Impact of on-pump and off-pump coronary artery bypass grafting on 10-year mortality versus percutaneous coronary intervention
Authors: Kageyama Shigetaka , Serruys Patrick W , Ninomiya Kai , O’Leary Neil , Masuda Shinichiro , Kotoku Nozomi , Colombo Antonio , van Geuns Robert-Jan , Milojevic Milan , Mack Michael J , Soo Alan , Garg Scot , Onuma Yoshinobu , Davierwala Piroze M ,   SYNTAX Extended Survival Investigators, Casselman Filip , de Bruyne Bernard , Christiansen Evald Høj , Ruiz-Nodar Juan M , Vermeersch Paul , Schultz Werner , Sabaté Manel , Guagliumi Giulio , Grubitzsch Herko , Stangl Karl , Darremont Olivier , Bentala M , den Heijer Peter , Preda Istvan , Stoler Robert , Mack Michael J , Szerafin Tamás , Buckner John K , Guber Myles S , Verberkmoes Niels , Akca Ferdi , Feldman Ted , Beyersdorf Friedhelm , Drieghe Benny , Oldroyd Keith , Berg Geoff , Jeppsson Anders , Barber Kimberly , Wolschleger Kevin , Heiser John , van der Harst Pim , Mariani Massimo A , Reichenspurner Hermann , Stark Christoffer , Laine Mika , Ho Paul C , Chen John C , Zelman Richard , Horwitz Phillip A , Bochenek Andrzej , Krauze Agata , Grothusen Christina , Dudek Dariusz , Heyrich George , Davierwala Piroze , Noack Thilo , Kolh Philippe , LeGrand Victor , Coelho Pedro , Ensminger Stephan , Nasseri Boris , Ingemansson Richard , Olivecrona Goran , Escaned Javier , Guera Reddy , Berti Sergio , Morice Marie-Claude , Chieffo Alaide , Burke Nicholas , Mooney Michael , Spolaor Alvise , Hagl Christian , Näbauer Michael , Jan Suttorp Maarten , Stine Ronald A , McGarry Thomas , Lucas Scott , Endresen Knut , Taussig Andrew , Accola Kevin , Canosi Umberto , Horvath Ivan , Cannon Louis , Talbott John D , Akins Chris W , Kramer Robert , Aschermann Michael , Killinger William , Narbute Inga , Holmes David R , Burzotta Francesco , Bogers Ad , Zijlstra Felix , Eltchaninoff Helene , Berland Jacques , Stefanini Giulio , Gonzalez Ignacio Cruz , Hoppe Uta , Kiesz Stefan , Gora Bartlomiej , Ahlsson Anders , Corbascio Matthias , Bilfinger Thomas , Carrie Didier , Tchétché Didier , Hauptman Karl-Eugen , Stahle Elisabeth , James Stefan , Sandner Sigrid , Laufer Günther , Lang Irene , Witkowski Adam , Thourani Vinod , Suryapranata Harry , Redwood Simon , Knight Charles , MacCarthy Philip , Curzen Nick , de Belder Adam , Banning Adrian , Gershlick Anthony 
Published: June 2023

Abstract

OBJECTIVES
The very long-term mortality of off-pump and on-pump coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in a randomized complex coronary artery disease population is unknown. This study aims to investigate the impact of on-pump and off-pump CABG versus PCI on 10-year all-cause mortality.

METHODS
The SYNTAX trial randomized 1800 patients with three-vessel and/or left main coronary artery disease to PCI or CABG and assessed their survival at 10 years. In this sub-study, the hazard of mortality over 10 years was compared according to the technique of revascularization: on-pump CABG (n = 725), off-pump CABG (n = 128) and PCI (n = 903).

RESULTS
There was substantial inter-site variation in the use of off-pump CABG despite baseline characteristics being largely homogeneous among the 3 groups. The crude rate of mortality was significantly lower following on-pump CABG versus PCI [25.6% vs 28.4%, hazard ratio (HR) 0.79, 95% confidence interval (CI) 0.65–0.96], while it was comparable between off-pump CABG and PCI (28.5% vs 28.4%, HR 0.98, 95% CI 0.69–1.40). After adjusting for the 9 variables included in the SYNTAX score II 2020, 10-year mortality remained significantly lower with on-pump CABG than PCI (HR 0.75 against PCI, P = 0.009).

CONCLUSIONS
In the SYNTAXES trial, 10-year mortality adjusted for major confounders was significantly lower following on-pump CABG compared to PCI. There was no evidence for unadjusted difference between off-pump CABG and PCI, although the unadjusted estimated HR had a wide CI. Site heterogeneity in the technique used in bypass surgery has had measurable effects on treatment performance.