Comparison of outcomes between off-pump versus on-pump coronary artery bypass surgery in elderly patients: a meta-analysis.
Cardiac surgery is challenging in elderly patients. Most elderly patients have comorbidities that increase the risk of death due to coronary revascularization. The presence of comorbidities also may affect the incidence of overall postoperative complications, which can result in increased length of hospital stay and cost (1). Due to the increase of the aging population and of life expectancy in many countries, incidence of coronary artery disease due to atherosclerosis and the rate of surgical revascularization have increased (2). Coronary artery bypass surgery (CABG) is considered a safe treatment option in some high-risk patients (3). However, elderly patients are considered of high risk for surgery; advanced age is an independent predictor for mortality, stroke, renal failure, and atrial fibrillation following CABG (2,4,5).
There is an ongoing debate regarding the benefit of CABG with (on-pump) or without (off-pump) cardiopulmonary bypass surgery, particularly with respect to benefits in the elderly. Two prior meta-analyses have compared CABG-related adverse events in elderly patients ([greater than or equal to]70 years of age (1) and octogenarians (6) between off-pump and on-pump CABG (1,6). In both studies, off-pump CABG was associated with a lower risk of stroke compared with on-pump CABG. However, the studies' findings differed with regard to the benefit of off-pump CABG on the incidence of death and atrial fibrillation following surgery. The purpose of the current meta-analysis was to compare the clinical outcomes of on-pump and off-pump CABG in patients who were [greater than or equal to]70 years of age.
Although the UN/WHO definition of elderly is people [greater than or equal to]60 years of age (7), an important aim of this meta-analysis was to update the information of a prior meta-analysis performed a decade ago by Panesar et al. (1), who defined elderly as people [greater than or equal to]70 years old. Hence, we chose the same definition as the prior paper to make the findings comparable.
Material and Methods
This study was performed in accordance with the PRISMA guidelines. Medline, PubMed, Cochrane and Google Scholar databases were searched until September 13, 2016 using the following search terms: coronary artery bypass grafting/CABG, off-pump, on-pump, and elderly. Included studies were randomized controlled trials (RCTs), prospective two-armed studies, or retrospective studies that compared on-pump versus off-pump CABG in elderly patients, aged [greater than or equal to]70 years, and reported quantitatively the outcomes of interest. Letters, comments, editorials, case reports, proceedings, and personal communications were excluded. Studies that evaluated repeated CABG were also excluded. The list of relevant studies was hand-searched by two independent reviewers and if there was disagreement on study inclusion, a third reviewer was consulted.
Data extraction and quality assessment
The following information/data were extracted from studies that met the inclusion criteria: the name of the first author, year of publication, study design, number of participants in each group, participant's age and gender, and the major outcomes. The quality of the included studies was evaluated using the Hayden's tool (7), which evaluates prognosis studies with regard to six areas of potential study biases: study participation, study attrition, measurement of prognostic factors, measurement of and controlling for confounding variables, measurement of outcomes, and analysis approaches. Quality assessment was also performed by two independent reviewers and a third reviewer was consulted to resolve any uncertainties.
The primary outcome was overall mortality and secondary outcomes were stroke within 30 days of the CABG surgery, rate of myocardial infarction, and length of hospital stay. Odds ratio (OR) was used to evaluate the effect size for mortality, stroke, and myocardial infarction; an OR < 1 indicates that off-pump CABG treatment was associated with lower risk of death, stroke, or myocardial infarction. Length of hospital stay is presented by standardized difference in means; negative values indicate shorter hospital stay in the off-pump group. Pooled estimate for odds ratio and standardized difference in means were calculated by DerSimonian and Laird random-effects model. A two-sided P-value <0.05 was considered to be statistically significant.
Heterogeneity was assessed using the Cochran Q and the [I.sup.2] statistic. For the Q statistic, P < 0.10 was considered to be statistically significant for heterogeneity. The [I.sup.2] statistic indicates the percentage of the observed between-study variability due to heterogeneity. The suggested ranges are as follows: no heterogeneity ([I.sup.2]=0-25%), moderate heterogeneity ([I.sup.2]=26-50%), large heterogeneity ([I.sup.2]=51-75%), and extreme heterogeneity ([I.sup.2]=76-100%). Sensitivity analysis was carried out for the primary outcomes using the leave-one-out approach. Publication bias was assessed by constructing a funnel plot for the primary outcome. The absence of publication bias was indicated by the data points forming a symmetric funnel-shaped distribution. Egger's test was performed to examine the symmetry of funnel plot; a one-tailed P>0.05 indicated there was no publication bias. Following recommendations from the Cochrane handbook (8), RCTs and non-randomized studies (non-RCTs) were analyzed separately. All analyses were performed using Comprehensive Meta-Analysis statistical software, version 2.0 (Biostat, USA).
