BEST EVIDENCE TOPIC ADULT CARDIAC

Interactive CardioVascular and Thoracic Surgery 20 (2015) 538545

doi:10.1093/icvts/ivu425 Advance Access publication 21 December 2014

Cite this article as: Al Jaaly E, Chaudhry UAR, Harling L, Athanasiou T. Should we consider beating-heart on-pump coronary artery bypass grafting over
conventional cardioplegic arrest to improve postoperative outcomes in selected patients?. Interact CardioVasc Thorac Surg 2015;20:53845.

Should we consider beating-heart on-pump coronary artery bypass

grafting over conventional cardioplegic arrest to improve
postoperative outcomes in selected patients?
Emad Al Jaaly, Umar A.R. Chaudhry, Leanne Harling* and Thanos Athanasiou
Department of Surgery and Cancer, St Marys Hospital, Imperial College London, London, UK
* Corresponding author. Department of Surgery and Cancer, Imperial College London, 10th Floor, QEQM Building, St Marys Hospital Campus, South Wharf Road,
London W2 1NY, UK. Tel: +44-203-3127630; fax: +44-203-3126309; e-mail: leanne.harling@imperial.ac.uk (L. Harling).
Received 18 July 2014; received in revised form 27 October 2014; accepted 25 November 2014

Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether beatingheart on-pump coronary artery bypass grafting (BH-ONCAB) offered superior mortality and morbidity outcomes when compared with
conventional on-pump coronary artery bypass grafting (C-ONCAB). Morbidity outcomes consisted of renal failure, stroke (transient or permanent), myocardial infarction, angina, congestive cardiac failure, reintervention and arrhythmias. Best evidence papers investigating BHONCAB versus C-ONCAB were considered. Where data were duplicated, the more credible evidence-based and recently published study
was included. Two hundred and thirty-one papers were found using the reported search, of which 11 represented the best evidence to
answer the clinical question. Two were prospective randomized controlled trials and the remaining 10 observational studies, of which one
was propensity-matched. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and
results of these papers are tabulated. Five of these studies demonstrated signicantly improved mortality following BH-ONCAB; however,
one study exhibited better survival after C-ONCAB. Notably, this study incorporated BH-ONCAB patients with signicantly more haemodynamic instability, thus possibly explaining the worse mortality outcomes. In terms of morbidity, a slightly more mixed picture is drawn.
Five studies report morbidity in favour of BH-ONCAB, whereas three studies include individual outcomes favouring C-ONCAB. The
remaining studies showed equivalent mortality and morbidity data. In summary, the results presented here suggest that BH-ONCAB may
improve survival following coronary artery bypass surgery. A key observation is that the greatest benets of BH-ONCAB appear to be in
studies including patients with considerably higher risk characteristics at the time of surgery (haemodialysis, end-stage coronary artery
disease, emergency surgery, low ejection fraction). There are limitations of the current evidence presented. Only two studies were randomized controlled trials. There was variability in sample size, selection criteria and preoperative risk proles between the studies. The studies
span many years, and the outcomes may have been affected by evolving technologies and differing patient proles between these periods.
Keywords: Coronary artery bypass On-pump Beating-heart Cardioplegia Outcomes

INTRODUCTION
A best evidence topic was constructed according to a structured
protocol. This is fully described in the ICVTS [1].

THREE-PART QUESTION
In ( patients undergoing on-pump coronary artery bypass grafting
surgery) is (the beating-heart or conventional cardioplegic arrest)
superior in terms of (mortality and morbidity outcomes)?

signicant triple-vessel disease, and angioplasty fails to achieve a

successful result. He is continued on medical therapy. A subsequent transthoracic echo demonstrates moderate left ventricular
impairment. His case is discussed at the multidisciplinary team
meeting, where you are asked to consider him for coronary
artery bypass surgery (CABG). Your trainee has recently studied
the beating-heart on-pump CABG (BH-ONCAB) technique, and
suggests that it might lead to improved outcomes. You therefore
appraise the literature to determine the optimal surgical strategy
in this patient.

