Skip to main content
SpringerLink
Log in

Off-pump coronary surgery: current justifications

  • Review Article
  • Published:
General Thoracic and Cardiovascular Surgery Aims and scope Submit manuscript

Abstract

Although the literature has failed to project an overall superiority of off-pump vs. on-pump surgery, nevertheless, small randomized control trials and large meta-analysis studies have concluded that the incidence of a stroke is less than 1 % when anaortic off-pump techniques are advocated in patients with diseased ascending aorta. Furthermore, off-pump techniques or their combination with hybrid procedures may lead to a reduction of adverse outcome in the aged high-risk population with concomitant poor left ventricular function and co-morbidities. However, despite this, controversy still exists among the cardiac surgery community in terms of the benefit of this technique and its safety; hence, off-pump is becoming out of fashion. In this review paper, by looking at a “marginal group of patients” (elderly, high risks, atherosclerotic aortas) we attempt to re-establish and justify this technique and re-invent its usage.

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

Access this article

Log in via an institution

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

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Shapira OM, Badhwar V, Shahian D, Jacobs JP, Izhar U, Bao Y, Korach A, Lattouf OM, Grover FL, Puskas JD. International participation in the society of thoracic surgeons national database. Ann Thorac Surg. 2014;97(4):1127–30.

  2. De Raet JM, Desimone JP, Sergeant PT. Off-pump coronary artery bypass grafting: Anno 2011. Multimed Man Cardiothorac Surg. 2011;(713).

  3. Patel NN, Akowuah E, Hutter JA. Patient preference for coronary artery bypass graft surgery performed on the arrested or beating heart: a questionnaire study. Eur J Cardiothorac Surg. 2011;40:1282–4.

    PubMed  Google Scholar 

  4. Letsou GV, Wu YX, Grunkemeier G, Rampurwala MM, Kaiser L, Salaskar AL. Off-pump coronary artery bypass and avoidance of hypothermic cardiac arrest improves early left ventricular function in patients with systolic dysfunction. Eur J Cardiothorac Surg. 2011;40:227–32.

    Article  PubMed  Google Scholar 

  5. Rastan AJ, Bittner HB, Gummert JF, Walther T, Schewick CV, Girdauskas E, et al. On-pump beating heart versus off-pump coronary artery bypass surgery—evidence of pump-induced myocardial injury. Eur J Cardiothorac Surg. 2005;27:1057–64.

    Article  PubMed  Google Scholar 

  6. Yeatman M, Caputo M, Narayan P, Ghosh AK, Ascione R, Ryder I, et al. Intracoronary shunts reduce transient intraoperative myocardial dysfunction during off-pump coronary operations. Ann Thorac Surg. 2002;73:1411–7.

    Article  PubMed  Google Scholar 

  7. Grundeman PF, Verlaan CW, van Boven WJ, Borst C. Ninety-degree anterior cardiac displacement in off-pump coronary artery bypass grafting: the Starfish cardiac positioner preserves stroke volume and arterial pressure. Ann Thorac Surg. 2004;78:679–84 (discussion 7–8).

    Article  PubMed  Google Scholar 

  8. Grundeman PF, Borst C, Verlaan CW, Meijburg H, Moues CM, Jansen EW. Exposure of circumflex branches in the tilted, beating porcine heart: echocardiographic evidence of right ventricular deformation and the effect of right or left heart bypass. J Thorac Cardiovasc Surg. 1999;118:316–23.

    Article  PubMed  CAS  Google Scholar 

  9. Saleh HZ, Pullan DM. Monitoring cardiac output trends with end-tidal carbon dioxide pressures in off-pump coronary bypass. Ann Thorac Surg. 2011;91:e81–2.

    Article  PubMed  Google Scholar 

  10. Khan NE, De Souza A, Mister R, Flather M, Clague J, Davies S, 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  PubMed  CAS  Google Scholar 

  11. Muneretto C, Bisleri G, Negri A, Manfredi J, Metra M, Nodari S, et al. Off-pump coronary artery bypass surgery technique for total arterial myocardial revascularization: a prospective randomized study. Ann Thorac Surg. 2003;76:778–82 (discussion 83).

    Article  PubMed  Google Scholar 

  12. Arom KV, Flavin TF, Emery RW, Kshettry VR, Petersen RJ, Janey PA. Is low ejection fraction safe for off-pump coronary bypass operation? Ann Thorac Surg. 2000;70:1021–5.

    Article  PubMed  CAS  Google Scholar 

  13. Vaccarino V, Abramson JL, Veledar E, Weintraub WS. Sex differences in hospital mortality after coronary artery bypass surgery: evidence for a higher mortality in younger women. Circulation. 2002;105:1176–81.

