On-pump Coronary Artery Bypass Surgery Research Articles

Three-year follow-up in a subset of high-risk patients randomly assigned to off-pump versus on-pump coronary artery bypass surgery: the Best Bypass Surgery Trial

ObjectiveTo evaluate off-pump versus on-pump coronary artery bypass grafting (CABG) in patients with three-vessel disease and a high-risk operative profile.DesignA randomised clinical trial.SettingRigshospitalet, University Hospital, Copenhagen, Denmark.Participants341 patients with three-vessel...

Do treatments effects differ between randomised trials and propensity score analyses? Evidence from a meta-propensity score analysis in off-pump versus on-pump coronary artery bypass surgery

Do treatments effects differ between randomised trials and propensity score analyses? Evidence from a meta-propensity score analysis in off-pump versus on-pump coronary artery bypass surgery

Invited Commentary

Invited Commentary

Risk factors of stroke and delirium after off-pump coronary artery bypass surgery

Off-pump coronary artery bypass surgery (CABG) has not abolished the risk of postoperative stroke and delirium seen for on-pump CABG. Advanced arteriosclerotic changes are common in both on-pump and off-pump CABG. We sought to analyze if advanced arteriosclerotic changes are risk factors of stroke or transient ischemic attack (TIA), and delirium after off-pump CABG. Patients undergoing off-pump CABG between 2001 and 2005 were reviewed using medical records (n=685). Potential risk factors of postoperative stroke and delirium were identified from previous studies. Further, variables retrieved from carotid artery duplex scanning as indices of advanced arteriosclerosis, were examined. The incidences of postoperative stroke/TIA and delirium after off-pump CABG were 2.6% (n=18) and 16.4% (n=112), respectively. Carotid artery stenosis >50% was a significant risk factor of stroke or TIA (P=0.02) as well as delirium (P=0.04) after off-pump CABG. A history of atrial fibrillation (AF) (P=0.037) or diabetes mellitus (P=0.041) was a risk factors of postoperative stroke or TIA. In contrast, age over 75 years (P=0.006), creatinine >1.3 mg/dl (99 μmol/l) (P=0.011), a history of hypertension (P=0.001), past history of AF (P=0.024), and smoking (P=0.048) were significant risk factors of postoperative delirium.

Off-Pump Bypass Surgery and Postoperative Stroke: California Coronary Bypass Outcomes Reporting Program

Coronary artery bypass surgery (CABG) is associated with a significant risk of stroke. Some studies suggest that off-pump CABG (OPCAB) may reduce postoperative stroke rate. We performed this study to evaluate the relationship between postoperative stroke and OPCAB compared with conventional on-pump CABG (CCB) in a recent, large cohort of patients. Data from the California CABG Outcomes Reporting Program were analyzed in patients who had OPCAB or CCB for isolated CABGs in 2006 to 2007. Two multivariable logistic regression models were developed for the analysis, and the "recycled predictions" method was used to compute risk-adjusted postoperative stroke rates in the two surgical groups. Of 30,426 isolated CABGs, 7,720 (23.7%) were OPCAB. The model developed in the CCB subset indicated that CCB had a lower predicted stroke risk than OPCAB, yet the observed rate of stroke was higher in the CCB subset. The model using both CCB and OPCAB patients revealed that OPCAB was associated with a reduction in postoperative stroke (adjusted odds ratio: 0.76, 95% confidence interval [CI] 0.59 to 0.98). For patients with cardiogenic shock, OPCAB was also associated with a lower risk-adjusted postoperative stroke rate compared with CCB (OPCAB: 3.06%, 95% CI 2.83% to 3.28%; CCB: 4.05%, 95% CI 3.76% to 4.33%, p < 0.001). However, the 793 (11%) OPCAB patients who were converted to CCB intraoperatively had an increased postoperative stroke rate (with conversion: 2.02%, 95% CI 1.04% to 3.00% versus without conversion: 0.96%, 95% CI 0.73% to 1.20%, p < 0.001). The OPCAB was associated with a significantly lower postoperative stroke rate compared with CCB even for older and higher risk patients. However, intraoperative OPCAB to CCB conversion was associated with the highest postoperative stroke rate.