CLINICAL SCENARIO

SEARCH STRATEGY

A 72-year old gentleman is referred to the local cardiologist with

chest pain on exertion. Coronary angiogram demonstrates

A literature search was performed using the PubMed, Ovid,

Embase and Cochrane databases using the terms: (beating-heart)

The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

E. Al Jaaly et al. / Interactive CardioVascular and Thoracic Surgery

539

Table 1: Best evidence papers

Author, date and
country,
Study type
(level of evidence)

Patient group

Outcomes

Key results

Comments

Edgerton et al.
(2004), Heart Surg
Forum, USA [2]

Overall, 4733 total CABG operations

were performed using four different
techniques between January 2000
and December 2002:
364 BH-ONCAB
2332 C-ONCAB

Mortality rate

16 patients (4.4%) in
BH-ONCAB vs 82 patients
(3.5%) in C-ONCAB

Conclusions:
BH-ONCAB was a safe procedure,
and often used for more unstable
patients

Atrial fibrillation

73 patients (20.1%) in
BH-ONCAB vs 554 patients
(23.8%) in C-ONCAB

16 surgeons, who perform both

off-pump and on-pump. No
exclusion criteria

Erkut et al. (2013),

Can J Surg,
Turkey [3]
Retrospective,
cohort study
(level 3 evidence)

A total of 131 CABG procedures were

undertaken in patients with an LVEF
in the range 2535% undergoing
surgery from August 2009 to
June 2012:
65 BH-ONCAB
66 C-ONCAB
All isolated CABG procedures
conducted by a single surgeon.
Patients with LV aneurysm,
post-infarction ventricular septal
defect, ruptured papillary muscle,
severe mitral regurgitation or
combined surgical procedures
were excluded

Izumi et al. (2006),

Ann Thorac Surg,
Japan [4]

31 patients with acute MI underwent

emergency surgery between January
1998 and June 2004:
15 BH-ONCAB

Renal failure

33 patients (9.1%) in
BH-ONCAB vs 106 patients
(4.6%) in C-ONCAB

Dialysis required

4 patients (1.1%) in
BH-ONCAB vs 25 patients
(1.1%) in C-ONCAB

MI

3 patients (0.8%) in
BH-ONCAB vs 24 patients
(1.0%) in C-ONCAB

Re-admission within
30 days

21 patients (5.9%) in
BH-ONCAB vs 146 patients
(6.3%) C-ONCAB

Stroke (permanent)

5 patients (1.4%) in
BH-ONCAB vs 28 patients
(1.2%) in C-ONCAB

Stroke (transient)

2 patients (0.6%) in
BH-ONCAB vs 8 patients
(0.3%) in C-ONCAB

In-hospital mortality

2 deaths (3.1%) in
BH-ONCAB vs 14 deaths
(21.2%) in C-ONCAB
(P = 0.001)

Survival at 1, 12 and 18
months

BH-ONCAB: 97%, 84%, 77%

C-ONCAB: 92%, 82%, 70%
(P > 0.05)

Perioperative MI

1 case (1.5%) in BH-ONCAB

vs 11 cases (16.7%) in
C-ONCAB (P = 0.012)

Postoperative renal
dysfunction

2 cases (3.1%) in BH-ONCAB

vs 11 cases (16.7%) in
C-ONCAB (P = 0.001)

Postoperative
haemodialysis

0 cases (0%) in BH-ONCAB

vs 5 cases (7.6%) in
C-ONCAB (P = 0.026)

Neurological
complications

2 cases (3.1%) in BH-ONCAB

vs 4 cases (6.1%) in
C-ONCAB (P = 0.78)

Mortality

2 deaths (13.3%) in
BH-ONCAB vs 5 deaths
(31.3%) in C-ONCAB
(P = 0.394)

Limitations:
Single-centre, unmatched,
non-randomized, observational
nature of study
No convincing conclusions can be
drawn between BH-ONCAB and
C-ONCAB, as statistical analysis is
not utilized to directly compare the
two techniques
Statistical differences in baseline
characteristics not highlighted
BH-ONCAB is thought to include
more unstable patients: greater
proportions of cardiogenic shock
requiring resuscitation, previous
CABG surgery, recent MI, lower EF
or unstable arrhythmias
Demographics:
Significant differences noted across
all four surgical techniques, not
directly between BH-ONCAB and
C-ONCAB. BH-ONCAB noted to
have significantly worse PROM and
EF. A greater proportion of patients
in resuscitation and cardiogenic
shock using BH-ONCAB
Conclusions:
BH-ONCAB is the preferred
method for CABG in patients with
LV dysfunction due to lower
postoperative mortality and
morbidity
Limitations:
Single-centre, unmatched,
non-randomized, observational
nature of study
Few numbers in either category
Demographics:
Unmatched patients had similar
preoperative and perioperative
characteristics, except for the use of
aortic cross-clamp for C-ONCAB.
Completeness of revascularization
was similar for both procedures

