Skip to main content
Log in

Off-Pump Versus On-Pump Coronary Artery Bypass Grafting

  • Ischemic Heart Disease (D Mukherjee, Section Editor)
  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Coronary artery bypass grafting (CABG) remains the preferred treatment in patients with complex coronary artery disease. However, whether the procedure should be performed with or without the use of cardiopulmonary bypass, referred to as off-pump and on-pump CABG, is still up for debate. Intuitively, avoidance of cardiopulmonary bypass seems beneficial as the systemic inflammatory response from extracorporeal circulation is omitted, but no single randomized trial has been able to prove off-pump CABG superior to on-pump CABG as regards the hard outcomes death, stroke or myocardial infarction. In contrast, off-pump CABG is technically more challenging and may be associated with increased risk of incomplete revascularization. The purpose of the review is to summarize the current literature comparing outcomes of off-pump versus on-pump coronary artery bypass surgery.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Montalescot G, Sechtem U, Achenbach S, et al. ESC guidelines on the management of stable coronary artery disease: The Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013. doi:10.1093/eurheartj/eht296.

    Google Scholar 

  2. Farkouh ME, Domanski M, Sleeper LA, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367:2375–84.

    Article  CAS  PubMed  Google Scholar 

  3. Mohr FW, Morice MC, Kappetein AP, et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet. 2013;381:629–38.

    Article  PubMed  Google Scholar 

  4. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360:961–72.

    Article  CAS  PubMed  Google Scholar 

  5. Li Z, Yeo KK, Parker JP, et al. Off-pump coronary artery bypass graft surgery in California, 2003 to 2005. Am Heart J. 2008;156:1095–102.

    Article  PubMed  Google Scholar 

  6. Borst C, Jansen EW, Tulleken CA, et al. Coronary artery bypass grafting without cardiopulmonary bypass and without interruption of native coronary flow using a novel anastomosis site restraining device ("Octopus"). J Am Coll Cardiol. 1996;27:1356–64.

    Article  CAS  PubMed  Google Scholar 

  7. Møller CH, Penninga L, Wetterslev J, et al. Off-pump versus on-pump coronary artery bypass grafting for ischaemic heart disease. Cochrane Database Syst Rev. 2012;3:CD007224. This study provides a systematic review, including quality assessment and meta-analysis, of randomized trials comparing off-pump and on-pump CABG.

    PubMed  Google Scholar 

  8. Gardner TJ. On-pump versus off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2007;133:1.

    Article  PubMed  Google Scholar 

  9. Taggart DP, Altman DG. Off-pump vs. on-pump CABG: are we any closer to a resolution? Eur Heart J. 2012;33:1181–3.

    Article  PubMed  Google Scholar 

  10. Diegeler A, Borgermann J, Kappert U, et al. Off-pump versus on-pump coronary-artery bypass grafting in elderly patients. N Engl J Med. 2013;368:1189–98. Randomized trial including more than 2200 elderly patients (> 75 years) undergoing off-pump versus on-pump CABG, the trial could not demonstrate significant differences in 30 day and 1 year composite outcome. However, incomplete revascularization and repeat revascularization were more often seen in the off-pump group.

    Article  CAS  PubMed  Google Scholar 

  11. Lamy A, Devereaux PJ, Prabhakaran D, et al. Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year. N Engl J Med. 2013;368:1179–88. The 1-year results of the largest randomized trial between off-pump and on-pump CABG. The trial demonstrated equivalent 1-year outcomes between groups.

    Article  CAS  PubMed  Google Scholar 

  12. Lamy A, Devereaux PJ, Prabhakaran D, et al. Off-pump or on-pump coronary-artery bypass grafting at 30 days. N Engl J Med. 2012;366:1489–97. This is the to date largest randomized trial comparing off-pump and on-pump CABG. The study found similar event rate in the primary outcome. However, off-pump CABG reduced the incidence of acute kidney injury, but increased repeat revascularization.

    Article  CAS  PubMed  Google Scholar 

  13. Angelini GD, Taylor FC, Reeves BC, Ascione R. Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised controlled trials. Lancet. 2002;359:1194–9.

    Article  PubMed  Google Scholar 

  14. Houlind K, Kjeldsen BJ, Madsen SN, et al. On-pump versus off-pump coronary artery bypass surgery in elderly patients: results from the Danish on-pump versus off-pump randomization study. Circulation. 2012;125:2431–9.

