35. 10-Year Outcomes After Off-Pump Versus On-Pump Coronary Artery Bypass Graft Surgery: Insights from the Arterial Revascularization Trial
*Umberto Benedetto1, *Mario F. L. Gaudino2, Stephen Gerry3, Alastair Gray3, Belinda Lees3, Marcus Flather4, *David P. Taggart3
1University of Bristol, Bristol, United Kingdom;2Cornell Medical School, New York; 3University of Oxford, Oxford, United Kingdom; 4Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom
Invited Discussant: *Marc Ruel
Objective: Controversy regarding the long-term effect of off-pump vs on-pump coronary artery bypass graft surgery remains. The Arterial Revascularization Trial was designed to compare 10-year outcomes following bilateral vs single internal thoracic artery grafts. The use of off-pump surgery was based on surgeon’s discretion. We investigated the effect of off-pump vs. on-pump surgery on late outcomes by performing a post-hoc analysis of the ART trial.
Methods: Of 3102 patients enrolled in ART, off-pump surgery was performed in 1252 patients (40.4%) and on-pump surgery was performed in 1699 patients (59.6%). Primary endpoint was 10-year mortality. Secondary endpoints included 10-year incidence of MI, stroke and repeat revascularization. Multivariable models and propensity matching were used to compare the two groups.
Results: The two groups were well matched for all baseline characteristics. Total number of grafts was 3.20 (0.87) vs. 3.19 (0.76) in the off-pump vs on-pump group respectively (P=0.70). 29 (2.3%)patients required intra-operative conversion from off-pump to on-pump. Overall hospital mortality was 1.0% and 1.1% in the off-pump vs on-pump group respectively (P=0.70).After 10 years, survival rate was 77.8%(75.4-80.1) vs. 79.8%(77.9-81.7) in the off-pump vs on-pump group respectively (log-rank P=0.21; Figure). After propensity matching and multivariable adjustment off-pump did not increase the risk of late mortality (HR 1.06; 95%CI 0.89-1.27; P=0.48). Off-pump was not associated with increased risk of subsequent MI (HR 0.83; 95%CI 0.58-1.20; P=0.34), stroke (HR 1.33; 95%CI 0.925-1.93; P=0.12) and repeat revascularization (HR 1.023; 95%CI 0.80-1.31; P=0.85).
Conclusions: The present post-hoc analysis of ART supports the hypothesis that off-pump does not increase the risk of late adverse events when compared to on-surgery.