After removal of duplications, 607 of the 932 originally identified studies were screened for inclusion (Figure 1). Of these, 494 were excluded for not being relevant and an additional 90 were excluded for not having patients who were [greater than or equal to]70 years of age, not reporting findings that compared on-pump versus off-pump CABG, the complete text was not available, or the publication described only the study protocol.
Twenty-three studies were included in the meta-analysis: three RCTs (9-11) and 20 non-RCTs (Supplementary Table S1) (12-30). The number of patients ranged from 29 to 12,697 with 24,127 patients in total. The mean or median age ranged from 73.9 to 84.0 years. Except for one study (13), all studies recruited mostly males, which ranged from 52 to 89%. The presence of hypertension, type 2 diabetes, and chronic obstructive pulmonary disease (COPD) varied across studies, as did renal function. The frequency of smokers also was heterogeneous among the studies. The length of follow-up in the studies ranged from 30 days to 10 years.
All studies reported data on mortality except for one non-RCT (9). There was no evidence of heterogeneity among RCTs (Q=0.08 P=0.962, [I.sup.2]=0%) or among the non-RCTs (Q=22.0, P=0.234, [I.sup.2]=18.0%) in the mortality data across the studies. The pooled OR for the three RCTs indicated no increase in the risk of death between off-pump and on-pump CABG (pooled OR=0.945, 95%CI=0.652 to 1.371, P=0.766). In contrast, among the 19 non-RCTs, patients treated with off-pump CABG had a lower risk of death than those treated with on-pump CABG (pooled OR=0.631, 95%CI=0.587 to 0.944, P=0.003; Figure 2).
Eighteen studies reported data on stroke occurrence. There was evidence of extreme heterogeneity among the thirteen non-RCT studies for the occurrence of stroke between the two treatment groups (Q=95.2, P<0.001, [I.sup.2]=84.2%) but not for the two RCTs (Q=0.73, P=0.394. [I.sup.2]=0%). Regardless of study design, there was no difference in the risk of stroke occurring within 30 days post-operative between the off-pump and on-pump groups (RCTs: pooled OR=0.725, 95%CI=0.469 to 1.120, P=0.147; non-RCTs: pooled OR=0.544, 95%CI=0.216 to 1.372, P=0.197; Figure 3A). Similarly, there was no difference between the two treatment groups in the chance of myocardial infarction (RCTs: pooled OR=1.177, 95%CI=0.703 to 1.971, P=0.536; non-RCTs: pooled OR=1.007, 95% CI=0.717 to 1.415, P=0.966; Figure 3B).
Because only one RCT provided data on length of hospital stay, the meta-analysis was performed using data only from 15 non-RCTs. There was extreme heterogeneity across the studies (Q=196.5, P<0.001, [I.sup.2]=92.9%). Patients treated with off-pump CABG had shorter hospital stay than those with on-pump CABG (pooled standardized difference in means=-0.401, 95%CI=-0.621 to -0.181, P<0.001; Figure 3C).
Sensitivity analysis was performed using the leave-one-out approach. For the three RCTs, removal of any one study did not significantly influence the results indicating no individual study overly influenced the findings (Figure 4). In contrast, for the non-RCTs, removal of the study by Sarin et al. (15) substantially affected the pooled odds (Figure 4).
Publication bias and quality assessment
Results of the Egger's test showed evidence of publication bias for the findings regarding overall mortality (t=1.90, P=0.036); beneficial treatment effect of off-pump CABG was found in studies with small sample size (Figure 5). Quality evaluation of the included studies showed overall adequate quality (Figure 6). About 50% of selected studies did not describe measurement of confounding factors and/ or did not take into account confounding effects in the statistical analyses.
