Off-Pump Versus On-Pump Coronary-Artery Bypass Grafting in Elderly Patients

Abstract

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...

Stroke associated with coronary artery bypass grafting

“…Additionally, other observational studies suggested that high-risk patients, such as patients with cerebrovascular atherosclerosis, severe atherosclerotic aorta or peripheral arterial disease, showed a significant reduction in stroke incidence after OPCAB [71][72][73]. Conversely, a number of randomized studies comparing the OPCAB strategies with the conventional on-pump CABG procedures have failed to show an advantage with OPCAB regarding stroke [74][75][76]. As an example, the ROOBY trial randomly assigned 2203 patients to either on-pump or offpump procedures and found no difference between the two groups in stroke rate [76].…”

Épidémiologie des accidents vasculaires cérébraux périopératoires

“…Pour les troubles cognitifs é valué s à un an, une mé ta-analyse confirme l'absence de diffé rences entre les deux techniques chirurgicales [63]. De plus, même si plusieurs é tudes plaident pour cette technique chez les patients à risque chirurgical é levé et âgé s de plus de 80 ans [64][65][66][67][68], une nouvelle é tude ne montre pas de diffé rence dans ce dernier groupe pour l'incidence des AVCI et des troubles cognitifs [69]. L'inté rêt des pontages coronaires à coeur battant est donc remis en question.…”

Invited Commentary

“…Combined with the recent outcomes of the GOPCABGE study [German Off-Pump Coronary Artery Bypass Grafting in Elderly Patients] demonstrating no difference in on-pump or off-pump CABG in elderly patients, much of the large, contemporary literature on off-pump CABG indicates that, unlike the results of the ROOBY [Randomized On/Off Bypass] trial, off-pump is at least noninferior to on-pump CABG [1,2].In this growing era of comparative effectiveness research, however, we see a trend toward assessing new technologies not only with regard to their clinical effectiveness but also cost effectiveness [3]. Thus, while onpump and off-pump techniques appear to have similar clinical outcomes, could one technique prove more effective through lower overall costs?…”

“…Combined with the recent outcomes of the GOPCABGE study [German Off-Pump Coronary Artery Bypass Grafting in Elderly Patients] demonstrating no difference in on-pump or off-pump CABG in elderly patients, much of the large, contemporary literature on off-pump CABG indicates that, unlike the results of the ROOBY [Randomized On/Off Bypass] trial, off-pump is at least noninferior to on-pump CABG [1,2].…”