Current evidence of coronary artery bypass grafting off-pump versus on-pump: a systematic review with meta-analysis of over 16 900 patients investigated in randomized controlled trials

Abstract

In the present systematic review with meta-analysis, we sought to determine the current strength of evidence for or against off-pump and on-pump coronary artery bypass grafting (CABG) with regard to hard clinical end-points, graft patency and cost-effectiveness. We performed a meta-analysis of only randomized controlled trials (RCT) which reported at least one of the desired end-points including: (i) major adverse cardiac and cerebrovascular events (MACCE), (ii) all-cause mortality, (iii) myocardial infarction, (iv) cerebrovascular accident, (v) repeat revascularization, (vi) graft patency and (vii) cost-effectiveness. The pooled treatment effects [odds ratio (OR) or weighted mean difference, 95% confidence intervals (95% CIs)] were assessed using a fixed or random effects model. A total of 16 904 patients from 51 studies were identified after literature search of the major databases using a predefined keyword list. The incidence of MACCE did not differ between the groups, neither during the first 30 days (OR: 0.93; 95% CI: 0.82-1.04) nor for the longest available follow-up (OR: 1.01; 95% CI: 0.92-1.12). While the incidence of mid-term graft failure (OR: 1.37; 95% CI: 1.09-1.72) and the need for repeat revascularization (OR: 1.55; 95% CI: 1.33-1.80) was increased after off-pump surgery, on-pump surgery was associated with an increased occurrence of stroke (OR: 0.74; 95% CI: 0.58-0.95), renal impairment (OR: 0.79; 95% CI: 0.71-0.89) and mediastinitis (OR: 0.44; 95% CI: 0.31-0.62). There was no difference with regard to hard clinical end-points between on- or off-pump surgery, including myocardial infarction or mortality. The present systematic review emphasizes that both off- and on-pump surgery provide excellent and comparable results in patients requiring surgical revascularization. The choice for either strategy should take into account the individual patient profile (comorbidities, life expectancy, etc.) and importantly, the surgeon's experience in performing on- or off-pump CABG in their routine practice.

Current outcomes of off-pump versus on-pump coronary artery bypass grafting: evidence from randomized controlled trials

“…OPCAB, off-pump coronary artery bypass; ONCAB, on-pump coronary artery bypass; RCT, randomized controlled trial; CI, confidence interval; RR, relative risk. (1,3) found no difference in myocardial infraction rates between ONCAB or OPCAB. In the meta-analysis by Deppe et al (3), the incidence of low cardiac output and infection were reduced with use off-pump.…”

“…The majority of the large RCTs to date failed to show a difference in early mortality between off-pump and on-pump surgery (1,3,(9)(10)(11)(12)(13). One small sample size RCT by Fattouch et al showed a reduced mortality in patients with ST elevation undergoing urgent/emergent off-pump coronary surgery compared to on-pump surgery (14).…”

“…This intense debate is held between three schools of thought: the "pure", off-pump surgeons, the onpump surgeons and the "selectivists" group that reserves off-pump surgery for selected cases only. Historically, the shift towards off-pump coronary artery bypass (OPCAB) grafting was proposed both to reduce the operation cost in developing countries but also to avoid the deleterious effects of the contact of blood with the artificial extracorporeal circuit (i.e., mainly the systemic inflammatory response and coagulopathy) (1)(2)(3). Furthermore, avoidance of aortic cannulation and minimisation of aortic manipulation would theoretically translate into reduced cerebral stroke, hence reduced morbidity and perioperative mortality (4).…”

“…Furthermore, avoidance of aortic cannulation and minimisation of aortic manipulation would theoretically translate into reduced cerebral stroke, hence reduced morbidity and perioperative mortality (4). On the other hand, on-pump surgeons argue that the comfort of the bypass circuit results in a better anastomotic technique that translates into a more complete revascularization and Review Article Current outcomes of off-pump versus on-pump coronary artery bypass grafting: evidence from randomized controlled trials better graft patency (3).…”

Off‐Pump Coronary Artery Bypass Grafting: 30 Years of Debate

“…The most recent meta‐analysis pooled angiographic data on 7011 grafts and found an OR of 1.51 for occlusion in the OPCAB arm (95% CI, 1.21–1.88; P =0.002) 84. Differences in surgeons’ experience, varying completeness of follow‐up, and angiographic definitions are the plausible reasons for the reported discrepancies.…”