title: On-pump versus off-pump surgical revascularization in patients with acute coronary syndromes: analysis from the Acute Catheterization and Urgent Intervention Triage Strategy trial.
abstract: OBJECTIVE
  Early invasive strategy, defined as early coronary angiography and subsequent revascularization, when appropriate, is recommended by current guidelines for the management of patients with moderate- to high-risk acute coronary syndromes. We sought to compare the outcomes of patients with acute coronary syndromes undergoing surgical revascularization with an on-pump versus off-pump approach.
  
  
  METHODS
  Among a total of 13,819 patients with moderate- to high-risk acute coronary syndromes enrolled in the Acute Catheterization and Urgent Intervention Triage Strategy trial, 1375 patients were triaged to isolated coronary artery bypass grafting. One thousand one hundred fifty-four patients underwent operations with cardiopulmonary bypass (the coronary artery bypass grafting group), and 221 patients underwent off-pump coronary artery bypass grafting (the off-pump coronary artery bypass grafting group). Propensity score matching (1:3) was applied to adjust for differences in baseline clinical and angiographic characteristics, yielding a total of 880 matched patients with acute coronary syndromes (220 managed with off-pump coronary artery bypass grafting and 660 managed with coronary artery bypass grafting).
  
  
  RESULTS
  At 30 days, patients undergoing off-pump coronary artery bypass grafting had fewer events of bleeding (43.7% vs 56.3%, P = .0005) and myocardial infarction (7.3% vs 12.1%, P = .055) but higher rates of reintervention (3.7% vs 1.2%, P = .02). At 1 year, there was no difference between groups in death, total myocardial infarctions, reinterventions, strokes, or major adverse cardiac events, but there was a lower rate of non-Q-wave myocardial infarctions in the off-pump coronary artery bypass grafting group (4.6% vs 9.2%, P = .03).
  
  
  CONCLUSIONS
  In this large-scale study evaluating the outcomes of patients with acute coronary syndromes, off-pump coronary artery bypass grafting was associated with lower rates of bleeding and non-Q-wave myocardial infarction but more reinterventions early after the procedure. At 1 year, there was no major outcome difference between the 2 surgical strategies.
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY, USA. mdbengal@gmail.com
authors.forename: Yanai
authors.initials: Y
authors.lastname: Ben-Gal
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
authors.forename: Craig R
authors.initials: CR
authors.lastname: Smith
authors.forename: Mathew R
authors.initials: MR
authors.lastname: Williams
authors.forename: Giora
authors.initials: G
authors.lastname: Weisz
authors.forename: Allan S
authors.initials: AS
authors.lastname: Stewart
authors.forename: Hiroo
authors.initials: H
authors.lastname: Takayama
authors.forename: Philippe
authors.initials: P
authors.lastname: Genereux
authors.forename: Michael
authors.initials: M
authors.lastname: Argenziano
mesh_terms: D054058:Acute Coronary Syndrome / Q000601:surgery*; D001026:Coronary Artery Bypass; D047549:Coronary Artery Bypass, Off-Pump; D005260:Female; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology; D011183:Postoperative Complications; D012086:Reoperation; D020521:Stroke / Q000209:etiology; D016896:Treatment Outcome