Conclusions:
BH-ONCAB has the possibility of
being an acceptable surgical option
for acute MI, associated with lower

Continued

BEST EVIDENCE TOPIC

Retrospective,
cohort study
(level 3 evidence)

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540

Table 1: (Continued)
Author, date and
country,
Study type
(level of evidence)

Patient group

Outcomes

Key results

Comments

Retrospective,
cohort study
(level 3 evidence)

16 C-ONCAB

Renal failure

2 cases (13.3%) in
BH-ONCAB vs 10 cases
(64.3%) in C-ONCAB
(P = 0.009)

postoperative morbidity and

mortality

BH-ONCAB procedures took

place during 20022004, whereas
C-ONCAB took place during
19982001
The same surgeon performed all 31
CABG, and no exclusion criteria were
mentioned

Limitations:
Single-centre, unmatched,
non-randomized, observational
nature of study
Different time periods during
which procedures took place, with
BH-ONCAB operations being
undertaken later
Few numbers in either category
Demographics:
All preoperative characteristics
were similar, as were target vessels
and choice of grafts, except for the
greater use of radial artery graft for
BH-ONCAB (8 vs 2, P = 0.003)

Mizutani et al.
(2007), Ann Thorac
Surg, Japan [5]
Retrospective,
cohort study
(level 3 evidence)

A total of 559 patients underwent

CABG between January 1995 and
March 2005. Patients were then
consequently matched using
propensity scores for preoperative
characteristics:
114 BH-ONCAB
114 C-ONCAB

In-hospital mortality

3 deaths (2.6%) in
BH-ONCAB vs 11 deaths
(9.6%) in C-ONCAB
(P = 0.0273)

Stroke

3 cases (2.6%) in BH-ONCAB

vs 8 cases (7.0%) in
C-ONCAB (P = 0.1223)

BH-ONCAB procedures took place

between December 2005 and March
2005

Renal failure

The decision of which type of

procedure was made by the
operating surgeon. Patients who
required concomitant procedure
or percutaneous cardiopulmonary
support preoperatively were
excluded, and those who underwent
LV vent insertion in the BH-ONCAB
group

Atrial fibrillation

3 cases (2.6%) in BH-ONCAB

vs 6 cases (5.3%) in
C-ONCAB (P = 0.4990)
29 cases (25.4%) in
BH-ONCAB vs 9 cases (7.9%)
in C-ONCAB (P = 0.0004)

Conclusions:
BH-ONCAB can be performed
safely and in high-risk patients and
may be of most benefit to
haemodynamically unstable
patients
Limitations:
Single-centre, non-randomized,
observational nature of study
Different time periods during
which procedures took place, with
BH-ONCAB operations being
undertaken later
BH-ONCAB procedures had
different perioperative outcomes,
which may account for the
postoperative differences
Few numbers in either category
Demographics:
No differences were noted in
preoperative patient characteristics
after matching. BH-ONCAB had
significantly reduced operative time,
CPB time, total blood loss, peak CK,
IABP use, number of bypass grafts
and complete revascularization
(42.1% vs 77.2%, P<0.0001)

Narayan et al.
(2011), Eur J
Cardiothorac Surg,
UK [6]
Prospective,
randomized
controlled trial
(level 2 evidence)

81 patients randomized receive

either CABG surgery between
January 2003 and October 2004:
40 BH-ONCAB,
41 C-ONCAB
Patients were selected if they were
undergoing elective, multivessel,
isolated, primary CABG.
Randomization involved stratification
by consultant team and was

In-hospital deaths

0 deaths in BH-ONCAB vs 0
deaths in C-ONCAB

5-year health outcomes

0 overall deaths in
BH-ONCAB vs 5 overall
deaths in C-ONCAB
3 cardiac-related events in
BH-ONCAB vs 2
cardiac-related events in
C-ONCAB

Conclusions:
BH-ONCAB has comparable
primary and secondary outcomes
with C-ONCAB
Limitations:
Single-centre study and few
number of patients in either group
Difficulty in interpreting 5-year
health outcomesunable to

Continued

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541

Table 1: (Continued)
Author, date and
country,
Study type
(level of evidence)

