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A randomised comparison of off-pump and on-pump multivessel coronary artery bypass surgery.  Khan N E,  De Souza A,  Mister R et al.  N Engl J Med 2004;  350:  21-28.

Coronary artery bypass grafting performed with cardiopulmonary bypass and cardiac arrest provides a motionless, bloodless surgical field, allowing optimal conditions for the construction of coronary anastomoses.  The effects of the use of coronary-artery bypass surgery without cardiopulmonary bypass and cardiac arrest (off-pump) on graft patency remains uncertain.  This study was a prospective, randomised, controlled study to compare graft-patency rates and clinical outcomes in off-pump and conventional on-pump surgery.  Overall, 50 patients were randomised to undergo on-pump coronary artery bypass grafting and 54 to undergo off-pump surgery. Surgical and anaesthetic techniques were standardised for both groups.  Clinical outcomes and troponin T levels were measured. Three months later patients underwent coronary angiography, including quantitative analysis.  The mean age of the patients was 63 years and 87% were men.  The on-pump group received a mean of 3.4 grafts and the off-pump 3.1 (p=0.41).  There were no deaths.  The was no significant difference in the median post-operative length of stay between the two groups.  The area under the curve of the troponin T levels was higher during the first 72 hours in the on-pump group than the off-pump group.  At three months, 127 of 130 grafts were patent in the on-pump group (98%) as compared with 114 of 130 (88%) in the off-pump group (p=0.002).  The patency rate was higher for all graft territories in the on-pump group than in the off-pump group.  It was concluded that off-pump coronary artery surgery was as safe as on-pump surgery and caused less myocardial damage.  However, the graft patency rate was lower at 3 months in the off-pump group than in the ob-pump group.  This difference may have implications with respect to the long-term outcome.

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