On vs. off pump coronary artery bypass grafting: the next chapter

Current guidance in the UK (1) (NICE guidelines) and the US (2) recommends the use of coronary artery bypass grafting (CABG) in the treatment of anatomically complex triple vessel disease. The UK also prefers CABG for the treatment of coronary artery disease in those >65 and those with diabetes (1), whilst the US recommends a heart team approach (2). Having made the decision to operate the next question that arises is whether to perform this with (on pump) or without (off pump) cardiopulmonary bypass. The attraction of off pump CABG is a reduction in the inflammatory response in combination with minimal aortic manipulation and avoidance of aortic cannulation, which may reduce the risk of stroke (3). However, many surgeons would argue that cardioplegic arrest provides the best conditions for optimal revascularisation (3,4). The debate as to which method is superior has been ongoing for the past 25 years.