To beat or not to beat? From one size fits it all to an individual coronary revascularization strategy

This editorial refers to ‘Early graft patency after off-pump and on-pump coronary artery bypass surgery: a prospective randomized study’, by M. Sousa Uva et al. doi:10.1093/eurheartj/ehq210 For decades, coronary artery bypass grafting (CABG) was routinely performed with cardiopulmonary bypass support and cardioplegic arrest. A deloaded, non-beating heart, a bloodless surgical field, and an easy exposure were regarded to be essential for manipulations on vessel sizes of less than a pencil lead. Surgical results were excellent, mortality declined constantly, and conventional CABG (cCABG) became a success story and the ‘bread and butter’ for cardiac surgeons since it was the first-choice revascularization strategy in multivessel coronary artery disease. However, some adverse clinical consequences, such as stroke, myocardial infarction, and inflammatory response syndrome, complicated by acute lung and kidney injury have largely been attributed to cardiopulmonary bypass circuit, hypothermic cardiac arrest, and aortic manipulation. Consequently, several efforts were made in the early 1990s to reduce morbidity and mortality by looking for safer alternatives to cCABG including off-pump beating heart bypass surgery (OPCAB) in multivessel coronary artery disease. As is often the case when new technical innovations expand and become available for routine use, advocates and opponents of OPCAB raised their voice. Initial controversies within the cardiac surgery community, however, were based more on general convictions than on scientifically proven data.1 During the last decade more and more prospective randomized studies and meta-analyses comparing OPCAB and cCABG surgery in low-risk patients or mixed-risk populations have become available.2–4 They usually failed to demonstrate any significant benefit of OPCAB surgery on early mortality or perioperative major cardiac and cerebrovascular events, but OPCAB was superior regarding blood loss, transfusion requirements, re-thoracotomy rate, ventilation time, intensive care unit (ICU) and hospital stay, and subsequently resource utilization. Most of the large observational studies comparing OPCAB … *Corresponding author. Tel: +49 341 865 1421, Fax: +49 341 865 1452, Email: mohrf{at}medizin.uni-leipzig.de

Comparison of Inflammatory Response during on-pump and off-pump Coronary Artery Bypass Surgery

On-pump coronary artery bypass graft (CABG) surgery has been traditionally associated with a higher magnitude of inflammatory response than off-pump CABG. However with the development of polymer-coated biocompatible extracorporeal circuits, we wanted to see if cardiopulmonary bypass still played an important role in triggering this inflammatory response. In this prospective observational study, 33 patients undergoing CABG surgeries (25 on-pump and 8 off-pump patients) were studied. Serial plasma cytokine (TNF IL-6, IL-10) and procalcitonin concentrations were measured at different time-points during and after the surgery. Demographic and baseline clinical data, intra-operative management details and post-operative complications were also collected from the patients' charts. Plasma levels of all 4 mediators increased during surgery and returned towards normal postoperatively. There were no differences between groups for any mediator at any time-point. We conclude that with the use of recent polymer-coated biocompatible extracorporeal circuits, the inflammatory response triggered by on-pump CABG becomes very similar in magnitude and pattern to that triggered by off-pump CABG. Thus, the surgical procedure contributes to most of the inflammatory response, with the extra-corporeal circuit having minimal to no effect on this response.

On-pump coronary artery bypass surgery without allogenic blood product transfusion

Introduction: Perioperative allogeneic blood product transfusion (ABPT) during cardiac surgery is associated with complications such as transfusion-related acute lung injury, prolonged ventilation and increased mortality. Objective of this study was to develop an on-pump coronary artery bypass grafting (CABG) program without ABPTs.

Remifentanil Reduces the Release of Biochemical Markers of Myocardial Damage After Coronary Artery Bypass Surgery: A Randomized Trial

Opioids, including remifentanil, have been demonstrated to confer cardiac protection against ischemia reperfusion injury in animals. This study evaluated whether remifentanil preconditioning is protective in first-time elective on-pump coronary artery bypass surgery patients receiving a standardized fentanyl (25 μg/kg in total) and propofol anesthetic. A prospective, double blind, randomized, controlled study. University hospital; single institution. Forty patients scheduled for first-time elective, on-pump coronary artery bypass surgery for at least 3 diseased vessels. Patients randomized to the remifentanil group (n = 20) received a 1 μg/kg bolus followed by a 0.5 μg/kg/min infusion for 30 minutes after induction but before sternotomy, while the control group (n = 20) received normal saline. Serial samples for measurement of creatine kinase (CK-MB), cardiac troponin I (cTnI), ischemia-modified albumin (IMA) and heart-type fatty-acid-binding protein (hFABP) were taken at baseline, prebypass, T = 10 minutes, 2, 6, 12, and 24 hours after cross-clamp release, to assess the degree of myocardial damage. Patients in the remifentanil group had lower levels of CK-MB from T = 2 hours to 24 hours, cTnI from T = 10 minutes to T = 12 hours, IMA from T = 10 minutes to T = 2 hours and h-FABP from T = 10 minutes to T = 12 hours (p < 0.05). The time to tracheal extubation was shorter in patients in the remifentanil group. The overall lengths of ICU and hospital stays were not different. The addition of remifentanil to the anesthesia regimen reduced the degree of myocardial damage. This incremental benefit may be attributable either to remifentanil itself or to an overall increased opioid dose, the latter may be necessary to trigger cardiac protection.

