Off-Pump Versus On-Pump Bypass Surgery for Left Main Coronary Artery Disease

Umberto Benedetto, John Puskas, Arie Pieter Kappetein, W. Morris Brown, F. Horkay, Piet W. Boonstra, G. Bogáts, Nicolas Noiseux, Ovidiu Dressler, Gianni D. Angelini, Gregg W. Stone, Patrick W. Serruys, Joseph F. Sabik, David P. Taggart

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

Background: Concerns remain for a greater risk of incomplete revascularization and reduced survival with off-pump coronary artery bypass grafting (CABG) surgery compared with on-pump surgery particularly in patients with left main disease and extensive underlying myocardial ischemia. Objectives: This study sought to compare outcomes following off-pump versus on-pump surgery for left main disease by performing a post hoc analysis from the multicenter, randomized EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial. Methods: The EXCEL trial was designed to compare percutaneous coronary intervention with everolimus-eluting stents versus CABG in patients with left main disease. CABG was performed with or without cardiopulmonary bypass (on-pump vs. off-pump surgery) according to the discretion of the operator. The 3-year outcomes in the off-pump and on-pump groups were compared using inverse probability of treatment weighting (IPTW) for treatment effect estimation. Results: Among 923 CABG patients, 652 and 271 patients underwent on-pump and off-pump surgery, respectively. Despite a similar extent of disease, off-pump surgery was associated with a lower rate of revascularization of the left circumflex coronary artery (84.1% vs. 90.0%; p = 0.01) and right coronary artery (31.1% vs. 40.6%; p = 0.007). After IPTW adjustment for baseline differences, off-pump surgery was associated with a significantly increased risk of 3-year all-cause death (8.8% vs. 4.5%; hazard ratio: 1.94; 95% confidence interval: 1.10 to 3.41; p = 0.02) and a nonsignificant difference in the risk for the composite endpoint of death, myocardial infarction, or stroke (11.8% vs. 9.2%; hazard ratio: 1.28; 95% confidence interval: 0.82 to 2.00; p = 0.28). Conclusions: Among patients with left main disease treated with CABG in the EXCEL trial, off-pump surgery was associated with a lower rate of revascularization of the coronary arteries supplying the inferolateral wall and an increased risk of 3-year all-cause death compared with on-pump surgery.

Original languageEnglish
Pages (from-to)729-740
Number of pages12
JournalJournal of the American College of Cardiology
Volume74
Issue number6
DOIs
Publication statusPublished - Aug 13 2019

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Coronary Artery Disease
Coronary Artery Bypass
Coronary Vessels
Cause of Death
Confidence Intervals
Off-Pump Coronary Artery Bypass
Percutaneous Coronary Intervention
Cardiopulmonary Bypass
Stents
Myocardial Ischemia
Therapeutics
Stroke
Myocardial Infarction
Survival

Keywords

  • coronary artery bypass grafting
  • left main disease
  • off-pump

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Benedetto, U., Puskas, J., Kappetein, A. P., Brown, W. M., Horkay, F., Boonstra, P. W., ... Taggart, D. P. (2019). Off-Pump Versus On-Pump Bypass Surgery for Left Main Coronary Artery Disease. Journal of the American College of Cardiology, 74(6), 729-740. https://doi.org/10.1016/j.jacc.2019.05.063

Off-Pump Versus On-Pump Bypass Surgery for Left Main Coronary Artery Disease. / Benedetto, Umberto; Puskas, John; Kappetein, Arie Pieter; Brown, W. Morris; Horkay, F.; Boonstra, Piet W.; Bogáts, G.; Noiseux, Nicolas; Dressler, Ovidiu; Angelini, Gianni D.; Stone, Gregg W.; Serruys, Patrick W.; Sabik, Joseph F.; Taggart, David P.

In: Journal of the American College of Cardiology, Vol. 74, No. 6, 13.08.2019, p. 729-740.

