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On-pump CABG may confer better survival than off-pump CABG
Over the long term, on-pump CABG was associated with better survival than off-pump CABG, but other outcomes did not differ, according to a new meta-analysis.
Researchers analyzed 8,145 participants from six randomized controlled trials comparing on-pump vs. off-pump CABG for which at least 4 years of data were available.
The outcomes of interest were mortality, MI, angina, revascularization and stroke. All studies had mortality as an endpoint, whereas five included MI, three included angina, five included revascularization and three included stroke. Five studies reported outcomes at 5 years and the sixth study reported outcomes at longer than 4 years.
Mortality differences
Mortality was higher in the off-pump group vs. the on-pump group (13.9% vs. 12.3%; OR = 1.16; 95% CI, 1.02-1.32), Neil A. Smart, PhD, from the School of Science and Technology, University of New England, Armidale, Australia, and colleagues wrote.
However, there were no significant differences between the groups in MI (off-pump, 8.4%; on-pump, 7.9%; OR = 1.06; 95% CI, 0.91-1.25), angina (off-pump, 2.3%; on-pump, 2.1%; OR = 1.09; 95% CI, 0.75-1.57), revascularization (off-pump, 5.9%; on-pump, 5.1%; OR = 1.15; 95% CI, 0.95-1.4) and stroke (off-pump, 2.2%; on-pump, 2.8%; OR = 0.78; 95% CI, 0.56-1.1), according to the researchers.
Points to consider
In a related editorial, David H. Adams, MD, from the department of cardiovascular surgery, Icahn School of Medicine at Mount Sinai, and Joanna Chikwe, MD, from the department of surgery at Stony Brook University, wrote that there are five points to consider when referring a patient for CABG:
- The on-pump vs. off-pump debate has been exhausted, so “the discussion needs to be reframed in terms of which patients may benefit more from one approach or the other.”
- Information on patient subgroups who benefit from one approach or the other is limited, so “patients will benefit most from referral to a surgeon with experience and documented excellent outcomes, rather than a targeted on- or off-pump technique preference.”
- Registry data can be helpful and “surgical revascularization in the modern era has clearly established an exceptional safety record.”
- Patients “benefit from the evolution of cardiopulmonary bypass support that is almost unrecognizable from the technology of even 10 years ago, and receive care from multidisciplinary teams that bring a level of experienced sophistication and safety that was primarily available only in select centers until relatively recently.”
- Advances in technology have helped address the shortcomings of on-pump CABG, whereas off-pump CABG results remain primarily driven by surgical expertise, so postoperative adverse events are few, and long-term outcomes such as those reported in the present analysis must be emphasized.
“Given the equivalent short-term safety of both approaches and the superior long-term outcomes now reported, an on-pump approach to coronary surgical revascularization continues to stand the test of time,” they concluded. – by Erik Swain
Disclosures: The authors and Chikwe report no relevant financial disclosures. Adams reports his institution receives royalty payments from Edwards Lifesciences and Medtronic.