Off-pump CABG tied to higher mortality in patients with left main disease
Off-pump, compared with on-pump, coronary artery bypass grafting (CABG) in patients with left main disease results in a lower rate of revascularization of the coronary arteries supplying the inferolateral wall and an increased risk of 3-year all-cause death, results of the EXCEL* trial have shown.
Of the 923 CABG patients, 652 underwent on-pump surgery and 271 off-pump. The extent of disease was similar between the two groups, but patients in the off-pump arm had a lower rate of revascularization of the left circumflex coronary artery (84.1 percent vs 90.0 percent; p=0.01) and right coronary artery (31.1 percent vs 40.6 percent; p=0.007).
After inverse probability of treatment weighting (IPTW) adjustment for baseline difference, an association was found between off-pump surgery and a significant increase in the risk of 3-year all-cause death (8.8 percent vs 4.5 percent; hazard ratio [HR], 1.94, 95 percent CI, 1.10–3.41; p=0.02), as well as a nonsignificant difference in the risk for the composite endpoint of death, myocardial infarction or stroke (11.8 percent vs 9.2 percent; HR, 1.28, 0.82–2.00; p=0.28).
The EXCEL trial compared percutaneous coronary intervention with everolimus-eluting stents with CABP in patients with left main disease. CABG was performed with or without cardiopulmonary bypass (on-pump vs off-pump surgery) according to the discretion of the operator. IPTW for treatment effect estimation was used to compare the 3-year outcomes in the off-pump and on-pump groups.
“Concerns remain for a greater risk of incomplete revascularization and reduced survival with off-pump CABG surgery compared with on-pump surgery particularly in patients with left main disease and extensive underlying myocardial ischaemia,” the authors said.
*Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization