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

Study Questions:

What are the benefits of coronary artery bypass grafting (CABG) without cardiopulmonary bypass in the elderly?

Methods:

The GOPCABE (German Off-Pump Coronary Artery Bypass Grafting in Elderly Patients) trial investigators randomly assigned patients 75 years of age or older who were scheduled for elective first-time CABG to undergo the procedure either without cardiopulmonary bypass (off-pump CABG) or with it (on-pump CABG). The primary endpoint was a composite of death, stroke, myocardial infarction, repeat revascularization, or new renal replacement therapy at 30 days and at 12 months after surgery. The study groups were compared with use of the log-rank test.

Results:

A total of 2,539 patients underwent randomization. At 30 days after surgery, there was no significant 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 [OR], 0.95; 95% confidence interval [CI], 0.71-1.28; p = 0.74) or four of the components (death, stroke, myocardial infarction, or new renal replacement therapy). Repeat revascularization occurred more frequently after off-pump CABG than after on-pump CABG (1.3% vs. 0.4%; Or, 2.42; 95% CI, 1.03-5.72; p = 0.04). At 12 months, there was no significant between-group difference in the composite endpoint (13.1% vs. 14.0%; hazard ratio, 0.93; 95% CI, 0.76-1.16; p = 0.48) or in any of the individual components. Similar results were obtained in a per-protocol analysis that excluded the 177 patients who crossed over from the assigned treatment to the other treatment.

Conclusions:

The authors concluded that in patients 75 years of age or older, there was no significant difference between on-pump and off-pump CABG with regard to the composite outcome.

Perspective:

This study found no significant difference between off-pump CABG and on-pump CABG, performed in elderly patients, with respect to the composite endpoint of death, stroke, myocardial infarction, repeat revascularization, or new renal replacement therapy after surgery at 30 days or 1 year. Overall, this trial does not support the assumption that off-pump CABG can improve the early outcome in high-risk patients. The results do support the American Heart Association Scientific Statement, which concluded that both on-pump and off-pump procedures may result in excellent outcomes and that other factors, such as the skill of the surgeon and the quality of the institution, are more likely to influence the outcome than the choice of a particular surgical technique.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention

Keywords: Myocardial Infarction, Stroke, Cross-Over Studies, Health Resources, Cardiopulmonary Bypass, Coronary Artery Bypass, Renal Replacement Therapy, United States


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