On-Pump vs. Off-Pump Coronary Artery Bypass Grafting in Patients with Significant Left Main Coronary Artery Stenosis

All articles of this category (opens in new window) Background: Coronary artery disease (CAD) with significant left main stenosis typically requires surgical revascularization. While on-pump CABG (ONCAB) remains the standard approach, off-pump CABG (OPCAB) may reduce perioperative complications, making a comparison essential to guide surgical strategy. Methods: A total of 1,816 patients undergoing isolated CABG for left main stenosis (>50%) between December 2009 and September 2024 were analyzed (ONCAB n = 1,062; OPCAB n = 754). Baseline and perioperative characteristics were compared, and 30-day outcomes were assessed using logistic regression adjusted for confounders. Results: OPCAB patients were older (71 ± 9 vs. 66 ± 9 years, p < 0.001), more often octogenarians (12.3% vs. 2.1%, p < 0.001), and had lower LVEF, reduced GFR, and more comorbidities (PAD 22.9% vs. 14.9%, COPD 8.2% vs. 5.1%, NYHA III/IV 50.7% vs. 43.7%; all p < 0.01). Procedure duration and transfusion requirements were lower in OPCAB, while hospital stay was slightly longer. After adjustment, logistic regression showed no significant difference in 30-day mortality between ONCAB (1.0%) and OPCAB (1.7%; OR 1.10, 95% CI: 0.46–2.55, p = 0.864). Incidence of 30-day MI (1.3% vs. 2.0%; OR 1.22, 95% CI: 0.56–2.63, p = 0.618) and postoperative renal failure (1.0% vs. 1.9%; OR 1.18, 95% CI: 0.51–2.75, p = 0.697) favored ONCAB. In contrast, OPCAB was associated with lower risks of prolonged catecholamine dependency (2.9% vs. 3.5%; OR 0.54, 95% CI: 0.30–0.95, p = 0.034) and major stroke (0.7% vs. 1.6%; OR 0.30, 95% CI: 0.12–0.86, p = 0.024). Rates of re-thoracotomy for bleeding (OR 0.69, 95% CI: 0.39–1.20, p = 0.190) and surgical revision (OR 0.94, 95% CI: 0.51–1.72, p = 0.837) were comparable between groups. Conclusion: Outcomes, including 30-day mortality, MI, RF, re-thoracotomy, DSWI, and surgical revision, were comparable between ONCAB and OPCAB. However, the risk of major stroke was more than threefold higher in the ONCAB group, and the risk of prolonged postoperative catecholamine dependency was nearly twice as high. Overall, both strategies appear safe for left main coronary artery disease, while OPCAB surgery offers specific advantages such as a significant reduction of stroke incidence. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany