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Long-Term Outcomes After Off-Pump vs. On-Pump CABG
Study Questions:
What is the long-term survival and morbidity after on-pump versus off-pump coronary artery bypass grafting (CABG)?
Methods:
The investigators linked mandatory clinical and administrative registries from New Jersey Department of Health to identify patients who underwent CABG between 2005 and 2011, by surgeons who had performed at least 100 off-pump or on-pump CABG operations. Survival, stroke, myocardial infarction, repeat revascularization, and new dialysis requirement were compared using Cox modeling, propensity scores, and instrumental variable analysis. Median follow-up was 6.8 years (range, 0-11.0 years); last follow-up date was December 31, 2015.
Results:
Among 42,570 CABG patients, 6,950 who underwent off-pump CABG and 15,295 who underwent on-pump CABG met study criteria. Off-pump CABG was associated with higher mortality (33.4% vs. 29.6% at 10 years; hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.04-1.18; p = 0.002) compared with on-pump CABG. Off-pump CABG was associated with a higher risk of incomplete revascularization (15.7% vs. 8.8%; p < 0.001), which was a predictor of late mortality (HR, 1.10; 95% CI, 1.03-1.17; p = 0.006) and higher rates of repeat revascularization (15.4% vs. 14.0% at 10 years; HR, 1.17; 95% CI, 1.01-1.37; p = 0.048). There were no significant differences in the rate of stroke, myocardial infarction, or new dialysis.
Conclusions:
The authors concluded that off-pump was associated with increased incomplete revascularization, repeat revascularization, and mortality at 10 years compared with on-pump CABG.
Perspective:
This study reports that in a contemporary cohort of patients undergoing CABG, the long-term risk of death associated with off-pump CABG was higher than that associated with on-pump CABG. Furthermore, off-pump CABG was associated with increased risk of incomplete revascularization and increased rates of repeat revascularization. These findings have implications for the optimal choice of procedure in the majority of patients undergoing surgical revascularization, with on-pump CABG being the most appropriate choice for most patients without contraindications to cardiopulmonary bypass. Additional studies are indicated to examine outcomes of procedures performed using contemporary technology and revascularization modalities to help select the optimum strategy for patients undergoing CABG.
Keywords: Cardiac Surgical Procedures, Cardiopulmonary Bypass, Coronary Artery Bypass, Coronary Artery Bypass, Off-Pump, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Renal Dialysis, Secondary Prevention, Stroke
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