    Article  PubMed  Google Scholar 

  15. Møller CH, Perko MJ, Lund JT, et al. No major differences in 30-day outcomes in high-risk patients randomized to off-pump versus on-pump coronary bypass surgery: the best bypass surgery trial. Circulation. 2010;121:498–504.

    Article  PubMed  Google Scholar 

  16. Puskas JD, Williams WH, Duke PG, et al. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125:797–808.

    Article  CAS  PubMed  Google Scholar 

  17. Shroyer AL, Grover FL, Hattler B, et al. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med. 2009;361:1827–37.

    Article  CAS  PubMed  Google Scholar 

  18. van Dijk D, Nierich AP, Jansen EW, et al. Early outcome after off-pump versus on-pump coronary bypass surgery: results from a randomized study. Circulation. 2001;104:1761–6.

    Article  PubMed  Google Scholar 

  19. Fattouch K, Guccione F, Dioguardi P, et al. Off-pump versus on-pump myocardial revascularization in patients with ST-segment elevation myocardial infarction: a randomized trial. J Thorac Cardiovasc Surg. 2009;137:650–6.

    Article  PubMed  Google Scholar 

  20. Hannan EL, Wu C, Smith CR, et al. Off-pump versus on-pump coronary artery bypass graft surgery: differences in short-term outcomes and in long-term mortality and need for subsequent revascularization. Circulation. 2007;116:1145–52.

    Article  PubMed  Google Scholar 

  21. Puskas JD, Kilgo PD, Lattouf OM, et al. Off-pump coronary bypass provides reduced mortality and morbidity and equivalent 10-year survival. Ann Thorac Surg. 2008;86:1139–46.

    Article  PubMed  Google Scholar 

  22. Marui A, Okabayashi H, Komiya T, et al. Benefits of off-pump coronary artery bypass grafting in high-risk patients. Circulation. 2012;126:S151–7.

    Article  PubMed  Google Scholar 

  23. Ascione R, Lloyd CT, Gomes WJ, et al. Beating versus arrested heart revascularization: evaluation of myocardial function in a prospective randomized study. Eur J Cardiothorac Surg. 1999;15:685–90.

    Article  CAS  PubMed  Google Scholar 

  24. Cavallaro P, Itagaki S, Seigerman M, Chikwe J. Operative mortality and stroke after on-pump vs off-pump surgery in high-risk patients: an analysis of 83 914 coronary bypass operations. Eur J Cardiothorac Surg. 2013. doi:10.1093/ejcts/ezt221.

    PubMed  Google Scholar 

  25. Emmert MY, Seifert B, Wilhelm M, et al. Aortic no-touch technique makes the difference in off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2011;142:1499–506.

    Article  PubMed  Google Scholar 

  26. Edelman JJ, Sherrah AG, Wilson MK, et al. Anaortic, total-arterial, off-pump coronary artery bypass surgery: why bother? Heart Lung Circ. 2013;22:161–70.

    Article  CAS  PubMed  Google Scholar 

  27. Misfeld M, Brereton RJ, Sweetman EA, Doig GS. Neurologic complications after off-pump coronary artery bypass grafting with and without aortic manipulation: meta-analysis of 11,398 cases from 8 studies. J Thorac Cardiovasc Surg. 2011;142:e11–7.

    Article  PubMed  Google Scholar 

  28. Ascione R, Lloyd CT, Underwood MJ, et al. On-pump versus off-pump coronary revascularization: evaluation of renal function. Ann Thorac Surg. 1999;68:493–8.

    Article  CAS  PubMed  Google Scholar 

  29. Caputo M, Yeatman M, Narayan P, et al. Effect of off-pump coronary surgery with right ventricular assist device on organ function and inflammatory response: a randomized controlled trial. Ann Thorac Surg. 2002;74:2088–95.

    Article  PubMed  Google Scholar 

  30. Tang AT, Knott J, Nanson J, et al. A prospective randomized study to evaluate the renoprotective action of beating heart coronary surgery in low risk patients. Eur J Cardiothorac Surg. 2002;22:118–23.

    Article  CAS  PubMed  Google Scholar 

  31. Seabra VF, Alobaidi S, Balk EM, et al. Off-pump coronary artery bypass surgery and acute kidney injury: a meta-analysis of randomized controlled trials. Clin J Am Soc Nephrol. 2010;5:1734–44.

    Article  PubMed Central  PubMed  Google Scholar 

  32. Robertson MW, Buth KJ, Stewart KM, et al. Complete revascularization is compromised in off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2013;145:992–8.

