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Randomized Controlled Trial
. 2019 Jan;107(1):92-98.
doi: 10.1016/j.athoracsur.2018.07.076. Epub 2018 Sep 28.

Off-Pump Versus On-Pump Impact: Diabetic Patient 5-Year Coronary Artery Bypass Clinical Outcomes

A Laurie W Shroyer  1 , Jacquelyn A Quin  2 , Todd H Wagner  3 , Brendan M Carr  4 , Joseph F Collins  5 , G Hossein Almassi  6 , Muath Bishawi  7 , Frederick L Grover  8 , Brack Hattler  9
Affiliations
Randomized Controlled Trial

Off-Pump Versus On-Pump Impact: Diabetic Patient 5-Year Coronary Artery Bypass Clinical Outcomes

A Laurie W Shroyer et al. Ann Thorac Surg. 2019 Jan.

Abstract

Background: For diabetic patients who require coronary artery bypass graft (CABG) operation, controversy persists whether an off-pump or an on-pump approach may be advantageous. This US-based, multicenter, randomized, controlled trial, Department of Veterans Affairs Randomization On versus Off Bypass Follow-up Study, compared diabetic patients' 5-year clinical outcomes for off-pump versus on-pump procedures.

Methods: From 2002 to 2008, 835 medically treated (ie, oral hypoglycemic agent or insulin) diabetic patients underwent either off-pump (n = 402) or on-pump (n = 433) CABG. Five-year primary end points included all-cause death and major adverse cardiovascular events (MACE; composite included all-cause death, myocardial infarction, or repeat revascularization). Secondary 5-year end points included cardiac death and MACE-related components. With baseline risk factors balanced, outcomes were evaluated by using a p value less than or equal to 0.01; nonsignificant trends were reported for p values greater than 0.01 and less than or equal to 0.15.

Results: Five-year all-cause death rates were 20.2% off pump versus 14.1% on pump (p = 0.0198). No differences were seen in MACE (32.6% off-pump approach versus 28.6% on-pump approach, p = 0.216), repeat revascularization (12.4% off-pump approach versus 11.8% on-pump approach, p = 0.770), and nonfatal myocardial infarction (12.7% off-pump approach versus 10.4% on-pump approach, p = 0.299). Cardiac death trended worse with off-pump CABG (9.0%) than with on-pump CABG (6.25%, p = 0.137). Sensitivity analyses that removed conversions confirmed these findings.

Conclusions: With a 6.1% absolute difference, a strong trend toward improved 5-year survival was observed with on-pump CABG for medically treated diabetic patients. No off-pump advantage was found for any 5-year end points. A future clinical trial now appears warranted to rigorously compare off-pump versus on-pump longer term outcomes for diabetic patients.

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Comment in

  • Invited Commentary.
    Yadava OP. Yadava OP. Ann Thorac Surg. 2019 Jan;107(1):98. doi: 10.1016/j.athoracsur.2018.08.028. Epub 2018 Oct 6. Ann Thorac Surg. 2019. PMID: 30300640 No abstract available.
  • Outcome Benefit of On-Pump Surgery in Diabetic Patients at 5 Years: Is It Convincing or Just Predictable?
    Narayan P. Narayan P. Ann Thorac Surg. 2019 Jun;107(6):1912-1913. doi: 10.1016/j.athoracsur.2018.11.027. Epub 2018 Dec 14. Ann Thorac Surg. 2019. PMID: 30557535 No abstract available.
  • Reply.
    Shroyer AL, Quin JA, Hattler B. Shroyer AL, et al. Ann Thorac Surg. 2019 Jun;107(6):1913. doi: 10.1016/j.athoracsur.2019.01.068. Epub 2019 Mar 7. Ann Thorac Surg. 2019. PMID: 30853588 No abstract available.
  • Factors Affecting Postoperative Mortality in Coronary Bypass Surgery.
    Gokalp O, Eygi B, Gurbuz A. Gokalp O, et al. Ann Thorac Surg. 2019 Oct;108(4):1266. doi: 10.1016/j.athoracsur.2019.02.034. Epub 2019 Mar 21. Ann Thorac Surg. 2019. PMID: 30905585 No abstract available.
  • Off-Pump Versus On-Pump: Should Graft Flow Confirmation at Time of Surgery Become Standard of Care?
    Magarakis M, Macias AE, Salerno TA. Magarakis M, et al. Ann Thorac Surg. 2019 Oct;108(4):1265. doi: 10.1016/j.athoracsur.2019.02.062. Epub 2019 Mar 27. Ann Thorac Surg. 2019. PMID: 30928549 No abstract available.
  • Reply.
    Shroyer AL, Quin JA, Hattler B. Shroyer AL, et al. Ann Thorac Surg. 2019 Oct;108(4):1266-1267. doi: 10.1016/j.athoracsur.2019.03.093. Epub 2019 May 3. Ann Thorac Surg. 2019. PMID: 31059680 No abstract available.
  • Reply.
    Shroyer AL, Quin JA, Hattler B. Shroyer AL, et al. Ann Thorac Surg. 2019 Oct;108(4):1265-1266. doi: 10.1016/j.athoracsur.2019.04.045. Epub 2019 Jun 1. Ann Thorac Surg. 2019. PMID: 31163130 No abstract available.

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