Patient group

generated by computer in blocks of

unequal length. Exclusion criteria
included: MI within the previous 7
days; severe LV dysfunction (EF
<30%); symptomatic CVD; renal
insufficiency; presence of bleeding
diathesis; bullous emphysema and/or
significant COPD (FEV1/FVC <40%),
history of pericarditis, median
sternotomy, thoracotomy, chest
irradiation or pleurodesis; smoking
<1 month prior to surgery, significant
PVD; aspirin use <4 days prior to
surgery

Outcomes

Key results

Comments

Event-free survival rate for

BH-ONCAB vs C-ONCAB is
HR 0.62 (95% CI 0.152.59)

determine which events occurred

in which ONCAB group for MI and
repeat revascularization

Postoperative infarction

0 cases in BH-ONCAB vs 1
case (2%) in C-ONCAB

Arrhythmias

New arrhythmias: 10 cases

(25%) in BH-ONCAB vs 10
cases (24%) in C-ONCAB,
effect size 1.02 (95% CI
0.372.83, P = 0.96)

No significance data available for

preoperative characteristics and
limited data available for
postoperative outcomes

Atrial fibrillation/flutter: 10
cases (25%) in BH-ONCAB vs
9 cases (22%) in C-ONCAB

The primary outcome focussed upon

biochemical markers of
inflammatory activation, myocardial
injury, cerebral injury and renal
injury at 1, 4, 12, 24 and 48 h
postoperatively

Demographics:
Information provided without
significance data. Baseline and
intraoperative characteristics were
reported to be similar in both
groups

Nodal rhythm: 0 cases in

BH-ONCAB vs 1 case (2%) in
C-ONCAB

Ventricular tachycardia: 1
case (3%) in BH-ONCAB vs 0
cases in C-ONCAB
Pegg et al. (2008),
Circulation,
UK [7]
Prospective,
randomized
controlled trial
(level 2 evidence)

50 patients with measured EF <54%

at cMRI and who successfully
completed the first CMR study were
randomly assigned between
November 2005 and November
2007:
25 BH-ONCAB
25 C-ONCAB
Randomization took place in blocks
of 10 by a Web-based randomization
program and the surgical team was
only un-blinded to the procedure
following administration of
anaesthetic agents
Patients referred to a single surgeon
for first-time isolated CABG were
screened, with only patients with an
eGFR >60 ml/min included, and
urgent patients approached for
inclusion if they were successfully
medically stabilized.
Patients were excluded if they:
required emergency CABG; had
Canadian Classification Score class
IVb angina; were enrolled in another
clinical trial; had typical CMR
contraindications; had normal LV
function as defined by
echocardiography, LV angiography
or nuclear scintigraphy
The primary outcome was serum
biochemical markers of myocardial

Death <30 days

1 death in BH-ONCAB vs 0
deaths in C-ONCAB
(P = 0.31)

Major adverse event

(stroke causing >24 h of
neurological disability,
reoperation or
reintubation)

3 cases in BH-ONCAB vs 1
case in C-ONCAB (P = 0.30)

MI, from serum

myocardial injury
indicators

6 cases from a total of 17

available cases in
BH-ONCAB vs 2 cases from
a total of 23 available cases
in C-ONCAB (P = 0.05)

Conclusions:
There was a significantly higher
incidence of new irreversible
myocardial injury in BH-ONCAB
Limitations:
Single-centre study with a small
sample size
Difficulty in recruitment due to:
logistical matters relating to cMRI,
better EF with cMRI when
compared with previous
investigative techniques, and
concerns relating to
contrast-induced acute kidney
injury
Only three women were
randomized in the current study
No significance data available for
preoperative characteristics
Demographics:
Information provided without
significance data. Similar age,
medications and preoperative LV
function. BH-ONCAB had a greater
proportion of urgent
revascularization, female gender,
higher logistic EuroSCORE and
lower eGFR. All operative features
were similar between the groups

Continued

BEST EVIDENCE TOPIC

Supraventricular
tachycardia: 2 cases (5%) in
BH-ONCAB vs 0 cases in
C-ONCAB

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542

Table 1: (Continued)
Author, date and
country,
Study type
(level of evidence)

Patient group

Outcomes

Key results

Comments

Postoperative death

6 deaths (7.7%) in
BH-ONCAB vs 9 deaths
(11.5%) in C-ONCAB
(P = 0.59)

