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Published on: March 27, 2018
Off-pump versus on-pump coronary artery bypass grafting: Insights from the Arterial Revascularization Trial
Umberto Benedetto1, Douglas G Altman2, Stephen Gerry2
1Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, United Kingdom.
Insights
Off-pump coronary artery bypass (OPCAB) and on-pump coronary artery bypass (ONCAB) demonstrate similar 5-year survival and major adverse event rates. This study suggests both OPCAB and ONCAB are equally safe and effective for cardiac revascularization.
Area of Science:
- Cardiovascular Surgery
- Cardiac Revascularization Techniques
- Clinical Trial Analysis
Background:
- Controversy exists regarding long-term outcomes of off-pump coronary artery bypass (OPCAB) versus on-pump coronary artery bypass (ONCAB).
- Previous studies reported varied adverse event rates, necessitating further comparative analysis.
- The Arterial Revascularization Trial (ART) initially compared internal thoracic artery grafting strategies.
Purpose of the Study:
- To conduct a post hoc analysis of the ART to compare 5-year outcomes between OPCAB and ONCAB.
- To evaluate the safety and efficacy of OPCAB versus ONCAB in a large patient cohort.
- To address the ongoing debate on the comparative effectiveness of these two CABG strategies.
Main Methods:
- A post hoc analysis of 3102 patients from the ART was performed.
- 1260 patients undergoing OPCAB were compared with 1700 patients undergoing ONCAB with cardioplegic arrest.
- Propensity score matching created 1260 pairs; outcomes analyzed included 5-year mortality and major cardiac/cerebrovascular events using stratified Cox models.
Main Results:
- Hospital mortality was comparable between OPCAB (1.0%) and ONCAB (1.2%) groups (P=.7).
- The 5-year mortality rates were similar: 8.9% for OPCAB and 8.3% for ONCAB (HR, 1.14; P=.35).
- Incidence of major cardiac and cerebrovascular events also showed no significant difference between groups (14.3% vs 13.8%; HR, 1.05; P=.65).
Conclusions:
- This post hoc analysis of the ART supports the hypothesis that OPCAB and ONCAB are equally effective.
- Both surgical strategies demonstrate comparable safety profiles at the 5-year follow-up.
- The findings suggest that the choice between OPCAB and ONCAB can be based on surgeon preference without compromising patient outcomes.
Background:
The long-term effects of off-pump coronary artery bypass continue to be controversial because some studies have reported increased adverse event rates with off-pump coronary artery bypass when compared with on-pump coronary artery bypass. The Arterial Revascularization Trial compared survival after bilateral versus single internal thoracic artery grafting. The choice of off-pump coronary artery bypass versus on-pump coronary artery bypass was based on the surgeon's discretion. We performed a post hoc analysis of the Arterial Revascularization Trial to compare 5-year outcomes with 2 strategies.
Methods:
Among 3102 patients enrolled in the Arterial Revascularization Trial, we selected 1260 patients who underwent off-pump coronary artery bypass versus 1700 patients who underwent on-pump coronary artery bypass with cardioplegic arrest for the present comparison. Primary outcomes were 5-year mortality and incidence of major cardiac and cerebrovascular events, including cardiovascular death, myocardial infarction, cerebrovascular accident, and revascularization after index procedure. Propensity score matching selected 1260 pairs for final comparison. Stratified Cox models were used for treatment effect estimate.
Results:
Hospital mortality was comparable between off-pump coronary artery bypass and on-pump coronary artery bypass groups (12 [1.0%] vs 15 [1.2%]; P = .7). Conversion rate to on-pump during off-pump coronary artery bypass was 29 of 1260 (2.3%). When compared with off-pump coronary artery bypass not converted, off-pump coronary artery bypass converted to on-pump presented a remarkably higher hospital mortality (10.3% vs 0.7%; P < .001). At 5 years, the mortality rate was 110 (8.9%) versus 102 (8.3%) in the off-pump coronary artery bypass and on-pump coronary artery bypass groups, respectively, with no significant difference (hazard ratio, 1.14; 95% confidence interval, 0.86-1.52; P = .35). Incidence of major cardiac and cerebrovascular events was 175 (14.3) versus 169 (13.8) in the off-pump coronary artery bypass and on-pump coronary artery bypass groups, respectively, with no significant difference (hazard ratio, 1.05; 95% confidence interval, 0.84-1.31; P = .65).
Conclusions:
The present post hoc Arterial Revascularization Trial analysis supports the hypothesis that both off-pump coronary artery bypass and on-pump coronary artery bypass are equally effective and safe.
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