Off- vs. On-Pump Surgery for Left Main Disease

Study Questions:

What are the outcomes following off-pump versus on-pump surgery for left main disease in a post hoc analysis from the multicenter, randomized EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial?

Methods:

The investigators conducted a post hoc retrospective analysis from the EXCEL trial. The EXCEL trial was designed to compare percutaneous coronary intervention with everolimus-eluting stents versus coronary artery bypass grafting (CABG) in patients with left main disease. CABG was performed with or without cardiopulmonary bypass (on-pump vs. off-pump surgery) according to the discretion of the operator. The 3-year outcomes in the off-pump and on-pump groups were compared using inverse probability of treatment weighting (IPTW) for treatment effect estimation.

Results:

Among 923 CABG patients, 652 and 271 patients underwent on-pump and off-pump surgery, respectively. Despite a similar extent of disease, off-pump surgery was associated with a lower rate of revascularization of the left circumflex coronary artery (84.1% vs. 90.0%; p = 0.01) and right coronary artery (31.1% vs. 40.6%; p = 0.007). After IPTW adjustment for baseline differences, off-pump surgery was associated with a significantly increased risk of 3-year all-cause death (8.8% vs. 4.5%; hazard ratio, 1.94; 95% confidence interval, 1.10-3.41; p = 0.02) and a nonsignificant difference in the risk for the composite endpoint of death, myocardial infarction, or stroke (11.8% vs. 9.2%; hazard ratio, 1.28; 95% confidence interval, 0.82-2.00; p = 0.28).

Conclusions:

The authors concluded that among patients with left main disease treated with CABG in the EXCEL trial, off-pump surgery was associated with a lower rate of revascularization of the coronary arteries supplying the inferolateral wall and an increased risk of 3-year all-cause death compared with on-pump surgery.

Perspective:

This post hoc analysis from the EXCEL trial reports that performance of off-pump compared with on-pump surgery was associated with use of fewer grafts, particularly to the left circumflex coronary artery and right coronary artery territories. While the two groups presented similar incidence of major adverse events during index hospitalization, off-pump surgery was associated with a significant twofold increase in mortality at 3 years. Additional prospective studies are indicated to assess the outcomes of off-pump surgery performed by experienced surgeons in patients with left main coronary artery disease. For now, for most patients with left main coronary disease along with extensive multivessel disease, on-pump surgery appears to be the preferred option.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease

Keywords: Cardiopulmonary Bypass, Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Bypass, Off-Pump, Coronary Artery Disease, Drug-Eluting Stents, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Risk, Secondary Prevention, Stroke


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