Is there a long-term survival benefit with on pump coronary artery bypass grafting?

A simple choice? Coronary artery bypass grafting (CABG) has become the gold standard of care for the treatment of coronary artery disease involving multiple vessels (1). This involves a choice as to whether to perform the surgery on (with cardiopulmonary bypass, CPB) or off pump (on the beating heart, without CPB). Each technique has its advantages and disadvantages. On pump surgery provides a motionless operative field, but can be associated with a number of complications including myocardial ischemic injury, coagulation disorders, neurocognitive deficits, strokes and a systemic inflammatory response (2). In contrast off pump surgery avoids aortic manipulation and, although more technically demanding (2), has been helped by the invention of stabilizing devices (3). The debate as to which approach is superior has been raging for over 40 years. Indeed, an excellent example of the division in opinion is the conduct of 90% of CABG off pump in India (2) compared to only 20% worldwide (4) and 13% in the US and Canada (5).