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Ann Thorac Surg 2000;69:1730-1731
© 2000 The Society of Thoracic Surgeons

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Discussion

Discussion

DR MICHAEL J. MACK (Dallas, TX): President Kouchoukos, Dr Pairolero. I would like to congratulate Dr Kshettry on his presentation and acknowledge the pioneering work of the Minneapolis group in cardiac surgery. I appreciate Dr Kshettry forwarding me a copy of his manuscript for review prior to this meeting.

Evaluation of any new procedure begins first with historical analysis, then registries followed by the design of this study, that is, comparison of contemporaneous cohorts. Further validation includes matched cohorts and the most rigorous controlled, prospective, randomized trials. I would propose that on the basis of the design and methodology of this study, the conclusions of no benefit or minimal benefit are premature.

What are the possible reasons that no greater benefit could be demonstrated from off-pump surgery? It is possible there really is no significant benefit, or there really is a benefit, and this will become more evident with time. There are only 135 patients in the off-pump group. With a low incidence of complication in both groups, power analysis would indicate the necessity of a larger study group to demonstrate differences between the two groups. The predicted risk was higher in the off-pump group, but the mortality results are not risk adjusted. Without risk adjustment the outcomes are not strictly comparable. It is also possible that high-risk subgroups that would receive benefit were not examined. Indeed, Dr Arom from your group recently presented a paper demonstrating a benefit from OPCAB in high-risk patients. If the groups that were most likely to receive benefit were examined independently, perhaps greater benefit could be defined.

Another conceivable reason is that the outcomes in both groups benefited from the selection of high-risk patients into off-pump surgery. If off-pump surgery is indeed most beneficial in high-risk patients, then improved outcomes in both groups would . . . [Full Text of this Article]

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