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On-Pump Beats Off-Pump CABG for Graft Patency

Even in the hands of expert surgeons

The development of cardiac stabilizers has renewed interest in beating-heart coronary artery bypass grafting (off-pump CABG). Use of cardiopulmonary bypass (on-pump CABG) is believed to contribute to postoperative morbidity including neuropsychological impairment. To compare these 2 techniques directly in unselected patients who required multivessel grafting, researchers in Britain randomized 104 patients (mean age, 62; 27% with diabetes) who needed at least 3 grafts to on-pump or off-pump CABG at a single center.

The mean number of grafts was similar in the 2 groups (on-pump, 3.4; off-pump, 3.1). Mean blood loss also was similar, although more on-pump patients needed transfusions and required re-sternotomy for bleeding. Six and 12-hour postoperative troponin T levels were significantly higher in on-pump patients, but the number of MIs was similar (on-pump, 0; off-pump, 1).

No deaths occurred by 3 months, and adverse-event incidence was similar in the 2 groups, as was the distribution of angina class. However, angiography (obtained in 80% of patients) showed a significantly higher overall rate of graft patency with on-pump than with off-pump surgery (98% vs. 88%). Compared with the on-pump group, the off-pump group used more radial-artery grafts and had a particularly low follow-up patency rate with these grafts (76%). Trends toward lower patency in off-pump than on-pump patients were observed for saphenous-vein grafts (91% vs. 95%), pedicled left internal thoracic artery grafts (92% vs. 100%), and all target-vessel territories.

Comment: In this randomized comparison, off-pump CABG was safe but was associated with significantly worse 3-month graft patency than was on-pump CABG. Two experienced surgeons performed the procedures, but relatively less experience with the off-pump technique could have contributed to the difference in patency rates between the procedures. Nevertheless, this study should raise concerns about long-term outcomes associated with off-pump CABG and should prompt future investigations to identify which patient subgroups benefit most from avoiding cardiopulmonary bypass.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology February 6, 2004

Citation(s):

Khan NE et al. A randomized comparison of off-pump and on-pump multivessel coronary-artery bypass surgery. N Engl J Med 2004 Jan 1; 350:21-8.

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