Using pump for bypass surgery - on-off-on again?

Expanded abstractCitationShroyer AL, Grover FL, Hattler B, Collins JF, McDonald GO, Kozora E, Lucke JC, Baltz JH, Novitzky D for the Veterans Affairs Randomized On/Off Bypass (ROOBY) Study Group: On-pump versus off-pump coronary artery bypass surgery. N Engl J Med 2009, 361:1827-37BackgroundCoronary-artery bypass grafting (CABG) has traditionally been performed with the use of cardiopulmonary bypass (on-pump CABG). CABG without cardiopulmonary bypass (off-pump CABG) might reduce the number of complications related to the heart-lung machine.MethodsObjectiveTo compare off-pump to on-pump CABG in terms of short- and long-term composite of complications and death from any cause, as well as completeness and durability of the procedure/grafting, neuropsychological outcomes, and use of major resources.DesignMulti-center single-blind, randomized controlled trial.Setting18 Veterans Affairs medical centers, 16 of which were teaching hospitals.Subjects2203 patients who were scheduled for urgent or elective CABG-only procedures.InterventionPatients were randomized to either on- or off-pump CABG. They underwent neuropsychological testing at baseline and one year, as well as follow-up angiography.Outcomes1) Primary short-term end-point: composite of death or major complications (reoperation, new mechanical support, cardiac arrest, coma, stroke or renal failure requiring dialysis) at discharge or day 30. 2) Primary long-term composite end-point: death from any cause within 1 year, nonfatal myocardial infarction between 30 days and 1 year, or repeat revascularization between 30 days and 1 year. 3) Secondary outcomes: completeness of revascularization, graft patency at 1 year, scores on neuropsychological tests.ResultsThere was no significant difference between off-pump and on-pump CABG in the rate of the 30-day composite outcome (7.0% and 5.6% respectively, P = 0.19). The rate of the 1-year composite outcome was higher for off-pump than for on-pump CABG (9.9% vs 7.4%, P = 0.04). The proportion of patients with fewer grafts completed than originally planned was higher with off-pump CABG than with on-pump CABG (17.8% vs 11.1%, P < 0.001). Follow up angiograms in 1371 patients who underwent 4093 grafts revealed that the overall rate of graft patency was lower in the off-pump group than in the on-pump group (82.6% vs. 87.8%, P < 0.01). There were no treatment-based differences in neuropsychological outcomes or short-term use of major resources..ConclusionsAt 1 year of follow-up, patients in the off-pump group had worse composite outcomes and poorer graft patency than did patients in the on-pump group. No significant differences between the techniques were found in the neuropsychological outcomes or use of major resources.

Patient-reported outcomes after on-pump and off-pump coronary artery bypass surgery

Patient-reported outcomes after on-pump and off-pump coronary artery bypass surgery

Patient-reported outcomes after on-pump and off-pump coronary artery bypass surgery

Patient-reported outcomes after on-pump and off-pump coronary artery bypass surgery

Stay off-pump and do not touch the aorta!

