Authors: Shereen Mohamed Olama , Mustafa Sameer R. Albagshi , Faten Mshal M. Alrowaili , Faisal Kareem S. Alruwaili , Bandar Inad Awad Alanazi , Bashayr Abdullah T. Aljafar , Daniya Sulaiman A. Alanazi , Aryam Shannan K. Alanazi , Anas Ied A. Alenezi , Leen Abdullah R. Alkhudayr , Hadeel Nawaf Fadhel Alenezi , Sumayyah Saud F. Alshammari , Sarah Nasser F. Almuhaysin , Roaa Salem Owayyid Alshammari , Shahad Enad Alenezi

Abstract

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 7 June 2025. Outcomes (repeat revascularization, late myocardial infarction, stroke/TIA, late mortality, major adverse cardiovascular events [MACE], and composite endpoints) were pooled as hazard ratios (HR) with 95% confidence intervals (CI), 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.

Keywords: Coronary artery bypass grafting, off-pump coronary artery bypass grafting, on-pump coronary artery bypass grafting, mid-term outcomes, long-term outcomes.