    Article  PubMed  Google Scholar 

  14. Puskas JD, Kilgo PD, Kutner M, Pusca SV, Lattouf O, Guyton RA. Off-pump techniques disproportionately benefit women and narrow the gender disparity in outcomes after coronary artery bypass surgery. Circulation. 2007;116:I192–9.

    Article  PubMed  Google Scholar 

  15. Ascione R, Caputo M, Calori G, Lloyd CT, Underwood MJ, Angelini GD. Predictors of atrial fibrillation after conventional and beating heart coronary surgery: a prospective, randomized study. Circulation. 2000;102:1530–5.

    Article  PubMed  CAS  Google Scholar 

  16. Athanasiou T, Aziz O, Mangoush O, Al-Ruzzeh S, Nair S, Malinovski V, et al. Does off-pump coronary artery bypass reduce the incidence of post-operative atrial fibrillation? A question revisited. Eur J Cardiothorac Surg. 2004;26:701–10.

    Article  PubMed  Google Scholar 

  17. Raja SG, Behranwala AA, Dunning J. Does off-pump coronary artery surgery reduce the incidence of postoperative atrial fibrillation? Interact CardioVasc Thorac Surg. 2004;3:647–52.

    Article  PubMed  Google Scholar 

  18. 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 

  19. Misfeld M, Potger K, Ross DE, McMillan D, Brady PW, Marshman D, et al. “Anaortic” off-pump coronary artery bypass grafting significantly reduces neurological complications compared to off-pump and conventional on-pump surgery with aortic manipulation. Thorac Cardiovasc Surg. 2010;58:408–14.

    Article  PubMed  CAS  Google Scholar 

  20. Vallely MP, Potger K, McMillan D, Hemli JM, Brady PW, Brereton RJ, et al. Anaortic techniques reduce neurological morbidity after off-pump coronary artery bypass surgery. Heart Lung Circ. 2008;17:299–304.

    Article  PubMed  Google Scholar 

  21. Edelman JJ, Yan TD, Bannon PG, Wilson MK, Vallely MP. Coronary artery bypass grafting with and without manipulation of the ascending aorta—a meta-analysis. Heart Lung Circ. 2011;20:318–24.

    Article  PubMed  Google Scholar 

  22. Asai T, Suzuki T, Nota H, Kuroyanagi S, Kinoshita T, Takashima N, Hayakawa M, Naito S. Off-pump coronary artery bypass grafting using skeletonized in situ arterial grafts. Ann Cardiothorac Surg. 2013;2(4):552–6.

    PubMed  PubMed Central  Google Scholar 

  23. Athanasiou T, Al-Ruzzeh S, Kumar P, Crossman MC, Amrani M, Pepper JR, et al. Off-pump myocardial revascularization is associated with less incidence of stroke in elderly patients. Ann Thorac Surg. 2004;77:745–53.

    Article  PubMed  Google Scholar 

  24. Sedrakyan A, Wu AW, Parashar A, Bass EB, Treasure T. Off-pump surgery is associated with reduced occurrence of stroke and other morbidity as compared with traditional coronary artery bypass grafting: a meta-analysis of systematically reviewed trials. Stroke. 2006;37:2759–69.

    Article  PubMed  Google Scholar 

  25. Li Z, Denton T, Yeo KK, Parker JP, White R, Young JN, et al. Off-pump bypass surgery and postoperative stroke: California coronary bypass outcomes reporting program. Ann Thorac Surg. 2010;90:753–9.

    Article  PubMed  Google Scholar 

  26. Afilalo J, Rasti M, Ohayon SM, Shimony A, Eisenberg MJ. Off-pump vs. on-pump coronary artery bypass surgery: an updated meta-analysis and meta-regression of randomized trials. Eur Heart J. 2012;33:1257–67.

    Article  PubMed  Google Scholar 

  27. Puskas JD, Thourani VH, Kilgo P, Cooper W, Vassiliades T, Vega JD, et al. Off-pump coronary artery bypass disproportionately benefits high-risk patients. Ann Thorac Surg. 2009;88:1142–7.

    Article  PubMed  Google Scholar 

  28. Barandon L, Richebe P, Munos E, Calderon J, Lafitte M, Lafitte S, et al. Off-pump coronary artery bypass surgery in very high-risk patients: adjustment and preliminary results. Interact CardioVasc Thorac Surg. 2008;7:789–93.

    Article  PubMed  Google Scholar 

  29. Kerendi F, Morris CD, Puskas JD. Off-pump coronary bypass surgery for high-risk patients: only in expert centers? Curr Opin Cardiol. 2008;23:573–8.

    Article  PubMed  Google Scholar 

  30. Rastan AJ, Walther T, Falk V, Lehmann S, Kempfert J, Mohr FW. Coronary artery bypass grafting on the beating heart in high-risk patients. Herz. 2007;32:483–90.