Due to the increase in the elderly population, the mean age of patients receiving CABG is rising (31); more than 80% of octogenarians have cardiovascular disease (32). Elderly patients are considered to be at significant risk of complications and death due to the presence of comorbidities (31). This study compared outcomes of off-pump and on-pump CABG in elderly adults who were [greater than or equal to] 70 years of age. Twenty-three studies, three RCTs and 20 non-RCTs, with 12,697 patients were included. We found no difference in the risk of mortality between patients treated with on-pump or off-pump CABG in the RCTs. However, there was a reduced chance of death in patients who received off-pump CABG compared with on-pump CABG in the non-RCTstudies. The difference in findings between the RCTs and the non-RCTs may be because patients included in the RCTs have lower operative risk due to enrollment criteria than those in the non-RCTs, which may be necessary for randomization into an experimental and control arm (1). Also, patients with more serious conditions may prefer the surgical method that their physician is more comfortable with or which has the higher success rate at their specific institution. The difference in findings between the RCTs and non-RCTs may also be due to the disproportionate number of publications available between study designs (3 vs 20, respectively) for each procedure, as well as the large heterogeneity in the data across studies.
The two treatment groups were similar in terms of the occurrence of 30-day post-operative stroke or myocardial infarction, suggesting that off-pump CABG is at least as effective as on-pump CABG. The findings from the prospective studies found that off-pump CABG treatment was associated with a shorter length of hospital stay. However, these findings may be confounded by the extreme heterogeneity of the data across the studies. Sensitivity analysis indicated that only one study (15) may have overly influenced the mortality findings for the non-RCT analysis. No evidence of publication bias was observed. Although, our findings differed with respect to mortality between RCTs and non-RCTSs and only non-RCTs were utilized to evaluate length of hospital stay, our findings suggest that there may be a benefit for off-pump compared with on-pump CABG in the risk of mortality and length of hospital stay in elderly patients.
Two prior meta-analyses have evaluated the use of off-pump and on-pump CABG in elderly patients (1,6). Panesar et al. (1) assessed early outcomes, in patients [greater than or equal to]70 years of age (n=4,921) who underwent either off-pump or on-pump CABG. Altarabsheh et al. (6) compared early adverse event following off-pump and on-pump CABG in octogenarians (n=18,310). Both our study and that of Panesar et al. (1) found a lower risk of death in the off-pump group then in the on-pump group. In the Panesar et al. study, a decrease in mortality risk associated with off-pump CABG was also observed in octogenarians. In contrast, Altarabsheh et al. (6) found that in octogenarians the risk of mortality was similar between CABG groups. Our study was similar to that of Panesar et al. who reported that the off-pump CABG group was associated with a shorter length of hospital stay than the on-pump CABG group. Both our study and that of Altarabsheh et al. found that the chance of myocardial infarction was comparable between treatment groups. Panesar et al. did not assess myocardial infarction. In contrast to our study, both Panesar et al. and Altarabsheh et al. found that the risk of stroke was lower in the off-pump CABG group compared with the on-pump group. Our finding with regard to stroke is limited by the extreme heterogeneity of the data across the studies. Both Panesar et al. and Altarabsheh et al. found no difference between groups in the rate of renal failure. We did not assess renal failure.
The inconsistencies in findings between the metaanalyses likely reflect the difference in number and designs of the included studies. In addition, the study of Altarabsheh et al. (6) focused on octogenarians while Panesar et al. (1) and our studies included patients that were [greater than or equal to]70 years of age. Moreover, the study of Panesar et al., which had a similar age population as ours, was performed 10 years ago, and since then there has been significant changes in both surgical equipment, physician technique, and medications that may have impacted the findings.
The heterogeneity we observed in the included studies may result in part from differences in patient populations, skills of the physicians, surgical procedures, and difference in patient inclusions/exclusion criteria, not only between RCTs and non-RCTs, but also across all studies. We did not compare the inclusion/exclusion criteria among the studies. In addition, not all the studies adjusted their data with propensity score matching analysis or multivariable analysis. For example, the RCT by Diegeler et al. (10) used multivariate models that incorporated clinical predictors to estimate the operative mortality, whereas the non-RCT study by Lin et al. (20) reported data based on unadjusted variables. Some non-RCTs, such as by Sarin et al. (15), provided propensity-adjusted, retrospective review of their patient data. These issues are consistent with our quality assessment of the studies. Overall, there was about 50% risk of bias for the presence of confounding measurement. The discrepancies across these studies highlight the need for additional well-controlled studies that evaluate the use of off-pump and on-pump CABG in elderly patients.