    Article  PubMed  Google Scholar 

  33. Nakano J, Okabayashi H, Noma H, et al. The impact of incomplete revascularization and angiographic patency on midterm results after off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2013. doi:10.1016/j.jtcvs.2013.03.026.

    Google Scholar 

  34. Al Ruzzeh S, George S, Bustami M, et al. Effect of off-pump coronary artery bypass surgery on clinical, angiographic, neurocognitive, and quality of life outcomes: randomised controlled trial. BMJ. 2006;332:1365.

    Article  PubMed Central  PubMed  Google Scholar 

  35. Khan NE, De Souza A, Mister R, et al. A randomized comparison of off-pump and on-pump multivessel coronary-artery bypass surgery. N Engl J Med. 2004;350:21–8.

    Article  CAS  PubMed  Google Scholar 

  36. Lingaas PS, Hol PK, Lundblad R, et al. Clinical and radiologic outcome of off-pump coronary surgery at 12 months follow-up: a prospective randomized trial. Ann Thorac Surg. 2006;81:2089–95.

    Article  PubMed  Google Scholar 

  37. Møller CH, Perko MJ, Lund JT, et al. Graft patency after off-pump versus on-pump coronary artery surgery in high-risk patients. Scand Cardiovasc J. 2010;44:161–7.

    Article  PubMed  Google Scholar 

  38. Puskas JD, Williams WH, Mahoney EM, et al. Off-pump vs conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial. JAMA. 2004;291:1841–9.

    Article  CAS  PubMed  Google Scholar 

  39. Sousa UM, Cavaco S, Oliveira AG, et al. Early graft patency after off-pump and on-pump coronary bypass surgery: a prospective randomized study. Eur Heart J. 2010;31:2492–9.

    Article  Google Scholar 

  40. Widimsky P, Straka Z, Stros P, et al. One-year coronary bypass graft patency: a randomized comparison between off-pump and on-pump surgery angiographic results of the PRAGUE-4 trial. Circulation. 2004;110:3418–23.

    Article  PubMed  Google Scholar 

  41. Nathoe HM, van Dijk D, Jansen EW, et al. A comparison of on-pump and off-pump coronary bypass surgery in low-risk patients. N Engl J Med. 2003;348:394–402.

    Article  PubMed  Google Scholar 

  42. Hu S, Zheng Z, Yuan X, et al. Increasing long-term major vascular events and resource consumption in patients receiving off-pump coronary artery bypass: a single-center prospective observational study. Circulation. 2010;121:1800–8.

    Article  PubMed  Google Scholar 

  43. Takagi H, Mizuno Y, Niwa M, et al. A meta-analysis of randomized trials for repeat revascularization following off-pump versus on-pump coronary artery bypass grafting. Interact Cardiovasc Thorac Surg. 2013. doi:10.1093/icvts/ivt316.

    Google Scholar 

  44. Møller CH, Perko MJ, Lund JT, et al. Three-year follow-up in a subset of high-risk patients randomly assigned to off-pump versus on-pump coronary artery bypass surgery: the Best Bypass Surgery trial. Heart. 2011;97:907–13. In this trial high-risk patients were randomized to off-pump versus on-pump CABG. Increased mortality was found in the off-pump group.

    Article  PubMed  Google Scholar 

  45. Lemma MG, Coscioni E, Tritto FP, et al. On-pump versus off-pump coronary artery bypass surgery in high-risk patients: operative results of a prospective randomized trial (on-off study). J Thorac Cardiovasc Surg. 2012;143:625–31.

    Article  PubMed  Google Scholar 

  46. Keeling WB, Williams ML, Slaughter MS, et al. Off-pump and on-pump coronary revascularization in patients with low ejection fraction: a report from the society of thoracic surgeons national database. Ann Thorac Surg. 2013;96:83–8.

    Article  PubMed  Google Scholar 

  47. Kunadian V, Zaman A, Qiu W. Revascularization among patients with severe left ventricular dysfunction: a meta-analysis of observational studies. Eur J Heart Fail. 2011;13:773–84.

    Article  PubMed Central  PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Christian H. Møller and Daniel A. Steinbrüchel declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Christian H. Møller.

Additional information

This article is part of the Topical Collection on Ischemic Heart Disease

Rights and permissions

Reprints and permissions

About this article

Cite this article

Møller, C.H., Steinbrüchel, D.A. Off-Pump Versus On-Pump Coronary Artery Bypass Grafting. Curr Cardiol Rep 16, 455 (2014). https://doi.org/10.1007/s11886-013-0455-2

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11886-013-0455-2

Keywords

Navigation