Survival at 1, 3, 5 years

BH-ONCAB: 90, 82, 71%

C-ONCAB: 89, 83, 73%
P = NS

Conclusions:
In end-stage coronary artery
disease BH-ONCAB is associated
with lower postoperative mortality
and morbidity due to better
myocardial and renal protection

injury, and cMRI for function and

delayed hyper-enhancement after
surgery. For these outcomes,
following further exclusions (death,
CVA, need for pacing wires), the
number of patients for each group
were:
21 BH-ONCAB
24 C-ONCAB
Prifti et al. (2007),
Ann Thorac Surg,
Japan [8]
Retrospective,
cohort study
(level 3 evidence)

156 patients with end-stage

coronary artery disease with low
LVEF between January 1993 and
December 2000 underwent CABG
surgery:
78 BH-ONCAB
78 C-ONCAB
C-ONCAB patients were selected in a
randomized fashion from an age-,
sex- and LVEF-corrected group
Patients with LV aneurysm,
post-infarction VSD, severe MR and
combined surgical procedures were
excluded

Sabban et al.
(2007),
Neurosciences
(Riyadh),
Saudi Arabia [9]

127 patients in total underwent

isolated CABG between January 2005
and December 2005:
33 BH-ONCAB
73 C-ONCAB

Retrospective,
cohort study
(level 3 evidence)

Four surgeons performed the

operations and the choice between
different techniques was made
following surgical assessment
The focus of this study was
neurological outcomes

Perioperative MI

1 case (1.3%) in BH-ONCAB

vs 8 cases (10.3%) in
C-ONCAB (P = 0.039)

Postoperative
neurological
complications (transient
or permanent deficit)

3 cases (4%) in BH-ONCAB

vs 3 cases (4%) in C-ONCAB
(P = 1.0)

Postoperative renal
dysfunction

28 cases (36%) in
BH-ONCAB vs 45 cases
(58%) in C-ONCAB (P = 0.01)

Postoperative
ultrafiltration

7 cases (9%) in BH-ONCAB

vs 19 cases (24%) in
C-ONCAB (P = 0.018)

Reoperation at
follow-up

7 cases (9%) in BH-ONCAB

vs 8 cases (10.3%) in
C-ONCAB (P = NS)

Postoperative death

2 deaths in BH-ONCAB vs 3
deaths in C-ONCAB
(P = 0.53 across all three
categories)

Stroke

0 cases in BH-ONCAB vs 2
cases in C-ONCAB

Limitations:
Single-centre, non-randomized,
observational nature of study
Few numbers in either category
Demographics:
Preoperative and operative data
were similar between both groups
except for CPB time and number of
surgical revisions for haemorrhage,
which were both significantly
higher for C-ONCAB

Conclusions:
Between the three types of CABG
procedure, there was no significant
difference in the prevalence of
neurological complications, and
there was a trend towards fewer
neurological outcomes in the
BH-ONCAB and OPCAB groups
Limitations:
Single-centre, unmatched,
non-randomized, observational
nature of study
Few numbers in either category
Selection bias amongst surgeons
Demographics:
All variables were similar except for
height (lower for the C-ONCAB
group) and EF (lower for the
BH-ONCAB group)

Continued

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543

Table 1: (Continued)
Author, date and
country,
Study type
(level of evidence)

Patient group

Outcomes

Key results

Comments

Tarakji et al. (2011),

JAMA, USA [10]

Patients underwent CABG using four

different operative techniques
between January 1982 and
December 2010 including:
234 BH-ONCAB
18970 C-ONCAB

All postoperative stroke

4 cases (1.7%) in BH-ONCAB

vs 253 cases (1.3%) in
C-ONCAB

Conclusions:
The occurrence of stroke declined
despite an increased risk profile.
More than half of strokes occurred
postoperatively as opposed to
intraoperatively

Prospective, cohort
study
(level 3 evidence)

Limitations:
Single-centre, unmatched,
non-randomized, observational
nature of study

Included patients underwent isolated

primary or reoperative CABG
surgery. Those who had undergone
concomitant procedures were
excluded

Issues relating to stroke outcomes:

unknown aetiologies and
competing risks

The primary focus of the study was

to investigate temporal trends in
stroke after CABG and to identify risk
factors and various associations for
longitudinal outcomes

