The views of supporters and opponents of off-pump CABG have remained essentially unchanged in the intervening period. A meta-analysis by Afilalo and colleagues23 of almost 9,000 patients
from 59 randomized trials showed no difference between the two techniques in postoperative mortality and myocardial infarction but did report a lower incidence of stroke in the off-pump group (1.4% versus Inhibitors,research,lifescience,medical 2.1%, odds ratio 0.7, 95% CI 0.49–0.99). However, an important consideration in many of the randomized trials was the question about the actual surgical experience of those performing the off-pump surgery. Indeed, two trials reporting worse outcomes with off-pump surgery were severely criticized on the basis of the inexperience of the participating surgeons—emphasized by high rates of conversion from off-pump to on-pump surgery.23,24 Two recently Inhibitors,research,lifescience,medical published trials provide far more definitive answers. First, the CORONARY Trial, which enrolled 4,752 patients in 79 centers in 19 countries, had previously reported no significant difference at
30 days in the primary composite outcome of death, myocardial infarction, stroke, or new renal failure between the two techniques.25 The trial has now reported the 1-year outcomes26 Inhibitors,research,lifescience,medical and showed no significant difference in the primary composite outcome between off-pump and on-pump CABG (12.1% off-pump versus 13.3% on-pump,
hazard ratio 0.91,P = 0.24). In particular, there was no difference in the incidence of individual components of the primary outcome in terms of death, myocardial infarction, stroke, or new renal failure. Furthermore, and in contrast to previous studies, Inhibitors,research,lifescience,medical there was no significant increase in the incidence of repeat revascularization for off-pump CABG at 1 year. Additionally, there was no difference in neurocognitive outcomes at 1 year between the two groups. The most likely explanation of the differences between Inhibitors,research,lifescience,medical the findings of the CORONARY Trial and two of the Metformin largest previous trials Resveratrol reporting inferior outcomes for off-pump CABG is that the CORONARY Trial not only enrolled a far greater number of patients but, crucially, recruited surgeons with a far higher level of surgical expertise in off-pump surgery. A second trial (GOPCABE), which randomized 2,539 patients aged 75 years or older to on-pump and off-pump CABG, has been published very recently.27 Again, the primary outcome was a composite of death, stroke, myocardial infarction, repeat revascularization, or new renal replacement therapy at 30 days and at 1 year after surgery. The authors reported no significant differences in the composite outcome either at 30 days (7.8% off-pump versus 8.2% on-pump, P = 0.74) or at 12 months (13.1% versus 14%, P = 0.48).