title: Clinical outcomes in randomized trials of off- vs. on-pump coronary artery bypass surgery: systematic review with meta-analyses and trial sequential analyses.
abstract: OBJECTIVE
  To assess the clinical outcomes of off- vs. on-pump coronary artery bypass surgery in randomized trials.
  
  
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Cardio-Thoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark. chm@ctu.rh.dk
authors.forename: Christian H
authors.initials: CH
authors.lastname: Møller
authors.forename: Luit
authors.initials: L
authors.lastname: Penninga
authors.forename: Jørn
authors.initials: J
authors.lastname: Wetterslev
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Steinbrüchel
authors.forename: Christian
authors.initials: C
authors.lastname: Gluud
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000150:complications / Q000401:mortality*; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000379:methods / Q000401:mortality*; D047549:Coronary Artery Bypass, Off-Pump / Q000009:adverse effects / Q000401:mortality; D023921:Coronary Stenosis / Q000150:complications / Q000601:surgery; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000401:mortality*; D016032:Randomized Controlled Trials as Topic; D020521:Stroke / Q000150:complications / Q000401:mortality*; D016896:Treatment Outcome