Off- vs. On-Pump Coronary Artery Bypass Grafting Long-Term Survival is Driven by Incompleteness of Revascularisation

Udit Thakur, Nitesh Nerlekar, Rahul G. Muthalaly, Andrea Comella, Nathan C. Wong, James D. Cameron, Richard W. Harper, Julian A. Smith, Adam J. Brown

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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 >4 years. 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 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 >4 years 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. Trial registration: CRD42018102019.

Original languageEnglish
Pages (from-to)149-155
Number of pages7
JournalHeart Lung and Circulation
Issue number1
Publication statusPublished - Jan 2020


  • Coronary artery bypass grafting
  • Meta-analysis
  • Mortality
  • Off-pump
  • On-pump

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