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J Thorac Cardiovasc Surg 2007;133:623-631
© 2007 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Does off-pump or minimally invasive coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with percutaneous coronary intervention? A meta-analysis of randomized trials

Daniel Bainbridge, MD, FRCPC^a,_*, Davy Cheng, MD, MSc, FRCPC^a,,_*, Janet Martin, PharmD^b,, Richard Novick, MD, MSc, FRCSC^c, The Evidence-based Peri-operative Clinical Outcomes Research (EPiCOR) Group

^a Department of Anesthesia & Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
^b Department of Pharmacy, Physiology & Pharmacology, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
^c Division of Cardiac Surgery, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada.

Presented at the Health Technology Assessment International (HTAi) Conference in Rome, June 20–22, 2005.

Received for publication September 11, 2006; revisions received October 25, 2006; accepted for publication November 1, 2006.

^_* Address for reprints: D. Cheng, MD, MSc, FRCPC, Department of Anesthesia & Perioperative Medicine, London Health Sciences Centre—University Hospital, 339 Windermere Rd, Room 3-CA19, London, Ontario, Canada N6A 5A5. (Email: davy.cheng{at}lhsc.on.ca).

Objective: To determine, through meta-analysis, whether off-pump coronary artery bypass, including minimally invasive off-pump coronary artery bypass, improves short-term and midterm outcomes compared with percutaneous coronary intervention for single- or double-vessel coronary artery disease.

Methods: The primary outcome was need for coronary reintervention at 1 to 5 years. Secondary outcomes included all major clinical morbidities and resource utilization. A comprehensive search was undertaken to identify all randomized trials of off-pump coronary artery bypass versus percutaneous coronary intervention. MEDLINE, Cochrane Library, EMBASE, and abstract databases were searched up to May 2006. All randomized trials comparing off-pump coronary artery bypass (sternotomy or minimally invasive) versus percutaneous coronary intervention and reporting at least one predefined outcome were included. Odds ratios (OR, 95% confidence intervals [CI]) and weighted mean differences (WMD, 95% CI) were analyzed.

Results: Six trials involving 989 patients were included. Compared with percutaneous coronary intervention, off-pump coronary artery bypass decreased angina recurrence (OR 0.54, 95% CI 0.34–0.87) and need for reintervention at 1 to 5 years (OR 0.24, 95% CI 0.15–0.40). Major adverse coronary events were significantly reduced (OR 0.44, 95% CI 0.30–0.63) and event-free survival was significantly increased at 1 to 5 years (OR 2.32, 95% CI 1.62–3.32) for off-pump coronary artery bypass versus percutaneous coronary intervention. Coronary stenosis at 6 months was reduced with off-pump coronary artery bypass compared with percutaneous coronary intervention (OR 0.31, 95% CI 0.18–0.55). Hospital stay was significantly increased with off-pump coronary artery bypass versus percutaneous coronary intervention (WMD 4.03, 95% CI 2.37–5.70). Quality of life favored off-pump coronary artery bypass in some domains but was reported in few studies. Death, myocardial infarction, and stroke did not significantly differ.

Conclusions: In single- or double-vessel disease, off-pump coronary artery bypass improved short-term and midterm clinical outcomes compared with percutaneous coronary intervention but was associated with an increased length of hospital stay.

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