Two other prior meta-analyses (33,34) also evaluated the use of off-pump CABG in cardiovascular surgery, but in contrast to our study, they did not limit their analysis to patients who were [greater than or equal to]70 years of age. The meta-analysis of Sa et al. (34) included 47 RCTs with 13,524 patients (6,758 for off-pump and 6,766 for on-pump CABG). They found no difference between treatments in 30-day mortality or myocardial infarction. However, there was a difference between procedures in stroke favoring off-pump CABG (P=0.049). Godinho et al. (33) included nine randomized studies with 75,086 patients. They found an 18% reduction in mortality and a 25% lower risk of stroke with off-pump CABG compared with on-pump CABG (P [less than or equal to] 0.03). A significant difference between the two surgical techniques with respect to procedure-associated complications, particularly kidney complications (P=0.74) and sepsis (P=0.93) was also found. The difference in findings between these two meta-analysis likely reflects the different studies included. Neither study evaluated differences in length of hospital stay between surgical techniques.
There are several limitations to our study. Extreme heterogeneity across the studies was observed both for 30-day post-operative stroke ([I.sup.2]=80.6%) and length of hospital stay ([I.sup.2]=92.2%). This type of variability between studies may compromise the reliability of statistical analysis. Although off-pump CABG was associated with lower mortality risk, the large variance in length of follow-up time from 30 days to 10 years may confound the findings. The effect of a treatment on a person's health may evolve over time. Many of the complications may not occur until later in life, or the impact of treatment may not be obvious during the first few weeks after surgery, such that outcomes measured using longer follow-up times may be more reliable than shorter follow-up times. The definition of secondary endpoints of myocardial infarction and stroke, when reported, varied across studies, which may have impacted the results; only one RCT (11) and four non-RCTs (23,25,28,29) describe a definition for myocardial infraction and/or stroke. In addition, some of the non-RCTs used in our study may have included selection bias, which may confound the findings. For surgical techniques, such as the ones investigated, randomization is sometimes difficult and unethical. Physician skills, health condition of individual patients, the availability of equipment, and appropriate supportive staff are all potential confounding factors that can affect the choice of surgery. Patients having surgery must give their informed consent to the procedure for ethical reasons, which may also cause bias and make it difficult to blind a study. Although our quality assessment found a low risk of bias overall in study participation and attrition, it is unlikely that the study results are highly affected by selection bias. This may explain the lack of randomized control trials that are available currently.
In summary, our study and that of Panesar et al. (1) suggest that off-pump CABG may reduce the risk of mortality in elderly patients who are [greater than or equal to]70 years of age with ischemic heart disease compared with conventional CABG. However, in our study, the findings for survival benefit were only observed using the pooled data from the non-RCTs, and not from the RCTs. Although RCTs are the ''gold standard'' for clinical studies, data from non-RTCs studies should not be dismissed as they have potential clinical significance. More randomized trials are needed in order to explore further the benefits of using off-pump CABG compared to conventional CABG in elderly patients and to determine if it is a safe surgical option for high-risk patients with comorbidities, which often increase the rate of morbidity or death following cardiopulmonary bypass surgery.
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This project was financially supported by the National High Technology Research and Development Program of China (863 Program, 2014AA020539), National Natural Science Foundation of China (#81260047, #81660070), Jiangxi Province Natural Science Foundation (20151BA B205007, 150274) and Jiangxi Province Outstanding Youth Talent Funded Projects (20162BCB23059).
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Z.G. Zhu  *, W. Xiong  *, J.L. Ding , J. Chen , Y. Li , J.L. Zhou  and J.J. Xu 
 Department of Cardiothoracic Surgery, the Second Affiliated Hospital of Nanchang University, Nanchang, China
 Guangxi University of Chinese Medicine, Nanning, China
 Department of Gastroenterology, the Second Affiliated Hospital of Nanchang University, Nanchang, China
Correspondence: J.J. Xu: <firstname.lastname@example.org> | J.L. Zhou: <email@example.com>
* These authors contributed equally to this study.
