery is associated with fewer grafts and lower graft patency, potentially leading to a higher risk of cardiovascular morbidity and need for repeated coronary interventions. Since 2009, four major randomized controlled trials have been published, increasing the level of evidence significantly.