    Article  PubMed  Google Scholar 

  31. Lemma MG, Coscioni E, Tritto FP, Centofanti P, Fondacone C, Salica A, 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 

  32. Jarral OA, Saso S, Athanasiou T. Off-pump coronary artery bypass in patients with left ventricular dysfunction: a meta-analysis. Ann Thorac Surg. 2011;92:1686–94.

    Article  PubMed  Google Scholar 

  33. 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  PubMed Central  Google Scholar 

  34. Kuss O, von Salviati B, Borgermann J. Off-pump versus on-pump coronary artery bypass grafting: a systematic review and meta-analysis of propensity score analyses. J Thorac Cardiovasc Surg. 2010;140:829–35, 35 e1–13.

  35. Polomsky M, He X, O’Brien SM, Puskas JD. Outcomes of off-pump versus on-pump coronary artery bypass grafting: impact of preoperative risk. J Thorac Cardiovasc Surg. 2013;145(5):1193–8.

    Article  PubMed  Google Scholar 

  36. Kinoshita T, Asai T, Suzuki T, Kambara A, Matsubayashi K. Off-pump bilateral versus single skeletonized internal thoracic artery grafting in high-risk patients. Circulation. 2011;124(11):130–4.

    Article  Google Scholar 

  37. Panesar SS, Athanasiou T, Nair S, Rao C, Jones C, Nicolaou M, et al. Early outcomes in the elderly: a meta-analysis of 4921 patients undergoing coronary artery bypass grafting—comparison between off-pump and on-pump techniques. Heart. 2006;92:1808–16.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  38. LaPar DJ, Bhamidipati CM, Reece TB, Cleveland JC, Kron IL, Ailawadi G. Is off-pump coronary artery bypass grafting superior to conventional bypass in octogenarians? J Thorac Cardiovasc Surg. 2011;141:81–90.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Saleh HZ, Shaw M, Fabri BM, Chalmers JA. Does avoidance of cardiopulmonary bypass confer any benefits in octogenarians undergoing coronary surgery? Interact CardioVasc Thorac Surg. 2011;12:435–9.

    Article  PubMed  Google Scholar 

  40. Kinoshita T, Asai T, Suzuki T, Kuroyanagi S, Hosoba S, Takashima N. Off-pump bilateral skeletonized internal thoracic artery grafting in elderly patients. Ann Thorac Surg. 2012;93(2):531–6.

    Article  PubMed  Google Scholar 

  41. Ben-Gal Y, Stone GW, Smith CR, Williams MR, Weisz G, Stewart AS, et al. On-pump versus off-pump surgical revascularization in patients with acute coronary syndromes: analysis from the Acute Catheterization and Urgent Intervention Triage Strategy trial. J Thorac Cardiovasc Surg. 2011;142:e33–9.

    Article  PubMed  Google Scholar 

  42. Moscarelli M, Harling L, Ashrafian H, Athanasiou T. Should we consider off-pump coronary artery bypass grafting in patients with acute coronary syndrome? Interact Cardiovasc Thorac Surg. 2013;16(3):350–5.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Novitzky D, Baltz JH, Hattler B, Collins JF, Kozora E, Shroyer AL, et al. Outcomes after conversion in the Veterans Affairs randomized on versus off bypass trial. Ann Thorac Surg. 2011;92:2147–54.

    Article  PubMed  Google Scholar 

  44. Mukherjee D, Ahmed K, Baig K, Patel VM, Darzi A, Athanasiou T. Conversion and safety in off-pump coronary artery bypass: a system failure that needs re-emphasis. Ann Thorac Surg. 2011;91:630–9.

    Article  PubMed  Google Scholar 

  45. Urso S, Sadaba JR, Pettinari M. Impact of off-pump to on-pump conversion rate on post-operative results in patients undergoing off-pump coronary artery bypass. Interact CardioVasc Thorac Surg. 2012;14:188–93.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Konety SH, Rosenthal GE, Vaughan-Sarrazin MS. Surgical volume and outcomes of off-pump coronary artery bypass graft surgery: does it matter? J Thorac Cardiovasc Surg. 2009;137(1116–23):e1.

    PubMed  Google Scholar 

  47. Lapar DJ, Mery CM, Kozower BD, Kern JA, Kron IL, Stukenborg GJ, et al. The effect of surgeon volume on mortality for off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2012;143:854–63.

    Article  PubMed  Google Scholar 

  48. Sepehripour AH, Athanasiou T. Is there a surgeon or hospital volume-outcome relationship in off-pump coronary artery bypass surgery? Interact Cardiovasc Thorac Surg. 2013;16(2):202–7.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Bougioukakis P, Mandewirth M, Babin-Ebell J, Diegeler A. Quality management and learning curve after coronary artery off-pump heart surgery. eComment. Interact Cardiovasc Thorac Surg. 2013;16(2):207–8. doi:10.1093/icvts/ivs541.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Locker C, Schaff HV, Dearani JA, Joyce LD, Park SJ, Burkhart HM, Suri RM, Greason KL, Stulak JM, Li Z, Daly RC. Multiple arterial grafts improve late survival of patients undergoing coronary artery bypass graft surgery: analysis of 8622 patients with multivessel disease. Circulation. 2012;126(9):1023–30.