Research output: Contribution to journalArticle

Benedetto, U, Puskas, J, Kappetein, AP, Brown, WM, Horkay, F, Boonstra, PW, Bogáts, G, Noiseux, N, Dressler, O, Angelini, GD, Stone, GW, Serruys, PW, Sabik, JF & Taggart, DP 2019, 'Off-Pump Versus On-Pump Bypass Surgery for Left Main Coronary Artery Disease', Journal of the American College of Cardiology, vol. 74, no. 6, pp. 729-740. https://doi.org/10.1016/j.jacc.2019.05.063
Benedetto, Umberto ; Puskas, John ; Kappetein, Arie Pieter ; Brown, W. Morris ; Horkay, F. ; Boonstra, Piet W. ; Bogáts, G. ; Noiseux, Nicolas ; Dressler, Ovidiu ; Angelini, Gianni D. ; Stone, Gregg W. ; Serruys, Patrick W. ; Sabik, Joseph F. ; Taggart, David P. / Off-Pump Versus On-Pump Bypass Surgery for Left Main Coronary Artery Disease. In: Journal of the American College of Cardiology. 2019 ; Vol. 74, No. 6. pp. 729-740.
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abstract = "Background: Concerns remain for a greater risk of incomplete revascularization and reduced survival with off-pump coronary artery bypass grafting (CABG) surgery compared with on-pump surgery particularly in patients with left main disease and extensive underlying myocardial ischemia. Objectives: This study sought to compare outcomes following off-pump versus on-pump surgery for left main disease by performing a post hoc analysis from the multicenter, randomized EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial. Methods: The EXCEL trial was designed to compare percutaneous coronary intervention with everolimus-eluting stents versus CABG in patients with left main disease. CABG was performed with or without cardiopulmonary bypass (on-pump vs. off-pump surgery) according to the discretion of the operator. The 3-year outcomes in the off-pump and on-pump groups were compared using inverse probability of treatment weighting (IPTW) for treatment effect estimation. Results: Among 923 CABG patients, 652 and 271 patients underwent on-pump and off-pump surgery, respectively. Despite a similar extent of disease, off-pump surgery was associated with a lower rate of revascularization of the left circumflex coronary artery (84.1{\%} vs. 90.0{\%}; p = 0.01) and right coronary artery (31.1{\%} vs. 40.6{\%}; p = 0.007). After IPTW adjustment for baseline differences, off-pump surgery was associated with a significantly increased risk of 3-year all-cause death (8.8{\%} vs. 4.5{\%}; hazard ratio: 1.94; 95{\%} confidence interval: 1.10 to 3.41; p = 0.02) and a nonsignificant difference in the risk for the composite endpoint of death, myocardial infarction, or stroke (11.8{\%} vs. 9.2{\%}; hazard ratio: 1.28; 95{\%} confidence interval: 0.82 to 2.00; p = 0.28). Conclusions: Among patients with left main disease treated with CABG in the EXCEL trial, off-pump surgery was associated with a lower rate of revascularization of the coronary arteries supplying the inferolateral wall and an increased risk of 3-year all-cause death compared with on-pump surgery.",
keywords = "coronary artery bypass grafting, left main disease, off-pump",
author = "Umberto Benedetto and John Puskas and Kappetein, {Arie Pieter} and Brown, {W. Morris} and F. Horkay and Boonstra, {Piet W.} and G. Bog{\'a}ts and Nicolas Noiseux and Ovidiu Dressler and Angelini, {Gianni D.} and Stone, {Gregg W.} and Serruys, {Patrick W.} and Sabik, {Joseph F.} and Taggart, {David P.}",
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T1 - Off-Pump Versus On-Pump Bypass Surgery for Left Main Coronary Artery Disease

AU - Benedetto, Umberto

AU - Puskas, John

AU - Kappetein, Arie Pieter

AU - Brown, W. Morris

AU - Horkay, F.

AU - Boonstra, Piet W.

AU - Bogáts, G.

AU - Noiseux, Nicolas

AU - Dressler, Ovidiu

AU - Angelini, Gianni D.