The focus was on factors

determining intra- and
postoperative stroke outcomes,
with limited data available to
directly compare BH-ONCAB with
C-ONCAB

Tsai et al. (2012),

Nephrol Dial
Transplant,
Taiwan [11]
Retrospective,
cohort study
(level 3 evidence)

Uva et al. (2004),

Rev Port Cardiol,
Portugal [12]
Retrospective,
cohort study
(level 3 evidence)

186 patients with chronic dialysis

underwent isolated CABG between
January 2002 and January 2010
including:
48 BH-ONCAB,
82 C-ONCAB
Those included involved patients
who underwent regular
haemodialysis at least 6 months
before CABG. Patients who had
concomitant surgery or a previous
cardiac operation were excluded
from this study

30-day mortality

2 deaths (4.2%) in
BH-ONCAB vs 7 deaths
(8.5%) in C-ONCAB
(P = 0.34)

Survival at 2, 4, 6, 8 years

BH-ONCAB: 91.1, 81.4, 76.5,

73.8%
C-ONCAB: 70.1, 66.7, 65.1,
65.1%
HR 0.091 (95% CI 0.030
0.271), P 0.001

Conclusions:
BH-ONCAB may be more
beneficial for patients receiving
haemodialysis in terms of both
short- and long-term outcomes
Limitations:
Single-centre, unmatched,
non-randomized, observational
nature of study
Few numbers in either category

Freedom from cardiac

events at 2, 4, 6, 8 years
(including cardiac death,
MI, repeated CABG or
PCI and CCF)

BH-ONCAB: 95.7, 86.7, 80.0,

80.0%
C-ONCAB: 87.1, 80.5, 76.3,
65.8%
(P = 0.231)

Stroke

1 case (2.1%) in BH-ONCAB

vs 5 cases (6.1%) in
C-ONCAB (P = 0.29)

Arrhythmias

9 cases (18.8%) in
BH-ONCAB vs 17 cases
(20.7%) in C-ONCAB
(P = 0.79)

241 consecutive patients undergoing

isolated CABG via four methods
between January 2001 and June
2001 including:
47 BH-ONCAB,
66 C-ONCAB

In-hospital death

2 deaths (4.2%) in
BH-ONCAB vs 1 death
(1.5%) in C-ONCAB

Mortality at follow-up

3 deaths in BH-ONCAB vs 2
deaths in C-ONCAB

Excluded patients were those

undergoing one-vessel bypass, with

In-hospital MI

1 case (2.1%) in BH-ONCAB

vs 2 cases (3.0%) in

Demographics:
BH-ONCAB patients were
significantly older, and had a higher
BMI, greater proportion of patients
smoking, COPD, PVD and aortic
calcification

Conclusions:
No one method of CABG was
superior over another in terms of
mortality, morbidity or length of
stay. Mid-term outcomes for
survival and relief of angina were
similar
Limitations:
Single-centre, unmatched,

Continued

BEST EVIDENCE TOPIC

Demographics:
Differences were noted in most
preoperative characteristics

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544

Table 1: (Continued)
Author, date and
country,
Study type
(level of evidence)

Patient group

CRF under dialysis and those

undergoing concomitant procedures
such as carotid endarterectomy, LV
aneurysmectomy or closure of VSD
All patients were initially considered
for OPCAB. The decision on which
type of procedure was based on
coronary anatomy and LV volume

Outcomes

Key results

Comments

C-ONCAB

non-randomized, observational
nature of study

In-hospital atrial
fibrillation

10 cases (21.3%) in
BH-ONCAB vs 14 cases
(21.2%) in C-ONCAB

In-hospital stroke/TIA

2 cases (4.2%) in BH-ONCAB

vs 2 cases (3.0%) in
C-ONCAB

PCI intervention at
follow-up

3.1% in BH-ONCAB vs 5.2%

in C-ONCAB

Freedom from angina at

follow-up

91.9% in BH-ONCAB vs
93.5% in C-ONCAB

Few numbers in either category

Demographics:
Nearly all preoperative risk factors
were similar among the four groups

BH-ONCAB: beating-heart on-pump coronary artery bypass grafting; CABG: coronary artery bypass surgery; C-ONCAB: conventional on-pump coronary
artery bypass grafting; EF: ejection fraction; ONCAB: on-pump coronary artery bypass grafting; cMRI and CMR: cardiac magnetic resonance imaging; COPD:
chronic obstructive pulmonary disease; CPB: cardiopulmonary bypass; CRF: chronic renal failure; FEV1: forced expiratory volume in the first 1 second; FVC:
forced vital capacity; CI: cardiac index; IABP: intra-aortic balloon pump; LV: left ventricle; LVEF: left ventricular ejection fraction; MI: myocardial infarction;
OPCAB: off pump coronary artery bypass grafting; PCI: percutaneous coronary intervention; PROM: patient-reported outcome measures; PVD: peripheral
vascular disease; TIA: transient ischaemic attack.

