On-Pump versus Off-Pump Coronary-Artery Bypass Surgery

[Igor Bulatov]

Volume 361:1827-1837 November 5, 2009 Number 19
http://content.nejm.org/cgi/content/short/361/19/1827
On-Pump versus Off-Pump Coronary-Artery Bypass Surgery
A. Laurie Shroyer, Ph.D., Frederick L. Grover, M.D., Brack Hattler, M.D., Joseph F. Collins, Sc.D., Gerald O. McDonald, M.D., Elizabeth Kozora, Ph.D., John C. Lucke, M.D., Janet H. Baltz, R.N., Dimitri Novitzky, M.D., Ph.D., for the Veterans Affairs Randomized On/Off Bypass (ROOBY) Study Group



ABSTRACT

Background Coronary-artery bypass grafting (CABG) has traditionally been performed with the use of cardiopulmonary bypass (on-pump CABG). CABG without cardiopulmonary bypass (off-pump CABG) might reduce the number of complications related to the heart–lung machine.

Methods We randomly assigned 2203 patients scheduled for urgent or elective CABG to either on-pump or off-pump procedures. The primary short-term end point was a composite of death or complications (reoperation, new mechanical support, cardiac arrest, coma, stroke, or renal failure) before discharge or within 30 days after surgery. The primary long-term end point was a composite of death from any cause, a repeat revascularization procedure, or a nonfatal myocardial infarction within 1 year after surgery. Secondary end points included the completeness of revascularization, graft patency at 1 year, neuropsychological outcomes, and the use of major resources.

Results There was no significant difference between off-pump and on-pump CABG in the rate of the 30-day composite outcome (7.0% and 5.6%, respectively; P=0.19). The rate of the 1-year composite outcome was higher for off-pump than for on-pump CABG (9.9% vs. 7.4%, P=0.04). The proportion of patients with fewer grafts completed than originally planned was higher with off-pump CABG than with on-pump CABG (17.8% vs. 11.1%, P<0.001). Follow-up angiograms in 1371 patients who underwent 4093 grafts revealed that the overall rate of graft patency was lower in the off-pump group than in the on-pump group (82.6% vs. 87.8%, P<0.01). There were no treatment-based differences in neuropsychological outcomes or short-term use of major resources.

Conclusions At 1 year of follow-up, patients in the off-pump group had worse composite outcomes and poorer graft patency than did patients in the on-pump group. No significant differences between the techniques were found in neuropsychological outcomes or use of major resources. (ClinicalTrials.gov number, NCT00032630 [ClinicalTrials.gov] .)