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Better Long-Term Survival with On-Pump vs. Off-Pump CABG

Summary and Comment |
June 6, 2014

Better Long-Term Survival with On-Pump vs. Off-Pump CABG

  1. Howard C. Herrmann, MD

Overall mortality risk was 50% higher in patients who underwent off-pump versus on-pump coronary artery bypass grafting.

  1. Howard C. Herrmann, MD

Compared with on-pump coronary artery bypass grafting (CABG), off-pump surgery offers potential advantages of reduced bleeding, reduced need for transfusion, and superior neurocognitive outcomes. However, few studies have compared long-term survival with each strategy.

In the current study, investigators compared all-cause mortality in 2333 patients who underwent off-pump CABG and 2570 patients who underwent on-pump surgery between 1989 and 2012 at a single center in Korea. Compared with the on-pump group, rates of diabetes, hypertension, and single-vessel coronary artery disease (CAD) were higher in the off-pump group. Mean ejection fraction was also slightly higher in the off-pump group, but age, sex, and prevalence of left-main CAD were similar between the two groups. More distal anastomoses were performed in the on-pump group (mean, 3.7 vs. 3.0), but more arterial grafts were used in the off-pump group.

All-cause mortality was similar between the two groups at 30 days and 1 year but increased more in the off-pump group during long-term follow-up (median, 6.4 years). Using propensity-matched adjustment, overall mortality risk was nearly 50% higher with off-pump versus on-pump CABG (mortality rates, 22% vs. 17%; hazard ratio, 1.48; 95% confidence interval, 1.14–1.90).

Comment

In this large, retrospective comparison, on-pump CABG was associated with better long-term survival compared with off-pump CABG. These findings are consistent with results of smaller studies and meta-analyses. Possible explanations for the better outcome with on-pump surgery include more-complete revascularization, superior graft patency for technical reasons (not assessed in this study), and the higher mortality observed in patients who crossed over from off-pump to on-pump surgery.

  • Disclosures for Howard C. Herrmann, MD at time of publication Consultant / Advisory board Gerson Lehrman Group; Siemens; St. Jude Medical; Leerink Swann; Wells Fargo; Massachusetts Medical Society; Morgan Stanley; Edwards Lifesciences Speaker's bureau Society of Cardiovascular Angiography and Interventions; Montefiore Medical Center; American Association for Thoracic Surgery Equity Micro-Interventional Devices, Inc. Grant / Research support Abbott Vascular; Edwards Lifesciences; Gore; Medtronic; St. Jude Medical; Siemens; Boston Scientific; Regado Biosciences; Cordis; Cardiokinetix; University of Laval; MitraSpan Editorial boards Catheterization and Cardiovascular Interventions; Circulation-Cardiovascular Interventions; Journal of Interventional Cardiology; Journal of Invasive Cardiology Royalties Mount Sinai Medical Center, Miami, FL

Citation(s):

Reader Comments (3)

Pietro Vandoni Physician, Cardiology, JHH , Jilin Province China

Retrospective and single center study, are the two bias that affect the reliability of these results..I will continue to believe that for some patients (elderly, history of CVA, neoplasia…) off-pump surgery may offer immediate and late better result than on-pump surgery. Probably off-pump surgery is the only possible way for surgery to compete with PCI in the fast evolving scenario of myocardial revascularization.

KALLINIKOS TSAKONAS Physician, Cardiology

IT'S LOGICAL FOR MANY REAWONS '' ON -PUMP'' GIVES AT LEAST TECHNICAL PROBLEMS TO THE THORACIC SURGEON GOOD BUT OBVIOUS THESE RESULTS!

Philip Saccoccia Jr MD FCAP Physician, Pathology, Medical Laboratory Service

Study is large and survival difference is highly significant. But a well done prospective randomized controlled trial (RCT) should mitigate confounding factors such as pre-existing conditions and technical differences and show entirely different outcomes.

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