Off-pump CABG reduces stroke and bleeding but increases long-term mortality and incomplete revascularization risk compared to on-pump surgery

ObjectiveDiabetes is a major risk factor for coronary artery disease. We compared outcomes of off-pump (OPCAB) versus on-pump (ONCAB) coronary artery bypass grafting in diabetic patients using propensity-adjusted observational studies.MethodsWe searched PubMed, Scopus, Web of Science, and the Cochrane Library for studies comparing OPCAB and ONCAB in diabetic patients using propensity-score matching or covariate adjustment. Eligible studies reported short-term or long-term clinical outcomes. Primary endpoints were early (in-hospital or 30-day) mortality and long-term survival. Secondary outcomes included stroke, myocardial infarction, reoperation for bleeding, atrial fibrillation, renal replacement therapy, low cardiac output syndrome, and completeness of revascularization. Pooled odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using random-effects models.ResultsNine studies (observation periods 1996-2021), including >10,000 diabetic patients, met criteria. There was no significant difference in early mortality between OPCAB and ONCAB (OR 0.71, 95% CI 0.44-1.14;  = .15). Long-term mortality was significantly higher with OPCAB (HR 1.16, 95% CI 1.01-1.33;  = .04), while mid-term survival showed no difference. OPCAB was associated with lower risks of stroke (OR 0.47, 95% CI 0.24-0.94;  = .03) and reoperation for bleeding (OR 0.60, 95% CI 0.41-0.88;  = .009), but higher risks of incomplete revascularization (OR 2.07, 95% CI 1.60-2.68;  < .00001) and atrial fibrillation (OR 1.70, 95% CI 1.16-2.47;  = .006).ConclusionsIn diabetic patients undergoing CABG, OPCAB lowers stroke and bleeding risk but increases incomplete revascularization and is associated with significantly higher long-term mortality. Choice of technique should be individualized with emphasis on complete revascularization.