Can we settle the on-pump or off-pump debate with more than a million patients?

Off- Versus On-Pump Coronary Surgery and the Effect of Follow-Up Length and Surgeons' Experience: A Meta-Analysis

Background The debate on the relative benefits of off-pump and on-pump coronary artery bypass surgery ( OPCABG and ONCABG ) is still open. We aimed to provide an updated and complete summary of the evidence on the differences between OPCABG and ONCABG and to explore whether the length of the follow-up and the surgeons' experience in OPCABG modify the comparative results. Methods and Results All randomized clinical trials comparing OPCABG and ONCABG were included. Primary outcome was follow-up mortality. Secondary outcomes were operative mortality, perioperative stroke, perioperative myocardial infarction, and late repeated revascularization. Subgroup analyses were performed based on the length of the follow-up and the percentage of crossover from the OPCABG group (used as a surrogate of surgeon experience with OPCABG ). One hundred four trials were included (20 627 patients, OPCABG : 10 288; ONCABG : 10 339). Weighted mean follow-up time was 3.7 years (range 1-7.5 years). OPCABG was associated with a higher risk of follow-up mortality (incidence rate ratio 1.11, 95% confidence interval 1.00-1.23, P=0.05). The difference was significant only for trials with mean follow-up of ≥3 years and for studies with a crossover rate of ≥10%. There was a trend toward lower risk of perioperative stroke and higher need for late repeated revascularization in the OPCABG arm. Conclusions OPCABG is associated with a higher incidence of incomplete revascularization, an increased need for repeated revascularization, and decreased midterm survival compared with ONCABG . Surgeon inexperience in OPCABG is associated with late mortality.