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Updated: Jan 30, 2026
Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Off- vs. On-Pump Coronary Artery Bypass Grafting Long-Term Survival is Driven by Incompleteness of Revascularisation
Udit Thakur1, Nitesh Nerlekar2, Rahul G Muthalaly1
1Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Melbourne, Vic, Australia; Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Vic, Australia.
Insights
Off-pump coronary artery bypass grafting (CABG) shows higher long-term mortality and need for repeat procedures compared to on-pump CABG. This suggests on-pump CABG may offer better long-term outcomes due to reduced revascularization requirements.
Area of Science:
- Cardiovascular Surgery
- Surgical Outcomes Research
Background:
- Off-pump coronary artery bypass grafting (CABG) avoids extracorporeal circulation but is technically demanding, potentially leading to incomplete revascularization.
- On-pump CABG may offer prognostic benefits, but the underlying mechanisms require clarification.
- This study investigates if repeat revascularization drives long-term outcome differences between on-pump and off-pump CABG.
Purpose of the Study:
- To evaluate short, medium, and long-term outcomes of on-pump versus off-pump coronary artery bypass grafting (CABG).
- To determine if increased need for repeat revascularization in off-pump CABG contributes to long-term mortality differences.
Main Methods:
- A systematic review and meta-analysis of randomized controlled trials (RCTs) with at least 100 patients per arm.
- Included studies were searched from electronic databases.
- Primary outcome was long-term all-cause mortality; secondary outcomes included cardiac death, stroke, myocardial infarction, and repeat revascularization at 30 days, 12 months, and >4 years.
Main Results:
- Thirteen RCTs involving 13,234 patients were analyzed.
- Off-pump CABG was linked to higher long-term all-cause mortality (OR 1.18) and increased need for repeat bypass surgery (OR 2.57).
- A significant increase in revascularization for off-pump CABG was observed at 12 months (OR 1.59); no significant differences in stroke or myocardial infarction were found.
Conclusions:
- Off-pump CABG is associated with significantly higher long-term all-cause mortality.
- This increased mortality may be attributed to a greater requirement for repeat revascularization at 1- and 5-year follow-ups.
- On-pump CABG may provide superior long-term prognostic benefits.
Background:
Off-pump coronary artery bypass grafting (CABG) negates the requirement for extracorporeal circulation used with the traditional on-pump approach. However, off-pump CABG is technically more challenging and may theoretically lead to less complete revascularisation. Recent data suggests a prognostic benefit for traditional on-pump CABG, but the mechanism for this remains unclear. We hypothesised that the inferior outcomes with off-pump CABG could be driven by the need for repeat revascularisation, with this benefit only becoming clear at long-term follow-up. We therefore evaluated short, medium and long-term outcomes of patients undergoing revascularisation with on vs. off-pump CABG.
Methods:
Electronic databases were searched to identify suitable randomised controlled trials enrolling ≥100 patients in each arm. Clinical outcomes were extracted at 30-days, 12-months or >4years. The primary outcome was long-term all-cause death, while secondary outcomes included 30-day, 12-month and >4-year cardiac death, stroke, myocardial infarction or revascularisation.
Results:
Thirteen (13) studies comprising 13,234 patients were included. Off-pump CABG was associated with an increased risk of all-cause death (Odds Ratio [OR] 1.18, 95% confidence interval [CI] 1.02-1.32, p=0.01) and repeat bypass surgery (OR 2.57, 95%CI 1.23-5.39, p=0.01) at long-term follow-up. A significant, increased requirement for revascularisation in off-pump was seen at 12-month follow-up (OR 1.59, 95%CI 1.09-2.33, p=0.02). No differences were noted between groups at 30-days, 12-months and >4years for myocardial infarction or stroke.
Conclusions:
Off-pump CABG is associated with significantly higher rates of all-cause mortality rate at long-term follow-up. These outcomes demonstrate a temporal relationship that may be driven by a greater requirement for repeat revascularisation at 1- and 5-year follow-up.
Study Registration:
CRD42018102019 (PROSPERO).
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