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Ann Thorac Surg 2001;71:1750-1751
© 2001 The Society of Thoracic Surgeons
a Department of Cardiovascular Surgery, University of Milan, Centro Cardiologico "I. Monzino" Foundation, IRCCS, Via Parea 4, 20138 Milan, Italy
(Email: giulio.pompilio{at}cardiologicomonzino.it).
We read with interest the article by Dr Arom and associates [1] concerning safety and efficacy of off-pump coronary artery bypass (OPCAB). They have compared low, medium, and high-risk OPCAB patients to similar groups of patients undergoing conventional coronary artery bypass (CCAB). The conclusions they have drafted from this retrospective study are that OPCAB procedures are as safe as on-pump procedures, and that OPCAB may be considered as an alternative especially in the high-risk patient population. We congratulate the authors on their elegant study and results, and would like to comment on the efficacy of OPCAB in high-risk patients.
There has been a continuous increasing interest in off-pump surgical revascularizations, either performed with a minimally invasive approach, or through median sternotomy. However, indications and efficacy of OPCAB procedures are still burning questions.
Our experience since 1995 involves 485 patients who underwent OPCAB, 102 of them via a minimally invasive approach through a left anterior mini-thoracotomy. Our OPCAB/CCAB ratio has continuously increased over time, being about 1:4 in the last year. We have had similar results compared with those of Dr Arom and colleagues, in terms of in-hospital mortality and morbidity. Nevertheless, focusing on the so-called high-risk patients, we believe that some adjunctive issues should be pointed out, especially with regard to which benefit we can offer to these patients when choosing the OPCAB strategy.
Using the "Higgins score" as a preoperative tool of risk stratification, we have previously conducted a retrospective nonrandomized case-matched study on our high-risk OPCAB versus CCAB patients [2]. We found that in these patients, OPCAB was beneficial in reducing transient and permanent neurologic complications, occurrence of postoperative atrial fibrillation, and requirement of blood transfusions. As a consequence of this, our series of OPCAB patients, according to Dr Arom and associates’ findings, significantly experienced a better early outcome, reducing in-hospital stay.
Nevertheless, as practice with OPCAB procedures has increased worldwide, we feel that more information is now needed, not "whether" OPCAB is efficacious in high-risk patients, but "when." "High-risk patient" is, in fact, a generic term in which we include a number of preoperative diseases and risk factors; the combination of them is often detrimental after CCAB. At present, what we suppose is that single risk factors, such as renal dysfunction [3] or older age [4], are likely to benefit from an OPCAB approach.
Thus, some questions remain: Would all patients, considered at high-risk, benefit from OPCAB? If not, which patients are likely to be better managed without cardiopulmonary bypass? Finally, what assumptions are needed for adjusting conventional risk models for OPCAB?
Dr Arom and coworkers’ study helped us to understand the great impact of OPCAB on mortality in high-risk cases, and the large applicability of this operation. However, as in our and others’ single-center experiences, the study population is limited and does not allow stratification of high-risk patient subgroups, and then drawing adjunctive information on OPCAB indications and efficacy. In short, OPCAB clinical trials on high-risk patients probably need further investigation. In this regard, we believe the answer to such intriguing questions is of great interest today, and may be addressed by prospective randomized multi-center studies with a large number of high-risk OPCAB and CCAB patients enrolled.
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  T. Athanasiou, S. Al-Ruzzeh, R. D. Stanbridge, R. P. Casula, B. E. Glenville, and M. Amrani Is the female gender an independent predictor of adverse outcome after off-pump coronary artery bypass grafting? Ann. Thorac. Surg., April 1, 2003; 75(4): 1153 - 1160. [Abstract] [Full Text] [PDF]
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