CLINICAL RESEARCH: CARDIAC SURGERY
Off-Pump Coronary Artery Surgery for Reducing Mortality and Morbidity
Meta-Analysis of Randomized and Observational Studies
Duminda N. Wijeysundera, MD*,*,
W. Scott Beattie, MD, PhD*,
George Djaiani, MD*,
Vivek Rao, MD, PhD ,
Michael A. Borger, MD, PhD,
Keyvan Karkouti, MD, MSc*, and
Robert J. Cusimano, MD
* Department of Anesthesia, Toronto General Hospital, Toronto, Ontario, Canada
Division of Cardiac Surgery, Toronto General Hospital, Toronto, Ontario, Canada
Department of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
Manuscript received February 22, 2005;
revised manuscript received May 15, 2005,
accepted May 31, 2005.
* Reprint requests and correspondence: Dr. Duminda N. Wijeysundera, EN 3-450, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada. (Email: duminda.wijeysundera{at}uhn.on.ca).
OBJECTIVES: The purpose of this study was to assess the effects of off-pump coronary bypass surgery (OPCAB) on mortality and morbidity.
BACKGROUND: Despite its potential for reducing morbidity and mortality, OPCAB’s role in clinical practice remains controversial.
METHODS: A meta-analysis of 37 randomized controlled trials (RCTs) (n=3,449) and 22 risk-adjusted (logistic regression or propensity-score) observational studies (n=293,617) was performed. Two reviewers performed literature searches (MEDLINE, EMBASE, PubMed, reference lists), quality assessment, and data extraction. Treatment effects were calculated as odds ratios (ORs) with 95% confidence intervals (CIs).
RESULTS: In RCTs, OPCAB was associated with reduced atrial fibrillation (OR 0.59; 95% CI 0.46 to 0.77) and trends toward reduced 30-day mortality (OR 0.91 95% CI 0.45 to 1.83), stroke (OR 0.52; 95% CI 0.25 to 1.05), and myocardial infarction (OR 0.79; 95% CI 0.50 to 1.25). Observational studies showed OPCAB to be associated with reduced 30-day mortality (OR 0.72; 95% CI 0.66 to 0.78), stroke (OR 0.62; 95% CI 0.55 to 0.69), infarction (OR 0.66; 95% CI 0.50 to 0.88), and atrial fibrillation (OR 0.78; 95% CI 0.74 to 0.82). At one to two years, OPCAB was associated with trends toward reduced mortality, but also increased repeat revascularization (RCT: OR 1.75, 95% CI 0.78 to 3.94; Observational: OR 1.35, 95% CI 0.76 to 2.39).
CONCLUSIONS: Randomized controlled trials did not find, aside from atrial fibrillation, the statistically significant reductions in short-term mortality and morbidity demonstrated by observational studies. These discrepancies might be due to differing patient-selection and study methodology. Future studies must focus on improving research methodology, recruiting high-risk patients, and collecting long-term data.
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Abbreviations and Acronyms
| | CCAB = conventional coronary artery bypass surgery | | CI = confidence interval | | CPB = cardiopulmonary bypass | | OPCAB = off-pump coronary artery bypass surgery | | OR = odds ratio | | RCT = randomized controlled trial |
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A systematic review of randomized trials comparing revascularization rate and graft patency of off-pump and conventional coronary surgery
J. Thorac. Cardiovasc. Surg.,
December 1, 2006;
132(6):
1409 - 1413.
[Abstract]
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S S Panesar, T Athanasiou, S Nair, C Rao, C Jones, M Nicolaou, and A Darzi
Early outcomes in the elderly: a meta-analysis of 4921 patients undergoing coronary artery bypass grafting--comparison between off-pump and on-pump techniques
Heart,
December 1, 2006;
92(12):
1808 - 1816.
[Abstract]
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I. J. Ferreira-Gonzalez, A. Ribera, P. Cascant, G. Permanyer-Miralda, and for the ARCA study group
Outcomes in off-pump vs. on-pump coronary artery bypass grafting stratified by pre-operative risk profile: an assessment using propensity score
Eur. Heart J.,
October 2, 2006;
27(20):
2473 - 2480.
[Abstract]
[Full Text]
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A. Ben Ari, E. Elinav, A. Elami, and I. Matot
Off-pump coronary artery bypass grafting in a patient with Child class C liver cirrhosis awaiting liver transplantation
Br. J. Anaesth.,
October 1, 2006;
97(4):
468 - 472.
[Abstract]
[Full Text]
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A. T.L. Ong and P. W. Serruys
Complete Revascularization: Coronary Artery Bypass Graft Surgery Versus Percutaneous Coronary Intervention
Circulation,
July 18, 2006;
114(3):
249 - 255.
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A. J. Rastan, J. I. Eckenstein, B. Hentschel, A. K. Funkat, J. F. Gummert, N. Doll, T. Walther, V. Falk, and F. W. Mohr
Emergency Coronary Artery Bypass Graft Surgery for Acute Coronary Syndrome: Beating Heart Versus Conventional Cardioplegic Cardiac Arrest Strategies
Circulation,
July 4, 2006;
114(1_suppl):
I-477 - I-485.
[Abstract]
[Full Text]
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S. Al-Ruzzeh, S. George, M. Bustami, J. Wray, C. Ilsley, T. Athanasiou, and M. Amrani
Effect of off-pump coronary artery bypass surgery on clinical, angiographic, neurocognitive, and quality of life outcomes: randomised controlled trial
BMJ,
June 10, 2006;
332(7554):
1365.
[Abstract]
[Full Text]
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G. N. Djaiani
Aortic arch atheroma: stroke reduction in cardiac surgical patients.
Seminars in Cardiothoracic and Vascular Anesthesia,
June 1, 2006;
10(2):
143 - 157.
[Abstract]
[PDF]
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R. H. Jones
The Year in Cardiovascular Surgery
J. Am. Coll. Cardiol.,
May 16, 2006;
47(10):
2094 - 2107.
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A. P. Kappetein, K. D. Dawkins, F. W. Mohr, M. C. Morice, M. J. Mack, M. E. Russell, J. Pomar, and P. W. J. C. Serruys
Current percutaneous coronary intervention and coronary artery bypass grafting practices for three-vessel and left main coronary artery disease.: Insights from the SYNTAX run-in phase
Eur J Cardiothorac Surg,
April 1, 2006;
29(4):
486 - 491.
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A. Weerasinghe, T. Athanasiou, P. Philippidis, J. Day, K. Mandal, O. Warren, J. Anderson, and K. Taylor
Platelet-monocyte pro-coagulant interactions in on-pump coronary surgery
Eur J Cardiothorac Surg,
March 1, 2006;
29(3):
312 - 318.
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