AND (cardiopulmonary bypass*, on-pump, cardioplegia)

AND (coronary artery bypass*) AND (survival*, mortality*, morbidity*, postoperative complications*, outcomes*). MeSH terms
are indicated with an asterisk. Related citations were also assessed
for suitable articles.

SEARCH OUTCOME
A total of 231 papers were found using the reported search. From
these, 11 papers were identied to provide the best evidence
to answer the clinical question. Outcomes of interest included both
mortality (early or late) and morbidity (including renal failure,
stroke, myocardial infarction, angina, congestive cardiac failure,
reintervention and arrhythmias). These are presented in Table 1.

RESULTS
Edgerton et al. [2] studied mortality and various morbidity outcomes
for four revascularization techniques, including 364 BH-ONCAB and
2332 C-ONCAB patients. Preoperatively, BH-ONCAB patients were
determined to have signicantly poorer characteristics, and this may
in part explain higher rates of mortality and renal failure. Levels of
signicance were used to compare all four surgical categories, and
so there is difculty in establishing the superiority of either BHONCAB or C-ONCAB. However, other outcomes were comparable,
and the authors concluded that BH-ONCAB was a safe procedure
for unstable patients.
Erkut et al. [3] examined BH-ONCAB versus C-ONCAB in patients
with a low ejection fraction (EF). BH-ONCAB utilized a suction stabilizer for regional heart immobilization, and the distal anastomosis
was completed before the proximal anastomosis. Despite including

fewer than 100 patients in either category, BH-ONCAB conferred

signicantly better mortality and morbidity outcomes.
Similarly, Izumi et al. [4] found signicantly better survival and
fewer cases of renal failure in 15 BH-ONCAB patients undergoing
emergency surgery for acute myocardial infarction (MI). It is
notable, however, that BH-ONCAB procedures were performed at
a slightly later time period than C-ONCAB. Similarly to the technique employed by Erkut et al., BH-ONCAB utilized a cardiac stabilizer and positioner during grafting, and the left anterior
descending artery was the rst target vessel for anastomosis.
Mizutani et al. [5] propensity-matched 114 patients; however,
BH-ONCAB patients had signicantly less complete revascularization compared with C-ONCAB. BH-ONCAB patients had signicantly improved survival, but a greater proportion suffered from
postoperative atrial brillation. There were comparable stroke and
renal failure outcomes.
In their prospective, randomized study of 40 BH-ONCAB and
41 C-ONCAB patients, Narayan et al. [6] demonstrated comparable primary and secondary outcomes for mortality, event-free
survival, MI and arrhythmias. However, although 5-year outcome
data are reported, these are challenging to interpret, as it is difcult to determine the events attributable to each ONCAB group
for MI and repeat revascularization.
Pegg et al. [7] also investigated differences between isolated
BH-ONCAB and C-ONCAB using a randomized controlled trial incorporating 25 patients in either group with an EF <54%. Although
30-day mortality and major adverse events were similar, there was
a signicantly higher incidence of new irreversible myocardial
injury in BH-ONCAB patients.
Prifti et al. [8] studied 78 BH-ONCAB and C-ONCAB patients with
end-stage coronary artery disease. BH-ONCAB was associated with
lower postoperative mortality and morbidity, in terms of perioperative MI, postoperative renal dysfunction and ultraltration.

E. Al Jaaly et al. / Interactive CardioVascular and Thoracic Surgery

CLINICAL BOTTOM LINE

The results of these 11 best evidence studies suggest that
BH-ONCAB may offer improved survival following CABG in specic patient sub-groups. A key observation is that four of the ve
studies favouring BH-ONCAB incorporate patients with a considerably greater preoperative risk prole (haemodialysis, endstage coronary artery disease, emergency surgery, low EF), suggesting that BH-ONCAB confers greater benet on this patient
sub-group.
Conict of interest: none declared.

