European Heart Journal Advance Access originally published online on July 15, 2008
European Heart Journal 2008 29(21):2601-2616; doi:10.1093/eurheartj/ehn335
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Clinical outcomes in randomized trials of off- vs. on-pump coronary artery bypass surgery: systematic review with meta-analyses and trial sequential analyses
1 Department of Cardio-thoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamvej 9, DK-2100 Copenhagen, Denmark
2 Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
Received 20 February 2008; revised 26 May 2008; accepted 27 June 2008; online publish-ahead-of-print 15 July 2008.
* Corresponding author. Tel: +45 3545 7154, Fax: +45 3545 7101, Email: chm{at}ctu.rh.dk
Aims: To assess the clinical outcomes of off- vs. on-pump coronary artery bypass surgery in randomized trials.
Methods and results: We searched electronic databases and bibliographies until June 2007. Trials were assessed for risk of bias. Outcome measures were all-cause mortality, myocardial infarction, stroke, atrial fibrillation, and renewed coronary revascularization at maximum follow-up. We applied trial sequential analysis to estimate the strength of evidence. We found 66 randomized trials. There was no statistically significant differences regarding mortality [relative risk (RR) 0.98; 95% confidence interval (CI) 0.66–1.44], myocardial infarction (RR 0.95; 95% CI 0.65–1.37), or renewed coronary revascularization (RR 1.34; 95% CI 0.83–2.18). We found a significant reduced risk of atrial fibrillation (RR 0.69; 95% CI 0.57–0.83) and stroke (RR 0.53; 95% CI 0.31–0.91) in off-pump patients. However, when continuity correction for zero-event trials was included, the reduction in stroke became insignificant (RR 0.62; 95% CI 0.32–1.19). Trial sequential analysis demonstrated overwhelming evidence supporting that off-pump bypass surgery reduces atrial fibrillation.
Conclusion: Off-pump surgery reduces the risks of postoperative atrial fibrillation compared with on-pump surgery. For death, myocardial infarction, stroke, and renewed coronary revascularization, the evidence is still weak and more low-bias risk trials are needed.
Key Words: Surgery • Systematic review • Meta-analysis • Cardiovascular disease • Cardiopulmonary bypass
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