Off-Pump Surgery Is Associated With Reduced Occurrence of Stroke and Other Morbidity as Compared With Traditional Coronary Artery Bypass Grafting

Abstract

Background and Purpose-There is growing enthusiasm for coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB). Although deleterious effects of CPB are known, it remains to be proven that avoiding CPB will result in reduction in morbidity. We sought to determine whether off-pump surgery is associated with reduced occurrence of adverse outcomes as compared with CABG with CPB. Methods-Studies were identified by searching the MEDLINE, EMBASE and the Cochrane Register 1980. We also searched the reference lists of randomized clinical trials (RCT) and reviews to look for additional studies. Study selection: RCTs comparing off-pump surgery to CABG with CPB. No restriction applied on the size of the trial or end point reports. Data extraction: 2 reviewers independently searched for studies, read abstracts and abstracted all data. Data synthesis: combined estimates were obtained using fixed or random effect meta-analyses. Relative risks and risk differences were calculated. Heterogeneity was assessed using 2 and I 2 values. Results-There were 3996 patients enrolled in 41 RCTs (mean age 62, 22% female). No study reported information on race. Off-pump CABG was associated with a 50% reduction in the relative risk of stroke (95% CI, 7% to 73%), 30% reduction in atrial fibrillation (AF; 95% CI, 16% to 43%) and 48% reduction in wound infection (95% CI, 26% to 63%) with no heterogeneity among RCTs. This translated into avoidance of 10 strokes, 80 cases of AF and 40 infections per 1000 CABG. Fewer distal grafts were performed and there was evidence for Ͼ10 reinterventions per 1000 with off-pump CABG. Long-term follow-up is not yet reported in the trials. Conclusions-Off-pump CABG is associated with reduced risk of stroke, AF and infections as compared with CABG with CPB. Evidence should be generalized taking into account RCT enrollment limitations, drawbacks related to training requirements, propensity to perform fewer grafts and likely reinterventions after off-pump surgery. (Stroke. 2006;37: 2759-2769.)

Guidelines on myocardial revascularization

“…Complete off-pump procedures in the hands of trained surgical teams seem to be associated with a reduced risk of stroke, AF, respiratory and wound infections, less transfusion, and shorter hospital length of stay [201]. Highly experienced teams obtain similar 1-year outcomes, graft patency, and quality of life with offpump vs. on-pump approaches.…”

The Impact of a Microbial Sealant to Reduce Surgical Site Infections in High Risk Cardiac Surgery Patients

“…It has been reported that off-pump coronary bypass surgery can reduce SSI. Sedrakyan et al [22] showed in a meta-analyzes that wound infections could be reduced by 48% at the same risk as compared with on-pump surgery (RR, 0.52; 95% CI, 0.37 to 0.74). Risk difference analyzes showed 40 SSI prevented per 1000 coronary bypass surgeries with an off-pump approach.…”

Transatlantic editorial: A comparison between European and North American guidelines on myocardial revascularization

“…Two additional prospective RCTs, focusing on elderly and high-risk patients, had failed to demonstrate a difference in 30-day or 1-year outcomes when on-or off-pump CABG was performed by experienced teams [50,51]. Interestingly, based on some of the same data available to the American group [47,52], the Europeans were more convinced of the potential value of off-pump surgery in high-risk patients, especially with regard to stroke, and recommended that off-pump CABG be 'considered' for subgroups of high-risk patients in high-volume off-pump centres as a COR IIa based on LOE B. Like their American colleagues, the European group was even more definitive regarding minimization of aortic manipulation and 'recommended' off-pump CABG and/or no touch on-pump techniques for patients with significant atherosclerotic aortic disease as a COR I with LOE B.…”