Received August 31, 2016 | Accepted December 13, 2016
Caption: Figure 1. PRISMA flow diagram.
Caption: Figure 5. Funnel plot for publication bias.
Caption: Figure 6. Quality assessment of included studies. A, Risk of bias assessment, and B, individual study assessment.
Figure 2. Summary table and forest plot of included studies for treatment effect of off-pump coronary artery bypass surgery (CABG) on mortality compared with on-pump CABG. RCT: randomized clinical trial. Author, year Statistics for each study Odds Lower Upper ratio limit limit RCT Reents, 2014 1.019 0.517 2.011 Diegeler, 2013 0.925 0.565 1.515 Houlind, 2012 0.873 0.314 2.428 Subtotal 0.945 0.652 1.371 Non-RCT Dhurandhar, 2015 0.774 0.490 1.222 Raja, 2013 0.862 0.295 2.514 Lee, 2013 0.984 0.086 11.276 Mirhosseini, 2013 0.649 0.103 4.110 Sarin, 2011 0.298 0.161 0.552 Saleh, 2011 0.700 0.215 2.280 Serrao, 2010 0.547 0.033 9.014 Tugtekin, 2007 0.728 0.229 2.312 D'Alfonso, 2004 0.429 0.122 1.504 Lin, 2003 0.219 0.008 5.856 Shimokawa, 2003 0.229 0.009 5.947 Mehanval, 2002 0.453 0.151 1.358 Hoff, 2002 0.160 0.009 2.809 Ascione, 2002 0.655 0.189 2.270 Hirose, 2001 3.634 0.172 76.812 Al-Ruzzeh, 2001 0.065 0.004 1.138 Ricci, 2001 1.286 0.778 2.124 Koutlas, 2000 0.109 0.006 1.836 Boyd, 1999 0.650 0.026 16.443 Subtotal 0.631 0.463 0.859 Total 0.744 0.587 0.944 Author, year Statistics for each study Z-Value p-Value RCT Reents, 2014 0.056 0.956 Diegeler, 2013 -0.309 0.757 Houlind, 2012 -0.260 0.795 Subtotal -0.297 0.766 Non-RCT Dhurandhar, 2015 -1.100 0.271 Raja, 2013 -0.272 0.785 Lee, 2013 -0.013 0.990 Mirhosseini, 2013 -0.459 0.646 Sarin, 2011 -3.852 0.000 Saleh, 2011 -0.592 0.554 Serrao, 2010 -0.422 0.673 Tugtekin, 2007 -0.538 0.590 D'Alfonso, 2004 -1.322 0.186 Lin, 2003 -0.906 0.365 Shimokawa, 2003 -0.887 0.375 Mehanval, 2002 -1.414 0.157 Hoff, 2002 -1.254 0.210 Ascione, 2002 -0.667 0.505 Hirose, 2001 0.829 0.407 Al-Ruzzeh, 2001 -1.871 0.061 Ricci, 2001 0.981 0.327 Koutlas, 2000 -1.539 0.124 Boyd, 1999 -0.261 0.794 Subtotal -2.921 0.003 Total -2.436 0.015 Heterogeneity test RCTs: Q = 0.08, P = 0.962, [I.sup.2] = 0% non-RCTs: Q = 22.0, P = 0.234, [I.sup.2] = 18.0% Figure 3. Summary tables and forest plots for treatment effect of off-pump and on-pump coronary artery bypass surgery (CABG) on (A) stroke within 30 days postoperative, (B) myocardial infarction, and (C) length of hospital stay. RCT: randomized clinical trial. A Stroke within 30 days postoperative Author, year Statistics for each study Odds Lower Upper ratio limit limit RCT Diegeler, 2013 0.822 0.487 1.388 Houlind, 2012 0.545 0.249 1.195 Subtotal 0.725 0.469 1.120 Non-RCT Dhurandhar, 2015 0.607 0.332 1.110 Raja, 2013 0.493 0.044 5.560 Lee, 2013 0.234 0.020 2.687 Sarin, 2011 0.621 