Survival in octogenarian patients undergoing coronary artery bypass grafting: on-pump vs off-pump

Introduction Coronary artery bypass grafting (CABG) is gradually increasing in the octogenarian due to increasing life expectancy, but the optimal surgical technique (on-pump vs off-pump) remains controversial. Aim To compare long-term survival after on-pump (ONCAB) versus off-pump CABG (OPCAB) in octogenarians and to evaluate whether survival approximates that of an age- and sex-matched Portuguese general population. Methods Longitudinal, retrospective, single-center study including consecutive patients aged ≥80 years who underwent primary isolated CABG between 2004 and 2015. The primary outcome was all-causes mortality accessed in November 2025. Long-term survival was analysed using Kaplan-Meier curves and log-rank test (OPCAB vs ONCABG comparison) and compared with expected survival derived from Portuguese life tables from Instituto Nacional de Estatística, by 1-sample Log-Rank test. Standardized mortality ratio (SMR) were estimated. Median follow-up was 8 years, maximum of 16 years. Results A total of 188 octogenarians underwent CABG (54% ONCAB; 46% OPCAB). Baseline characteristics were comparable. Most patients had three-vessel disease (74% ONCAB vs. 66% OPCAB), CCS class IV (71% vs. 73%), and recent myocardial infarction (<90 days: 52% vs. 56%). Regarding immediate post-operative period, OPCAB patients received fewer grafts (median 2 vs. 3; p<0.01), more frequently bilateral internal mammary arteries (31% vs 6%, p<0.01). ONCAB was associated with higher postoperative troponin levels (p<0.01), prolonged mechanical ventilation (17% vs. 6%, p=0.03), but hospital mortality (6% vs 4%, p=0.51), stroke (6% vs. 2%, p=0.29) and other major complications were not statistically different. Cumulative survival at 1-, 5-, and 10-years was 91%, 67% and 29% for OPCAB and 90%, 70% and 36% for ONCAB (p=0.18). Compared with general population, ONCAB showed improved survival (SMR 0.70, 95% CI 0.55–0.89; p<0.01), whereas OPCAB survival was comparable to the general population expected values (0.86; 95% CI 0.67–1.11; p=0.18). Conclusion CABG offers favourable long-term survival in octogenarians. ONCAB was associated with a statistically significant survival benefit compared with the general population, whereas OPCAB showed to be comparable to standardized expected values. Further analyses are needed to clarify the impact of surgical technique on long-term prognosis in this special population.