• Giovanni Filardo, Baron L Hamman, Briget da Graca, Danielle M Sass, Natalie J Machala, Safiyah Ismail, Benjamin D Pollock, Ashley W Collinsworth, and Paul A Grayburn.
• Department of Epidemiology, Baylor Scott & White Health, Dallas, Tex; Robbins Institute for Health Policy and Research, Baylor University, Waco, Tex; Department of Statistics, Southern Methodist University, Dallas, Tex. Electronic address: giovanfi@baylorhealth.edu.
• J. Thorac. Cardiovasc. Surg. 2018 Jan 1; 155 (1): 172-179.e5.

BackgroundDespite many studies comparing on- versus off-pump coronary artery bypass graft (CABG), there is no consensus as to whether one of these techniques offers patients better outcomes.MethodsWe searched PubMed from inception to June 30, 2015, and identified additional studies from bibliographies of meta-analyses and reviews. We identified 42 randomized controlled trials (RCTs) and 31 rigorously adjusted observational studies (controlling for the Society of Thoracic Surgeons-recognized risk factors for mortality) reporting mortality for off-pump versus on-pump CABG at specified time points. Trial data were extracted independently by 2 researchers using a standardized form. Differences in probability of mortality (DPM) were estimated for the RCTs and observational studies separately and combined, for time points ranging from 30 days to 10 years.ResultsRCT-only data showed no significant differences at any time point, whereas observational-only data and the combined analysis showed short-term mortality favored off-pump CABG (n = 1.2 million patients; 36 RCTs, 26 observational studies; DPM [95% confidence interval (CI)], -44.8% [-45.4%, -43.8%]) but that at 5 years it was associated with significantly greater mortality (n = 60,405 patients; 3 RCTs, 5 observational studies; DPM [95% CI], 10.0% [5.0%, 15.0%]). At 10 years, only observational data were available, and off-pump CABG showed significantly greater mortality (DPM [95% CI], 14.0% [11.0%, 17.0%]).ConclusionsEvidence from RCTs showed no differences between the techniques, whereas rigorously adjusted observational studies (with >1.1 million patients) and the combined analysis indicated that off-pump CABG offers lower short-term mortality but poorer long-term survival. These results suggest that, in real-world settings, greater operative safety with off-pump CABG comes at the expense of lasting survival gains.Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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