One of the major drawbacks in contemporary on-pump coronary artery bypass surgery is the inherent risk of intraoperative stroke. In addition, neurophysiological dysfunction and neurobehavioural changes have been reported in variable frequencies following on-pump bypass surgery. Cardiopulmonary bypass (CPB) causes a systemic inflammatory response, haemodilution, change in vascular resistance, absence of pulsatile flow, and large volume shifts. As a result, temporary cerebral oedema can be seen in magnetic resonance imaging (MRI) studies early after on-pump bypass surgery and has been identified as the substrate for what was termed ‘pump head’ in the past. Refinements of CPB circuits using biocompatible surfaces, the use of less traumatic oxygenators, and the addition of filters as well as the establishment of standardized perfusion protocols have improved the results of on-pump surgery. Despite these advances, CPB remains one major source for gaseous microembolization.1,2 Retransfusion of shed mediastinal blood during on-pump surgery has long been recognized as an additional source of embolization by fat particles and activation and derangement of the clotting cascade. Manipulation of the ascending aorta such as partial or total clamping and cannulation required for installation of CPB can cause additional solid emboli especially in the presence of atherosclerotic disease.3,4 Numerous studies have shown embolic showers in transcranial Doppler during cannulation and clamping and declamping manoeuvres. The release of particulate emboli correlates in particular with the release of the aortic cross-clamp.5 Gerriets et al. have reported a randomized controlled trial to demonstrate the impact of two different methods to decrease the embolic load during on-pump bypass surgery with partial aortic clamping in a … *Corresponding author. Tel: +41 44 255 32 98, Fax: +41 44 255 32 98, Email: volkmar.falk{at}usz.ch

Late outcomes of on-pump and off-pump redo coronary artery bypass grafting

Benefits of off-pump surgery are still widely debated in the literature comparing with conventional coronary artery bypass grafting. The aim of our study was to compare the late outcomes of patients who underwent on-pump redo coronary artery bypass surgery with those who had off-pump redo coronary artery bypass surgery. Two groups of patients were compared. Group 1 consisted of 34 patients who underwent off-pump redo coronary artery bypass surgery, and Group 2 included 160 patients who underwent on-pump redo coronary artery bypass surgery. Both groups of patients were operated on by the same team of surgeons at the same time period. Groups did not differ by age, gender, functional class, preoperative myocardial infarction rate, and left ventricular function. More patients with hypertension were in the off-pump group. Significantly more grafts were performed in the on-pump group. Survival, presence of angina, reoccurrence of postoperative myocardial infarction, necessity of percutaneous transluminal coronary angioplasty and reoperations were evaluated in late follow-up period. The duration of follow-up was 3.37+/-2.15 years in the off-pump group and 3.27+/-2.36 years in the on-pump group. Survival after 6 years in the off-pump and on-pump redo coronary artery bypass surgery groups was 85.3% and 83.6%, respectively (P=0.758). Five years after redo operation, 54.9% of patients who underwent off-pump coronary artery bypass surgery and 69.3% of patients who underwent on-pump coronary artery bypass surgery had no angina (P=0.174). There were no major cardiac events (percutaneous transluminal coronary angioplasty, death, myocardial infarction, and reoperations) after 6 years in 69.7% of patients in the off-pump group and 76.9% of patients in the on-pump group (P=0.343). Five years after redo surgery, 79.4% of patients in the off-pump group and 91.9% in the on-pump group were free of percutaneous transluminal coronary angioplasty (P<0.02). There was no difference in survival despite the fact that patients in the on-pump group received more grafts than those in the off-pump group. Recurrence of angina and incidence of major cardiac events were almost equal in both the groups. Percutaneous transluminal coronary angioplasty was more frequently performed in the patients of off-pump group at late follow-up.

Survival of patients on dialysis having off-pump versus on-pump coronary artery bypass surgery in the United States

Patients on dialysis sustain at least a threefold higher in-hospital mortality rate and markedly higher long-term mortality following coronary artery bypass graft surgery than the general population. Smaller studies have suggested that dialysis patients have superior outcomes with off-pump compared with on-pump coronary artery bypass surgery. From the United States Renal Data System database, 13,085 patients on dialysis having first coronary artery bypass surgery between 2001 and 2006 were identified. Of these, 2335 (17.8%) had off-pump coronary artery bypass surgery. The Kaplan-Meier method was used to estimate survival of patients having off-pump coronary artery bypass and patients having on-pump coronary artery bypass. A Cox proportional hazards model was used to assess effects of off-pump coronary artery bypass on mortality with adjustment for baseline patient characteristics. Off-pump coronary artery bypass surgery was associated with significantly reduced all-cause mortality compared with on-pump coronary artery bypass surgery (hazard ratio 0.92, 95% confidence interval 0.86-0.99, P = .02). The observed survival benefit was most notable in the first year after surgery (70.3% vs 68.7%) and was lost 2 years after surgery (55.4% vs 55.2%). No difference was noted in the in-hospital mortality rate with off-pump coronary artery bypass surgery versus on-pump coronary artery bypass surgery (9.7% vs 11.0%, P = .06). Cardiac mortality during the follow-up period was similar (23.6% vs 23.8%; adjusted hazard ratio 0.95, 95% confidence interval 0.86-1.04, P = .26). Use of internal thoracic grafts was independently associated with improved survival after coronary artery bypass surgery (hazard ratio, 0.92; 95% confidence interval, 0.87-0.98, P = .0057). Patients on dialysis sustain high in-hospital and 2-year mortality rates after coronary artery bypass surgery. Off-pump coronary artery bypass is associated with modestly increased survival compared with on-pump coronary artery bypass, a benefit most marked early after off-pump coronary artery bypass.

