title: Effects of on-pump and off-pump surgery in the Arterial Revascularization Trial.
abstract: OBJECTIVE
  The Arterial Revascularization Trial (ART) is a randomized comparison of bilateral internal mammary artery (BIMA) versus single internal mammary artery (SIMA) grafting in coronary artery bypass graft (CABG) surgery and is one of the largest randomized trials of surgery ever conducted. ART is also one of the largest studies of contemporary CABG with a high proportion of off-pump surgeries (41%). The objective of this post hoc analysis was to evaluate the surgical process and 1-year outcomes for surgery performed on-pump compared with off-pump.
  
  
  METHODS
  ART randomized 3102 patients with multivessel coronary artery disease (CAD) to SIMA or BIMA grafts to determine if BIMA grafts have an additional survival advantage at 10 years. The 1-year interim analysis showed an overall very low mortality and major morbidity rate irrespective of whether the procedure was with an SIMA or BIMA. The surgical process and 1-year outcomes were analysed according to whether surgery was performed on-pump or off-pump.
  
  
  RESULTS
  Baseline variables were not statistically significantly different between on- and off-pump surgery within each treatment group after taking account of the effects of clustering by individual surgeons. At both 30 days and 1 year, there was a low incidence of death (1.2%, 2.3%), stroke (1.1%, 1.7%), myocardial infarction (MI) (1.4%, 1.9%), repeat revascularization (0.5%, 1.5%) and wound reconstruction (1.2%). A similar average number of grafts were performed with on- and off-pump surgery (median = 3), but the duration of surgery was 20-30 min and ventilation time ∼ 2 h shorter with off-pump surgery. Blood loss and platelet transfusions were lower in the off-pump group, with no difference in the need for balloon pump or renal support. Sternal wound reconstruction was similar with off-pump surgery in the SIMA group (0.5 vs 0.6%) and lower with off-pump surgery in the BIMA group (1.4 vs 2.2%). Repeat revascularization was marginally higher in off-pump patients at 30 days (0.8 vs 0.3%) and at 1 year (1.7 vs 1.3%).
  
  
  CONCLUSIONS
  The outcomes of contemporary CABG are excellent with low mortality, stroke, myocardial infarction and need for wound reconstruction and repeat revascularization whether performed on-pump or off-pump.
  
  
  BACKGROUND
  Controlled-trials.com (ISRCTN46552265).
authors.affiliation: Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, Oxford, UK david.taggart@orh.nhs.uk.
authors.forename: David P
authors.initials: DP
authors.lastname: Taggart
authors.affiliation: Centre for Statistics in Medicine, University of Oxford, Oxford, UK Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Oxford, UK.
authors.forename: Douglas G
authors.initials: DG
authors.lastname: Altman
authors.affiliation: Department of Public Health, Health Economics Research Centre, University of Oxford, Headington, Oxford, UK.
authors.forename: Alastair M
authors.initials: AM
authors.lastname: Gray
authors.affiliation: Clinical Trials and Evaluation Unit, Royal Brompton and Harefield NHS Trust, London, UK National Heart and Lung Institute, Imperial College London, London, UK.
authors.forename: Belinda
authors.initials: B
authors.lastname: Lees
authors.affiliation: Clinical Trials and Evaluation Unit, Royal Brompton and Harefield NHS Trust, London, UK.
authors.forename: Fiona
authors.initials: F
authors.lastname: Nugara
authors.affiliation: Centre for Statistics in Medicine, University of Oxford, Oxford, UK Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Oxford, UK.
authors.forename: Ly-Mee
authors.initials: LM
authors.lastname: Yu
authors.affiliation: Clinical Trials and Evaluation Unit, Royal Brompton and Harefield NHS Trust, London, UK National Heart and Lung Institute, Imperial College London, London, UK.
authors.forename: Marcus
authors.initials: M
authors.lastname: Flather
mesh_terms: D000368:Aged; D001026:Coronary Artery Bypass / Q000379:methods* / Q000401:mortality* / Q000706:statistics & numerical data; D047549:Coronary Artery Bypass, Off-Pump; D003324:Coronary Artery Disease / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008323:Mammary Arteries / Q000601:surgery; D008875:Middle Aged
keywords: Arteries; Bypass; Coronary disease