In patients 75 years of age or older, there was no significant difference between on-pump and off-pump CABG with regard to the composite outcome of death, stroke, myocardial infarction, repeat revascularization, or new renal-replacement therapy within 30 days and within 12 months after surgery. (Funded by Maquet; GOPCABE ClinicalTrials.gov number, NCT00719667.).

In patients with AMI and successful coronary reperfusion, the size of delayed gadolinium enhancement at CE cardiac MR imaging significantly diminished during the 1st week after infarction. Thus, timing of CE cardiac MR imaging is crucial for accurate measurement of myocardial infarct size early after AMI.

T he benefits of coronary artery bypass grafting (CABG) without cardiopulmonary bypass in the elderly has yet to be determined. Patients 75 years or older who were scheduled for elective first-time CABG were randomly assigned to undergo the procedure either without cardiopulmonary bypass (off-pump CABG) or with it (on-pump CABG). The primary end point was a composite of death, stroke, myocardial infarction, repeat revascularization, or new renal replacement therapy at 30 days and 12 months after surgery. A total of 2539 patients underwent randomization. Thirty days after surgery, there was no marked difference between patients who underwent off-pump surgery and those who underwent on-pump surgery in terms of the composite outcome (7.8% vs 8.2%; odds ratio, 0.95%; 95% confidence interval [CI], 0.71-1.28) or of the components (death, stroke, myocardial infarction, or new renal replacement therapy). Repeat revascularization took place more often after off-pump CABG than after on-pump CABG (1.3% vs 0.4%; odds ratio, 2.42; 95% CI, 1.03-5.72). At 12 months, no between-group difference existed in the composite end point (13.1% vs 14.0%; hazard ratio, 0.93; 95% CI, 0.76-1.16) or in any of the separate components. Similar results were seen in a per-protocol analysis that excluded the 177 patients who crossed over from the assigned treatment to the other treatment. The investigators concluded that in patients 75 years or older, no marked difference existed between on-pump and off-pump CABG regarding the composite outcome of death, stroke, myocardial infarction, repeat revascularization, or new renal replace ment therapy within 30 days and within 12 months after surgery. COMMENTThe on/off bypass debate has been the focus of CABG surgery for more than a decade. Off-pump surgery was performed as an alternative to on-pump surgery to avoid or decrease complications related to cardiopulmonary bypass and/or to avoid manipulation or cross clamping of the aortic root and ascending aorta. With appropriate expertise, this was extended to routine surgery for coronary artery disease. Thus, outcomes from trials in off-pump surgery were comparable to on-pump surgery, particularly from institutions with adequate expertise in this type of procedure. However, there have been increasing reports of inferior graft patency in the short term and intermediate term requiring repeat revascularization associated with off-pump coronary surgery.The current study is a multicenter randomized controlled trial in elderly patients (≥75 years old) undergoing elective first-time CABG, thus targeting a potentially high-risk operative group. The randomization was rather robust; nearly a third of all potentially eligible patients were excluded. Furthermore, the authors showed that patients were not excluded owing to surgical preference for one technique over another. An important inclusion criterion was surgeon expertise, thereby excluding a potential bias toward unfavorable outcomes related to surgical skill.In 2394 elderly patients randomized to on/off-pump...