Reduced expression of systemic proinflammatory and myocardial biomarkers after off-pump versus on-pump coronary artery bypass surgery: A prospective randomized study

Background The effects of off-pump (OffPCABG) and on-pump (OnPCABG) coronary artery bypass grafting (CABG) on myocardium and inflammation are unclear. Objective Compare the inflammatory response and myocardial injury from patients (pts) submitted to OffPCABG with those that undergo OnPCABG. Methods Patients with normal left ventricular function were assigned to OffPCABG (n = 40) and OnPCABG (n = 41). Blood samples were collected before and 24 hours after surgery for determination of creatine kinase (CK)–MB (CK-MB), troponin I (cTnI), interleukin (IL)–6, IL-8, P-selectin, intercellular adhesion molecule (ICAM)-1 and C-reactive protein (CRP). Mortalities were registered at 12 months. Results Preoperative CK-MB and cTnI levels were 3.1 ± 0.6 IU and 1.2 ± 0.5 ng/mL for OffPCABG and 3.0 ± 0.5 IU and 1.0 ± 0.2 ng/mL for OnPCABG pts. Postoperative CK-MB and cTnI levels were 13.9 ± 6.5 IU and 19.0 ± 9.0 ng/mL for OffPCABG vs 29.5 ± 11.0 IU and 31.5 ± 10.1 ng/mL for OnPCABG ( P < .01). OffPCABG and OnPCABG pts had similar preoperative IL-6 (10 ± 7 and 9 ± 13 pg/mL), IL-8 (19 ± 7 and 17 ± 7 pg/mL), soluble P-selectin (70 ± 21 and 76 ± 23 pg/mL), soluble ICAM–1 (117 ± 50 and 127 ± 52 ng/mL), and CRP (0.09 ± 0.05 and 0.11 ± 0.07 mg/L). At 24 hours, for OffPCABG and OnPCABG: IL-6 was 37 ± 38* and 42 ± 41* ,† g/mL; IL-8, 33 ± 31* and 60 ± 15* ,† pg/mL; soluble P-selectin, 99 ± 26 and 172 ± 30* ,† pg/mL; soluble ICAM-1, 227 ± 47 and 236 ± 87* ,† ng/mL; and CRP, 10 ± 11* and 14 ± 13* ,† mg/L (* P < .01 vs preoperation; † P < .01 vs OffPCABG). Increased 24-hour postoperative CRP levels was the only marker to have significant positive correlations with events and occurred just for the OnPCABG pts. In-hospital and 1-year mortalities for the OnPCABG and OffPCABG pts were 2.0% and 2.2% ( P = .1) and 2.7% and 4.7% ( P = .06), respectively. Conclusions Thus, the absence of CPB during CABG preserves better the myocardium and attenuates inflammation—however, without improving survival.

A pilot randomized study of the neutrophil elastase inhibitor, Sivelestat, in patients undergoing cardiac surgery

The primary objective of this study was to determine the feasibility and safety of treatment with Sivelestat in humans to attenuate post-cardiopulmonary bypass lung injury. Twenty patients scheduled to undergo on-pump coronary artery bypass surgery were randomized to receive either 0.3 mg/kg/h intravenous Sivelestat sodium (Sivelestat group; n=10) or isotonic sodium chloride solution (placebo group, n=10), peri-operatively. Postoperative adverse events were recorded until hospital discharge. The alveolar-arterial oxygen gradient (A-aDO(2)), intrapulmonary shunt (Qs/Qt) and dynamic lung compliance were determined four times peri-operatively as secondary exploratory outcomes. All patients completed study protocol without discontinuation of intervention. The number of total adverse clinical outcomes, including atrial fibrillation and superficial wound infection, was nine in seven patients in the placebo group and four in four patients in the Sivelestat group (P=0.37). The mean duration of the postoperative hospital stay was shorter in the Sivelestat group (19.0+/-3.4 vs. 25.6+/-9.1, P=0.04). The exploratory analysis of relative changes in lung functions showed trends toward attenuation of lung injury in the Sivelestat group in all three pulmonary parameters, though the inter-group difference could be due to chance (P>0.05). It is feasible to administer Sivelestat as a preventive measure against lung dysfunction after cardiopulmonary bypass.