REFERENCES
[1] Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based
medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac
Surg 2003;2:4059.
[2] Edgerton JR, Herbert MA, Jones KK, Prince SL, Acuff T, Carter D et al.
On-pump beating heart surgery offers an alternative for unstable patients
undergoing coronary artery bypass grafting. Heart Surg Forum 2004;7:
815.
[3] Erkut B, Dag O, Kaygin MA, Senocak M, Limandal HK, Arslan U et al.
On-pump beating-heart versus conventional coronary artery bypass grafting for revascularization in patients with severe left ventricular dysfunction: early outcomes. Can J Surg 2013;56:398404.
[4] Izumi Y, Magishi K, Ishikawa N, Kimura F. On-pump beating-heart coronary artery bypass grafting for acute myocardial infarction. Ann Thorac Surg
2006;81:5736.
[5] Mizutani S, Matsuura A, Miyahara K, Eda T, Kawamura A, Yoshioka T et al.
On-pump beating-heart coronary artery bypass: a propensity matched
analysis. Ann Thorac Surg 2007;83:136873.
[6] Narayan P, Rogers CA, Bayliss KM, Rahaman NC, Panayiotou N,
Angelini GD et al. On-pump coronary surgery with and without cardioplegic arrest: comparison of inammation, myocardial, cerebral and
renal injury and early and late health outcome in a single-centre randomised controlled trial. Eur J Cardiothorac Surg 2011;39:67583.
[7] Pegg TJ, Selvanayagam JB, Francis JM, Karamitsos TD, Maunsell Z, Yu LM
et al. A randomized trial of on-pump beating heart and conventional cardioplegic arrest in coronary artery bypass surgery patients with impaired
left ventricular function using cardiac magnetic resonance imaging and
biochemical markers. Circulation 2008;118:21308.
[8] Prifti E, Bonacchi M, Frati G, Giunti G, Proietti P, Leacche M et al. Beating
heart myocardial revascularization on extracorporeal circulation in patients
with end-stage coronary artery disease. Cardiovasc Surg 2001;9:60814.
[9] Sabban MA, Jalal A, Bakir BM, Alshaer AA, Abbas OA, Abdal-Aal MM et al.
Comparison of neurological outcomes in patients undergoing conventional
coronary artery bypass grafting, on-pump beating heart coronary bypass,
and off-pump coronary bypass. Neurosciences (Riyadh) 2007;12:3541.
[10] Tarakji KG, Sabik JF III, Bhudia SK, Batizy LH, Blackstone EH. Temporal
onset, risk factors, and outcomes associated with stroke after coronary
artery bypass grafting. JAMA 2011;305:38190.
[11] Tsai YT, Lin FY, Lai CH, Lin YC, Lin CY, Tsai CS. On-pump beating-heart coronary artery bypass provides efcacious short- and long-term outcomes
in hemodialysis patients. Nephrol Dial Transplant 2012;27:205965.
[12] Uva MS, Rodrigues V, Monteiro N, Pereira F, Bervens D, Caria R et al.
Coronary surgery: which method to use? Rev Port Cardiol 2004;23:51730.

BEST EVIDENCE TOPIC

In their retrospective study, Sabban et al. [9] compared three

cardiopulmonary bypass strategies of which 33 cases were performed as BH-ONCAB and 73 as C-ONCAB. The primary focus of
the study was neurological and neuropsychological complications.
Postoperative deaths were comparable between BH-ONCAB and
C-ONCAB; however, there was a trend towards fewer neurological
complications in the BH-ONCAB group.
Tarakji et al. [10] performed a large prospective study (234
BH-ONCAB; 18 970 C-ONCAB) focusing on temporal trends in
stroke after CABG with the aim of identifying risk factors and
associations for peri- and postoperative stroke outcomes. There
was no signicant difference in stroke between BH-ONCAB
(1.7%) and C-ONCAB (1.3%); however, no other outcome data
were available.
Tsai et al. [11] investigated outcomes after CABG in haemodialysis patients. The 48 BH-ONCAB patients exhibited signicantly
improved survival when compared with C-ONCAB, with a trend
towards improved freedom from cardiac events and stroke.
Uva et al. [12] retrospectively analysed a total of 241 patients
undergoing four different CABG surgical strategies including 47
BH-ONCAB and 66 C-ONCAB. Overall survival and morbidity outcomes were found to be comparable between the two techniques.

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