AU - Stone, Gregg W.

AU - Serruys, Patrick W.

AU - Sabik, Joseph F.

AU - Taggart, David P.

PY - 2019/8/13

Y1 - 2019/8/13

N2 - Background: Concerns remain for a greater risk of incomplete revascularization and reduced survival with off-pump coronary artery bypass grafting (CABG) surgery compared with on-pump surgery particularly in patients with left main disease and extensive underlying myocardial ischemia. Objectives: This study sought to compare outcomes following off-pump versus on-pump surgery for left main disease by performing a post hoc analysis from the multicenter, randomized EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial. Methods: The EXCEL trial was designed to compare percutaneous coronary intervention with everolimus-eluting stents versus CABG in patients with left main disease. CABG was performed with or without cardiopulmonary bypass (on-pump vs. off-pump surgery) according to the discretion of the operator. The 3-year outcomes in the off-pump and on-pump groups were compared using inverse probability of treatment weighting (IPTW) for treatment effect estimation. Results: Among 923 CABG patients, 652 and 271 patients underwent on-pump and off-pump surgery, respectively. Despite a similar extent of disease, off-pump surgery was associated with a lower rate of revascularization of the left circumflex coronary artery (84.1% vs. 90.0%; p = 0.01) and right coronary artery (31.1% vs. 40.6%; p = 0.007). After IPTW adjustment for baseline differences, off-pump surgery was associated with a significantly increased risk of 3-year all-cause death (8.8% vs. 4.5%; hazard ratio: 1.94; 95% confidence interval: 1.10 to 3.41; p = 0.02) and a nonsignificant difference in the risk for the composite endpoint of death, myocardial infarction, or stroke (11.8% vs. 9.2%; hazard ratio: 1.28; 95% confidence interval: 0.82 to 2.00; p = 0.28). Conclusions: Among patients with left main disease treated with CABG in the EXCEL trial, off-pump surgery was associated with a lower rate of revascularization of the coronary arteries supplying the inferolateral wall and an increased risk of 3-year all-cause death compared with on-pump surgery.

AB - Background: Concerns remain for a greater risk of incomplete revascularization and reduced survival with off-pump coronary artery bypass grafting (CABG) surgery compared with on-pump surgery particularly in patients with left main disease and extensive underlying myocardial ischemia. Objectives: This study sought to compare outcomes following off-pump versus on-pump surgery for left main disease by performing a post hoc analysis from the multicenter, randomized EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial. Methods: The EXCEL trial was designed to compare percutaneous coronary intervention with everolimus-eluting stents versus CABG in patients with left main disease. CABG was performed with or without cardiopulmonary bypass (on-pump vs. off-pump surgery) according to the discretion of the operator. The 3-year outcomes in the off-pump and on-pump groups were compared using inverse probability of treatment weighting (IPTW) for treatment effect estimation. Results: Among 923 CABG patients, 652 and 271 patients underwent on-pump and off-pump surgery, respectively. Despite a similar extent of disease, off-pump surgery was associated with a lower rate of revascularization of the left circumflex coronary artery (84.1% vs. 90.0%; p = 0.01) and right coronary artery (31.1% vs. 40.6%; p = 0.007). After IPTW adjustment for baseline differences, off-pump surgery was associated with a significantly increased risk of 3-year all-cause death (8.8% vs. 4.5%; hazard ratio: 1.94; 95% confidence interval: 1.10 to 3.41; p = 0.02) and a nonsignificant difference in the risk for the composite endpoint of death, myocardial infarction, or stroke (11.8% vs. 9.2%; hazard ratio: 1.28; 95% confidence interval: 0.82 to 2.00; p = 0.28). Conclusions: Among patients with left main disease treated with CABG in the EXCEL trial, off-pump surgery was associated with a lower rate of revascularization of the coronary arteries supplying the inferolateral wall and an increased risk of 3-year all-cause death compared with on-pump surgery.

KW - coronary artery bypass grafting

KW - left main disease

KW - off-pump

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