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ISMICS Consensus Conference and Statements of Randomized Controlled Trials of Off-Pump Versus Conventional Coronary
John D Puskas1, Janet Martin, Davy C H Cheng
1From the *Department of Cardiovascular Surgery, Icahn School of Medicine, Mount Sinai, New York, NY USA; †Centre for Medical Evidence, Decision Integrity, Clinical Impact (MEDICI), Department of Anesthesia & Perioperative Medicine, and Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada; ‡Division of Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland; §Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; ∥Herz-Und Gefasse Klinik Bad Neustadt, University of Leipzig, Bad Neustadt, Germany; ¶Division of Cardiovascular and Thoracic Surgery, Lankenau Medical Center, Wynnewood, PA USA; #Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB Canada; **Division of Cardiac Surgery and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; ††Baylor Health System, Heart Hospital Baylor Plano, Dallas, TX USA; ‡‡Department of Cardiothoracic Surgery, Lenox Hill, New York, NY USA; §§University of Ottawa Heart Institute, Ottawa, Ontario, Canada; ∥∥Heart Vascular Institute, Cleveland Clinic, Cleveland, OH USA; and ¶¶Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.
Objective:
At this consensus conference, we developed evidence-informed consensus statements and recommendations on the practice of off-pump coronary artery bypass graft (OPCAB) by systematically reviewing and performing meta-analysis of the randomized controlled trials (RCTs) comparing OPCAB and conventional coronary artery bypass (CCAB).
Methods:
All RCTs of OPCAB versus CCAB through April 2013 were screened, and 102 relevant RCTs (19,101 patients) were included in a systematic review and meta-analysis (15 RCTs of 9551 high-risk patients; and 87 RCTs of 9550 low-risk patients) in accordance with the Cochrane Collaboration and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Consensus statements for the risks and benefits of OPCAB surgery in mortality, morbidity, and resource use were developed based on best available evidence.
Results:
Compared to CCAB, it is reasonable to perform OPCAB to reduce risks of stroke [class IIa, level of evidence (LOE) A], renal dysfunction/failure (class IIa, LOE A), blood transfusion (class I, LOE A), respiratory failure (class I, LOE A), atrial fibrillation (class I, LOE A), wound infection (class I, LOE A), ventilation time, and ICU and hospital length of stay (class I, LOE A). However, OPCAB may be associated with a reduced number of grafts performed (class I, LOE A) and with diminished graft patency (class IIa, LOE A, with increased coronary reintervention at 1 year and beyond (class IIa, LOE A), as well as increased mortality at a median follow-up of 5 years (class IIb, LOE A).
Conclusions:
OPCAB compared with CCAB may improve outcomes in the short-term (stroke, renal dysfunction, blood transfusion, respiratory failure, atrial fibrillation, wound infection, ventilation time, and length of stay). However, over the longer-term, OPCAB may be associated with reduced graft patency, and increased risk of cardiac re-intervention and death.