Off-pump versus on-pump coronary artery bypass grafting: Insights from the Arterial Revascularization Trial

Background: The long-term effects of off-pump coronary artery bypass continue to be controversial because some studies have reported increased adverse event rates with off-pump coronary artery bypass when compared with on-pump coronary artery bypass. The Arterial Revascularization Trial compared survival after bilateral versus single internal thoracic artery grafting. The choice of off-pump coronary artery bypass versus on-pump coronary artery bypass was based on the surgeon's discretion. We performed a post hoc analysis of the Arterial Revascularization Trial to compare 5-year outcomes with 2 strategies. Methods: Among 3102 patients enrolled in the Arterial Revascularization Trial, we selected 1260 patients who underwent off-pump coronary artery bypass versus 1700 patients who underwent on-pump coronary artery bypass with cardioplegic arrest for the present comparison. Primary outcomes were 5-year mortality and incidence of major cardiac and cerebrovascular events, including cardiovascular death, myocardial infarction, cerebrovascular accident, and revascularization after index procedure. Propensity score matching selected 1260 pairs for final comparison. Stratified Cox models were used for treatment effect estimate. Results: Hospital mortality was comparable between off-pump coronary artery bypass and on-pump coronary artery bypass groups (12 [1.0%] vs 15 [1.2%]; P = .7). Conversion rate to on-pump during off-pump coronary artery bypass was 29 of 1260 (2.3%). When compared with off-pump coronary artery bypass not converted, off-pump coronary artery bypass converted to on-pump presented a remarkably higher hospital mortality (10.3% vs 0.7%; P < .001). At 5 years, the mortality rate was 110 (8.9%) versus 102 (8.3%) in the off-pump coronary artery bypass and on-pump coronary artery bypass groups, respectively, with no significant difference (hazard ratio, 1.14; 95% confidence interval, 0.86-1.52; P = .35). Incidence of major cardiac and cerebrovascular events was 175 (14.3) versus 169 (13.8) in the off-pump coronary artery bypass and on-pump coronary artery bypass groups, respectively, with no significant difference (hazard ratio, 1.05; 95% confidence interval, 0.84-1.31; P = .65). Conclusions: The present post hoc Arterial Revascularization Trial analysis supports the hypothesis that both off-pump coronary artery bypass and on-pump coronary artery bypass are equally effective and safe

Safety of perioperative aprotinin administration during isolated coronary artery bypass graft surgery: Insights from the ART (Arterial Revascularization Trial)

Background: There is still uncertainty about the safety of aprotinin for coronary artery bypass graft (CABG) surgery. The Arterial Revascularization Trial (ART) was designed to compare survival after bilateral vs single internal thoracic artery grafting. A large proportion of the ART patients (~30%) received perioperative aprotinin. We investigated the association between perioperative Aprotinin administration and short (in-hospital) and long-term outcomes by performing a post-hoc analysis of the ART. Methods: Among patients enrolled in the ART (n=3102) from 2004 to 2007, we excluded those who did not undergo surgery (n=18) and those with no information regarding use of perioperative aprotinin (n=9). Finally, 836 out of 3076 patients (27%) received aprotinin. Propensity score matching (1:1) selected 536 pairs for final comparison. Conditional logistic and stratified Cox models were used to investigate treatment effect on short and long-term outcomes respectively. Results: Hospital mortality was significantly higher in the Aprotinin group (9,1.7% vs 1,0.2%; Odds ratio, OR: 9.12; 95% confidence interval CI 1.15-72.2; P=0.03). Aprotinin was also associated with an increased risk of intra-aortic balloon pump insertion (37, 6.9% vs 17, 3.2%; OR 2.26; 95%CI 1.26-4.07; P=0.006) and acute kidney injury (102, 19.0% vs 76, 14.2%; OR 1.42; 95%CI 1.03-1.97; P=0.03). We also found a non-significantly increased risk of in hospital reintervention in the Aprotinin group (7, 1.3% vs 2,0.4%; OR 3.53 95%CI 0.73-17.1; P=0.1). Aprotinin was not associated with a lower incidence of red blood cell transfusion (37, 6.9% vs 28, 5.2%; OR 1.34; 95%CI 0.81-2.23; P=0.25). and re-exploration (26, 4.9% vs 19, 3.5%; HR 1.39; 95%CI 0.76-2.53; P=0.28). At 5 years, all-cause mortality was significantly increased in the Aprotinin group (56, 10.6% vs 38, 7.3%; Hazard ratio 1.51; 95% CI 1.0-2.28; P=0.045). Conclusions: In the present post-hoc ART analysis, Aprotinin was associated with a significantly increased risk of early and late mortality