    Article  PubMed  Google Scholar 

  51. Emmert MY, Salzberg SP, Cetina Biefer HR, Sundermann SH, Seifert B, Grunenfelder J, et al. Total arterial off-pump surgery provides excellent outcomes and does not compromise complete revascularization. Eur J Cardiothorac Surg. 2012;41:e25–31.

    Article  PubMed  Google Scholar 

  52. Nakajima H, Kobayashi J, Toda K, Fujita T, Shimahara Y, Kasahara Y, et al. Angiographic evaluation of flow distribution in sequential and composite arterial grafts for three vessel disease. Eur J Cardiothorac Surg. 2012;41:763–9.

    Article  PubMed  Google Scholar 

  53. Navia D, Vrancic M, Piccinini F, Camporrotondo M, Thierer J, Gil C, Benzadon M. Is the second internal thoracic artery better than the radial artery in total arterial off-pump coronary artery bypass grafting? A propensity score-matched follow-up study. J Thorac Cardiovasc Surg. 2014;147(2):632–8.

    Article  PubMed  Google Scholar 

  54. Hwang HY, Cho KR, Kim KB. Equivalency of right internal thoracic artery and right gastroepiploic artery composite grafts: five-year outcomes. Ann Thorac Surg. 2013;96(6):2061–8.

    Article  PubMed  Google Scholar 

  55. Jeong DS, Kim YH, Lee YT, Chung SR, Sung K, Kim WS, Park PW. Revascularization for the right coronary artery territory in off-pump coronary artery bypass surgery. Ann Thorac Surg. 2013;96(3):778–85 (discussion 785).

    Article  PubMed  Google Scholar 

  56. Kim WS, Lee J, Lee YT, Sung K, Yang JH, Jun TG, Park PW. Total arterial revascularization in triple-vessel disease with off-pump and aortic no-touch technique. Ann Thorac Surg. 2008;86(6):1861–5.

    Article  PubMed  Google Scholar 

  57. Al-Ruzzeh S, Epstein D, George S, Bustami M, Wray J, Ilsley C, et al. Economic evaluation of coronary artery bypass grafting surgery with and without cardiopulmonary bypass: cost-effectiveness and quality-adjusted life years in a randomized controlled trial. Artif Organs. 2008;32:891–7.

    Article  PubMed  Google Scholar 

  58. Hu S, Zheng Z, Yuan X, Wang W, Song Y, Sun H, 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 

  59. Filardo G, Grayburn PA, Hamilton C, Hebeler RF Jr, Cooksey WB, Hamman B. Comparing long-term survival between patients undergoing off-pump and on-pump coronary artery bypass graft operations. Ann Thorac Surg. 2011;92:571–7 (discussion 7–8).

    Article  PubMed  Google Scholar 

  60. Wu C, Camacho FT, Culliford AT, Gold JP, Wechsler AS, Higgins RS, et al. A comparison of long-term mortality for off-pump and on-pump coronary artery bypass graft surgery. Circ Cardiovasc Qual Outcomes. 2012;5:76–84.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Alston RP. Brain damage and cardiopulmonary bypass: is there really any association? Perfusion. 2011;26(Suppl 1):20–6.

    Article  PubMed  Google Scholar 

  62. Cheng DC, Bainbridge D, Martin JE, Novick RJ, Evidence-Based Perioperative Clinical Outcomes Research Group. Does off-pump coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with conventional coronary artery bypass? A meta-analysis of randomized trials. Anesthesiology. 2005;102:188–203.

    Article  PubMed  Google Scholar 

  63. 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.

    Article  PubMed  CAS  Google Scholar 

  64. Diegeler A, Börgermann 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.

    Article  PubMed  CAS  Google Scholar 

Download references

Conflict of interest

All the authors have declared no competing interest.

Author information

Authors and Affiliations

  1. Cardiothoracic Department, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK

    Haralabos Parissis

  2. Cardiopulmonary Transplantation Department, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK

    B. C. Ramesh

  3. Thoracic Department, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA

    Bassel Al-Alao

Authors
  1. Haralabos Parissis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. B. C. Ramesh
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Bassel Al-Alao
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Haralabos Parissis.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Parissis, H., Ramesh, B.C. & Al-Alao, B. Off-pump coronary surgery: current justifications. Gen Thorac Cardiovasc Surg 62, 660–670 (2014). https://doi.org/10.1007/s11748-014-0470-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11748-014-0470-2

Keywords

Search

Navigation