Published online before print September 28, 2006, doi: 10.1161/01.STR.0000245081.52877.f2
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(Stroke. 2006;37:2759.)
© 2006 American Heart Association, Inc.
Original Contributions |
Off-Pump Surgery Is Associated With Reduced Occurrence of Stroke and Other Morbidity as Compared With Traditional Coronary Artery Bypass Grafting
A Meta-Analysis of Systematically Reviewed Trials
From the Center for Outcomes and Evidence (A.S.), Agency for Healthcare Research and Quality, Rockville, Md, USA; the Department of Public Health and Policy (A.S., A.P.), London School of Hygiene and Tropical Medicine, London, UK; the Department of Surgery (A.S.), Yale School of Medicine, New Haven, Conn, USA; the Health Services Research and Development Center (A.W.W.), Johns Hopkins University, Baltimore, Md, USA; the Department of Health Policy and Management (A.W.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md; the Evidence-Based Practice Center (E.B.B.), Johns Hopkins University, Baltimore, Md, USA; the Cardiothoracic Unit (T.T.), Guy’s Hospital, London, UK.
Correspondence to Artyom Sedrakyan, Center for Outcomes and Evidence, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850. E-mail asedraky@ahrq.gov
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Abstract |
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Background and Purpose— There is growing enthusiasm for coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB). Although deleterious effects of CPB are known, it remains to be proven that avoiding CPB will result in reduction in morbidity. We sought to determine whether off-pump surgery is associated with reduced occurrence of adverse outcomes as compared with CABG with CPB.
Methods— Studies were identified by searching the MEDLINE, EMBASE and the Cochrane Register 1980 to 2006 (February). We also searched the reference lists of randomized clinical trials (RCT) and reviews to look for additional studies. Study selection: RCTs comparing off-pump surgery to CABG with CPB. No restriction applied on the size of the trial or end point reports. Data extraction: 2 reviewers independently searched for studies, read abstracts and abstracted all data. Data synthesis: combined estimates were obtained using fixed or random effect meta-analyses. Relative risks and risk differences were calculated. Heterogeneity was assessed using 
2 and I2 values.
Results— There were 3996 patients enrolled in 41 RCTs (mean age 62, 22% female). No study reported information on race. Off-pump CABG was associated with a 50% reduction in the relative risk of stroke (95% CI, 7% to 73%), 30% reduction in atrial fibrillation (AF; 95% CI, 16% to 43%) and 48% reduction in wound infection (95% CI, 26% to 63%) with no heterogeneity among RCTs. This translated into avoidance of 10 strokes, 80 cases of AF and 40 infections per 1000 CABG. Fewer distal grafts were performed and there was evidence for >10 reinterventions per 1000 with off-pump CABG. Long-term follow-up is not yet reported in the trials.
Conclusions— Off-pump CABG is associated with reduced risk of stroke, AF and infections as compared with CABG with CPB. Evidence should be generalized taking into account RCT enrollment limitations, drawbacks related to training requirements, propensity to perform fewer grafts and likely reinterventions after off-pump surgery.
Key Words: atrial fibrillation • CABG • cardiac surgery • off-pump surgery • outcomes • stroke • systematic review
An extract of the first 250 words of the full text is provided, because this article has no abstract. |
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Introduction |
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The practice of coronary artery bypass graft surgery (CABG), as developed by Favaloro at the Cleveland Clinic,1 depended heavily on technological improvements in cardiopulmonary bypass (CPB) from its inception in 1967 and during its rapid dissemination in the next few years.2,3 However, there were surgeons who saw that CPB was not essential for myocardial revascularization,4 and the first substantial series (n=593) of CABG without CPB (off-pump) was reported by Buffolo in 1989.5
In the past 10 years we have witnessed growing interest in off-pump CABG.6 Although deleterious effects of CPB have been extensively investigated over the past 30 years, there is limited evidence that off-pump bypass surgery can offer any advantages compared with traditional CABG. When former President Bill Clinton had 4-vessel CABG on September 6, 2004, his surgeon, a known proponent of off-pump surgery, used CPB.7
Most of the recent randomized clinical trials (RCT) were single center studies and were not consistently supportive of off-pump coronary surgery.8 Surgeons favoring CPB (on-pump) express concerns for intraoperative myocardial ischemia, potential for recurrent angina/reinterventions, and for long "learning curve" requirements (ie, performing substantial number of procedures before competency is achieved).9 On the other hand, off-pump surgery has been proposed to have a potential for reducing in-hospital complications.10 Reducing the occurrence of morbidity such as postoperative stroke, myocardial infarction, atrial fibrillation and other complications is a high priority for cardiac care.
Strong evidence of benefits for off-pump bypass would have tremendous policy implications for over 280 000 CABG operations11 conducted in the United
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