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Abstract
On-pump coronary artery bypass surgery remains the gold standard for complex multivessel disease. Off-pump revascularization has matured as a technique over the last twenty years, but is used in less than 20% of cases worldwide. The poor uptake has been attributed to the significant learning curve in learning the procedure and conflicting evidence reports, together with concerns over mortality related conversion, graft patency and completeness of revascularization. Given these concerns, patient selection continues to be paramount and the subgroups that benefit most are hotly debated. Patients with left ventricular dysfunction constitute a high-risk subgroup which is enlarging in size. There is some evidence to suggest that avoidance of cardiopulmonary bypass in this group may lead to superior results in terms of early mortality, non-cardiac complications and organ dysfunction. Even with the theoretical risk of incomplete revascularization, the technique may be an attractive option in managing high-risk patients.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
Key issues
Coronary artery bypass surgery is the gold standard management of complex multivessel disease.
Patients with left ventricular dysfunction constitute a high-risk subgroup that is growing in size.
Off-pump surgery has matured significantly over the last 20 years, but still has poor uptake partly due to the difficulties in interpreting conflict evidence reports.
Most of the randomized studies to date have not shown significant benefits in avoiding cardiopulmonary bypass, but have generally analyzed small numbers of low-risk patients.
Observational data, which is more abundant in availability, have demonstrated benefit, particularly in high-risk patients.
Off-pump surgery may lead to superior results in terms of early mortality, noncardiac complications and organ dysfunction in patients with left ventricular dysfunction, but this is based on observational data only.
Even with mixed reports on graft patency and completeness of revascularization, the technique may be attractive to surgeons and intensivists in managing high-risk patients where organ dysfunction is a particular concern.
Patient selection is paramount as conversion to bypass is associated with a sevenfold increase in mortality.
As risk stratification evolves, clinicians will become more accountable for postoperative morbidity and resource consumption that off-pump surgery may help to offset.