0.287 1.343 Saleh, 2011 0.660 0.108 4.033 Serrao, 2010 1.698 0.067 42.756 Tugteldn, 2007 0.312 0.016 6.086 D'Alfonso, 2004 0.556 0.034 9.123 Lin, 2003 0.219 0.008 5.856 Mehanval, 2002 0.416 0.020 8.699 Dentaria, 2002 0.106 0.006 2.007 Hoff, 2002 0.106 0.006 1.817 Ascione, 2002 0.438 0.054 3.517 Ricci, 2001 6.688 4.767 9.383 Koutlas, 2000 0.827 0.095 7.230 Boyd, 1999 0.206 0.011 3.951 Subtotal 0.544 0.216 1.372 Total 0.688 0.464 1.020 Author, year Statistics for each study Z-Value p-Value RCT Diegeler, 2013 -0.732 0.464 Houlind, 2012 -1.515 0.130 Subtotal -1.450 0.147 Non-RCT Dhurandhar, 2015 -1.622 0.105 Raja, 2013 -0.572 0.567 Lee, 2013 -1.166 0.244 Sarin, 2011 -1.211 0.226 Saleh, 2011 -0.450 0.653 Serrao, 2010 0.322 0.748 Tugteldn, 2007 -0.769 0.442 D'Alfonso, 2004 -0.412 0.681 Lin, 2003 -0.906 0.365 Mehanval, 2002 -0.566 0.571 Dentaria, 2002 -1.496 0.135 Hoff, 2002 -1.548 0.122 Ascione, 2002 -0.777 0.437 Ricci, 2001 11.001 0.000 Koutlas, 2000 -0.172 0.864 Boyd, 1999 -1.049 0.294 Subtotal -1.290 0.197 Total -1.861 0.063 Heterogeneity test RCTs: Q = 0.73, P = 0.394, [I.sup.2] = 0% non-RCTs: Q = 95.2, P < 0.001, [I.sup.2] = 84.2% B Myocardial infarction Author, year Statistics for each study Odds Lower Upper ratio limit limit RCT Diegeler, 2013 0.900 0.522 1.552 Houind, 2012 1.523 0.901 2.575 Subtotal 1.177 0.703 1.971 Non-RCT Dhurandhar, 2015 1.365 0.706 2.638 Sarin, 2011 0.984 0.263 3.690 Saleh, 2011 0.327 0.033 3.195 Serrao, 2010 4.088 0.205 81.389 Tugtekm, 2007 0.733 0.030 18.148 D'Alfonso, 2004 0.981 0.269 3.574 Mehanval, 2002 0.895 0.229 3.499 Demaria, 2002 1.358 0.472 3.908 Ascione, 2002 0.877 0.325 2.365 Hirose, 2001 5.138 0.261 100.976 Al-Ruzzeh, 2001 0.214 0.011 4.216 Ricci, 2001 0.752 0.372 1.520 Koutlas, 2000 0.581 0.030 11.414 Subtotal 1.007 0.717 1.415 Total 1.056 0.795 1.402 Author, year Statistics for each study Z-Value p-Value RCT Diegeler, 2013 -0.379 0.704 Houind, 2012 1.570 0.116 Subtotal 0.619 0.536 Non-RCT Dhurandhar, 2015 0.926 0.355 Sarin, 2011 -0.023 0.981 Saleh, 2011 -0.961 0.337 Serrao, 2010 0.923 0.356 Tugtekm, 2007 -0.189 0.850 D'Alfonso, 2004 -0.029 0.977 Mehanval, 2002 -0.160 0.873 Demaria, 2002 0.568 0.570 Ascione, 2002 -0.259 0.796 Hirose, 2001 1.077 0.281 Al-Ruzzeh, 2001 -1.014 0.310 Ricci, 2001 -0.794 0.427 Koutlas, 2000 -0.358 0.721 Subtotal 0.043 0.966 Total 0.376 0.707 Heterogeneity test RCTs: Q = 1.86, P = 0.173, [I.sup.2] = 46.1% non-RCTs: Q = 6.03, P = 0.915, [I.sup.2] = 0% C Length of hospital stay Author, year Statistics for each study Std diff Lower Upper in means limit limit Dhurandhar, 2015 -0.003 -0.067 0.061 Raja, 2013 -0.027 -0.352 0.297 Mirhosseini, 2013 -1.299 -1.781 -0.816 Sarin, 2011 0.059 -0.072 0.191 Saleh, 2011 -0.067 -0.336 0.201 Serrao, 2010 -0.358 -0.769 0.052 D'Alfonso, 2004 0.132 -0.251 0.514 Lin, 2003 -2.152 -3.076 -1.229 Shimokawa, 2003 -0.962 -1.602 -0.323 Mehanval, 2002 -1.104 -1.290 -0.918 Demaria, 2002 -0.082 -0.433 0.268 Hoff, 2002 -0.397 -0.696 -0.099 Ascione, 2002 -0.009 -0.159 0.141 Hirose, 2001 -0.617 -0.922 -0.312 Boyd, 1999 -0.417 -0.860 0.025 Total -0.401 -0.621 -0.181 Author, year Statistics for each study Z-Value p-Value Dhurandhar, 2015 -0.087 0.930 Raja, 2013 -0.165 0.869 Mirhosseini, 2013 -5.278 0.000 Sarin, 2011 0.884 0.377 Saleh, 2011 -0.494 0.622 Serrao, 2010 -1.712 0.087 D'Alfonso, 2004 0.673 0.501 Lin, 2003 -4.568 0.000 Shimokawa, 2003 -2.952 0.003 Mehanval, 2002 -11.632 0.000 Demaria, 2002 -0.461 0.645 Hoff, 2002 -2.609 0.009 Ascione, 2002 -0.120 0.904 Hirose, 2001 -3.965 0.000 Boyd, 1999 -1.848 0.065 Total -3.569 0.000 Heterogeneity test Q = 196.5, P < 0.001, [I.sup.2] = 92.9% Figure 4. Sensitivity-analysis for treatment effect of off-pump coronary artery bypass surgery (CABG) on mortality compared with on-pump CABG. Author, year Statistics with study removed Odds Lower Upper ratio limit limit RCT Reents, 2014 0.915 0.587 1.427 Diegeler, 2013 0.972 0.552 1.712 Houlind, 2012 0.957 0.642 1.426 Non-RCT Dhurandhar, 2015 0.589 0.407 0.853 Raja, 2013 0.609 0.436 0.851 Lee, 2013 0.620 0.448 0.857 Mirhosseini, 2013 0.623 0.449 0.865 Sarin, 2011 0.784 0.603 1.019 Saleh, 2011 0.618 0.442 0.865 Serrao, 2010 0.626 0.452 0.865 Tugtekin, 2007 0.617 0.441 0.863 D'Alfonso, 2004 0.640 0.461 0.887 Lin, 2003 0.633 0.461 0.870 Shimokawa, 2003 0.633 0.460 0.870 Meharwal, 2002 0.640 0.460 0.891 Hoff, 2002 0.640 0.469 0.875 Ascione, 2002 0.621 0.445 0.868 Hirose, 2001 0.621 0.456 0.846 Al-Ruzzeh, 2001 0.658 0.493 0.878 Ricci, 2001 0.557 0.423 0.733 Koutlas, 2000 0.648 0.478 0.877 Boyd, 1999 0.624 0.452 0.863 Author, year Statistics with study removed Z-Value p-Value RCT Reents, 2014 -0.391 0.696 Diegeler, 2013 -0.098 0.922 Houlind, 2012 -0.217 0.828 Non-RCT Dhurandhar, 2015 -2.801 0.005 Raja, 2013 -2.901 0.004 Lee, 2013 -2.891 0.004 Mirhosseini, 2013 -2.829 0.005 Sarin, 2011 -1.822 0.068 Saleh, 2011 -2.810 0.005 Serrao, 2010 -2.838 0.005 Tugtekin, 2007 -2.823 0.005 D'Alfonso, 2004 -2.677 0.007 Lin, 2003 -2.817 0.005 Shimokawa, 2003 -2.817 0.005 Meharwal, 2002 -2.646 0.008 Hoff, 2002 -2.802 0.005 Ascione, 2002 -2.792 0.005 Hirose, 2001 -3.025 0.002 Al-Ruzzeh, 2001 -2.844 0.004 Ricci, 2001 -4.171 0.000 Koutlas, 2000 -2.810 0.005 Boyd, 1999 -2.854 0.004
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|Author:||Zhu, Z.G.; Xiong, W.; Ding, J.L.; Chen, J.; Li, Y.; Zhou, J.L.; Xu, J.J.|
|Publication:||Brazilian Journal of Medical and Biological Research|
|Date:||Mar 1, 2017|
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