Key result
On-pump CABG is associated with ~62% higher MACE risk vs. off-pump despite fewer late MIs.
Why the study?
The long-term comparative outcomes of on-pump and off-pump CABG remain disputed.
Does on-pump CABG compared with off-pump CABG reduce mid- and long-term MACE, repeat revascularization, late myocardial infarction, stroke/TIA, and late mortality in adults undergoing primary surgical coronary revascularization?
Meta-Analysis (n=18,729)
Yes
Does on-pump CABG compared with off-pump CABG reduce mid- and long-term MACE, repeat revascularization, late myocardial infarction, stroke/TIA, and late mortality in adults undergoing primary surgical coronary revascularization?
Across 25 RCTs (18,729 patients), on-pump CABG reduced late myocardial infarction while off-pump CABG was associated with lower long-term MACE and composite events, with no difference in late mortality, repeat revascularization, or stroke/TIA, supporting individualized surgical selection.
Answers are grounded in this paper and cite their sources.
Highlights MACE-MI trade-off favoring individualized CABG pump selection; extends RCT evidence to mid- and long-term outcomes.
The long-term comparative outcomes of on-pump and off-pump coronary artery bypass grafting (CABG) remain disputed. We performed a random-effects meta-analysis of 25 randomized controlled trials (18,729 patients) comparing on-pump versus off-pump CABG, searching MEDLINE/PubMed, Cochrane CENTRAL, Web of Science, ProQuest, ClinicalTrials.gov, Scopus, and grey literature through June 7, 2025. Outcomes (repeat revascularization, late myocardial infarction, stroke/TIA, late mortality, major adverse cardiovascular events [MACE], and composite endpoints) were pooled as hazard ratios (HRs) with 95% confidence intervals (CIs), expressed as on-pump versus off-pump. On-pump CABG significantly reduced late myocardial infarction (HR 0.58; p = 0.01). Off-pump CABG was associated with significantly lower MACE (HR 1.62; p = 0.003), with the greatest benefit at 5–10 years (HR 2.18; p < 0.00001) and persisting beyond 10 years (HR 1.89; p = 0.03) and with a lower composite-endpoint risk (HR 1.24; p = 0.04). No significant differences were found for late mortality, repeat revascularization, or stroke/TIA. Risk of bias was moderate to high, and the certainty of evidence was low to very low for most outcomes. On-pump CABG confers a long-term reduction in myocardial infarction, whereas off-pump CABG is associated with a lower MACE and composite cardiovascular event burden; neither technique differs for late mortality, repeat revascularization, or cerebrovascular events. Surgical strategy should be individualized, and further high-quality trials are warranted.
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Olama et al. (2026) conducted a meta-analysis in Coronary artery disease undergoing primary coronary artery bypass grafting (CABG) (n=18,729). On-pump coronary artery bypass grafting (CABG) vs. Off-pump coronary artery bypass grafting (CABG) was evaluated on Major adverse cardiovascular events (MACE: cardiovascular mortality, non-fatal myocardial infarction, or non-fatal stroke) (HR 1.62, 95% CI 1.18-2.21, p=0.003). On-pump CABG was associated with a higher risk of MACE (HR 1.62, p=0.003) but reduced late myocardial infarction (HR 0.58, p=0.01) compared to off-pump CABG.
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