Off‐Pump Coronary Artery Bypass Grafting: 30 Years of Debate (original) (raw)

Journal of the American Heart Association

O ff-pump coronary artery bypass surgery (OPCAB) has been performed for >30 years. The promotion of OPCAB was based on its potential benefits over some of the limitations of traditional on-pump coronary artery bypass surgery (ONCAB) by avoiding the trauma of cardiopulmonary bypass (CPB) and by minimizing aortic manipulation. As such, reductions in early mortality and perioperative neurological events, renal failure, blood product transfusions, and hospital length of stay were expected according to the OPCAB proponents. In contrast, critics of OPCAB remain concerned about incomplete and/or poorer quality coronary revascularization with a potential increase in the need for repeat revascularization and late mortality. Despite 3 decades of debate, 115 randomized trials, and >60 meta-analyses comparing on-and off-pump coronary artery bypass grafting (CABG), controversy on both the role of and indications for OPCAB remains vigorous. In this review, we provide a comprehensive update of the evidence for the differences in the biological effects of offand on-pump surgery and the comparison of the clinical and angiographic results of the 2 techniques. Furthermore, we critically address the relevant technical aspects of OPCAB, the importance of surgeon experience, and the difference in the costs for the 2 procedures. Search Strategy The Arterial Grafting International Consortium (ATLANTIC) Alliance is an international writing group on coronary surgery. In January 2018, a comprehensive search to identify studies that evaluated the biological, clinical, angiographic, and economic aspects of OPCAB was performed in the following databases from inception to present: Ovid Medline, Ovid Embase, and the Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials [CENTRAL], Cochrane Methodology Register). Search keywords included myocardial revascularization in combination with coronary artery bypass, on pump, off pump, and OPCAB. Relevant abstracts were reviewed, and the related articles function was used for all included studies. References for all selected studies were cross-checked. The writing group selected the most relevant papers according to both methodological and clinical considerations. Observational series were considered only in the absence of data from randomized controlled trials (RCTs). The Technical Evolution of Beating-Heart Coronary Artery Bypass Surgery The very first direct coronary revascularization procedures in the early 1960s were performed on the beating heart