Do Management Strategies for Coronary Artery Disease Influence 6-Year Cognitive Outcomes?

Previous uncontrolled studies have suggested that there is late cognitive decline after coronary artery bypass grafting that may be attributable to use of the cardiopulmonary bypass pump. In this prospective, nonrandomized, longitudinal study, we compared cognitive outcomes after on-pump coronary artery bypass surgery (n = 152) with off-pump bypass surgery patients (n = 75); nonsurgical cardiac comparison subjects (n = 99); and 69 heart-healthy comparison (HHC) subjects. The primary outcome measure was change from baseline to 72 months in the following cognitive domains: verbal memory, visual memory, visuoconstruction, language, motor speed, psychomotor speed, attention, executive function, and a composite global score. There were no consistent differences in 72-month cognitive outcomes among the three groups with coronary artery disease (CAD). The CAD groups had lower baseline performance, and a greater degree of decline compared with HHC. The degree of change was small, with none of the groups having more than 0.5 SD decline. None of the groups was substantially worse at 72 months compared with baseline. Compared with subjects with no vascular disease risk factors, the CAD patients had lower baseline cognitive performance and greater degrees of decline over 72 months, suggesting that in these patients, vascular disease may have an impact on cognitive performance. We found no significant differences in the long-term cognitive outcomes among patients with various CAD therapies, indicating that management strategy for CAD is not an important determinant of long-term cognitive outcomes.

Sex differences in resource use after on-pump and off-pump coronary artery bypass surgery: A propensity score-matched cohort

Previous studies have demonstrated that off-pump coronary artery bypass surgery (OPCAB) is associated with less use of hospital resources compared with on-pump coronary artery bypass surgery (ONCAB). To determine whether there is a sex effect between the two procedures regarding resource utilization. Between 1996 and 2004, 13,522 patients (10,637 men and 2885 women) underwent coronary artery bypass grafting surgery at the Toronto General Hospital (Toronto, Ontario). Among the men, 10,121 patients underwent ONCAB and 516 underwent OPCAB. The female population consisted of 2723 ONCAB and 162 OPCAB patients. Both groups were matched to standard preoperative risk factors. A propensity score macro-matched 471 OPCAB men to 471 ONCAB men, and 148 OPCAB women to 148 ONCAB women. The mean (+/- SD) postoperative length of stay (7.5+/-6.5 days versus 6.4+/-5.5 days; P<0.0001) was significantly higher in ONCAB compared with OPCAB in the male population. The mean length of stay in the intensive care unit and the mean ventilation time was similar between the groups. However, in the female population, there were no differences in mean postoperative length of stay (8+/-5.9 days versus 8+/-6 days; P=0.4), mean length of stay in the intensive care unit (43+/-38 h versus 53+/-81 h; P=0.4) or mean ventilation time (9.8+/-9.7 h versus 11+/-13 h; P=0.8). These results suggest that the benefits of OPCAB in terms of hospital resource use are influenced by sex. The potential beneficial effects are not demonstrated in the female population.

On-pump Coronary Artery Bypass Surgery in High-risk Patients Aged over 65 Years (EuroSCORE 6 or More): Impact on Early Outcomes

The results of on-pump coronary artery bypass graft (CABG) surgery in 166 high-risk elderly patients (EuroSCORE 6 or more; over age 65 years [mean 71.8 years]) were compared with 176 low-risk elderly patients (EuroSCORE below 6; over age 65 years [mean 68.8 years]). There was no significant difference in hospital mortality or number of grafts between the two groups. Rates of inotropic agent use, intra-aortic balloon pump insertion and atrial fibrillation, and the duration of intensive care unit and hospital stay were significantly higher in high-risk than low-risk patients. There were no significant differences in the incidence of major complications between the two groups. The results suggest that, in selected patients, on-pump CABG can be safely performed in high-risk patients over 65 years old with no effect on mortality.