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Ann Thorac Surg 2002;74:2120
© 2002 The Society of Thoracic Surgeons
a Director of Research, Miami Heart Research Institute, 801 Arthur Godfrey Road, 5th Floor, Miami Beach, FL 33140, USA
e-mail: doctorwu18{at}aol.com
Despite remarkable advances in diagnosis and treatment, coronary artery disease is the leading cause of death in women [1]. Even in an era of increasing percutaneous interventions, coronary artery bypass grafting (CABG) remains the treatment of choice for many women with multiple coronary lesions. The results of CABG continue to demonstrate a higher operative mortality in women than men [2]. In an effort address this challenge, Brown and his colleagues in this issue of The Annals, explore the impact off-pump coronary surgery has on mortality and morbidity in CABG in women.
Maintaining a large multi-institutional registry is challenging and its use by the author must be commended. Since participation in such a database is nonvoluntary, this study represents the current status of the clinical practice of cardiac surgery. It is more complete than any single voluntary or selective prospective institutional study could achieve. Outcomes in off-pump coronary surgery in women, to date, have been preliminary and therefore this large experience represents a most welcome beginning.
However, several notes of caution must be mentioned. Since only 15.6% of the patients underwent off-pump surgery, there is reason to believe that an obvious selection bias exists in the series. This is corroborated by the vast differences in clinical profiles of the two patient groups. This type of finding is expected in any retrospective comparative study, which introduces a new surgical technique. The numerous statistical analyses performed, however, do little to assess the presence of a patient selection bias. Nowhere is it noted that on-pump surgery was an independent predictor of hospital mortality or morbidity, nor is there any suggestion that outcomes are equivalent in patients matched by a comparable propensity for a surgeon’s choice of procedure. The 42% higher mortality rate reported in the on-pump group does not control for those variables which have been demonstrated to significantly influence patient outcomes. Moreover, despite the difference in risk profile, the raw data demonstrates a mortality difference of marginal significance. Further, only one "major" and one "minor" complication in the series achieved statistical significance. Since preoperative shock and acute myocardial infarction were more prevalent in the on-pump group, it is not surprising that the occurrence of postoperative shock/hemorrhage would also be higher in that group.
More importantly, we must ask whether or not the authors’ hypotheses address the fundamental issue: Why is operative mortality higher in female rather than in male CABG patients? Is there a reason, either clinical or theoretic, to presume that eliminating the use of cardiopulmonary bypass would solve or ameliorate the problem? If the issue is one of body surface area [3], the use of cardiopulmonary bypass through hemodilution, may well aggravate the problem. If, on the other hand, small body surface area is a surrogate for reduced coronary artery size [4], then the added precision afforded by the use of cardiopulmonary bypass with cardioplegic arrest might be beneficial. The significantly fewer vessels bypassed in the off-pump group may imply a technical limitation of the procedure and may be of grave concern as it relates to complete revascularization, especially of small vessels. If, however, the higher risk profile of female patients is the essential problem [5], then a surgical technique which seems to select patients with a lower risk profile would not be likely to help, unless it were demonstrated to be beneficial for those specific factors which appear to be more prevalent in women than men.
Perhaps the place to begin is with a basic analysis of the entire experience to address the issues. Is the mortality in the multi-institutional registry higher for women than men? Is this true for both on- and off-pump surgery? Is there a comparative advantage to off-pump versus on-pump surgery in the mortality between men and women?
This introduction by Brown and his colleagues should stimulate further investigation into the role of off-pump CABG in the surgical treatment of coronary artery disease in women. Until then, it is too early to speculate what influence, if any, the use of off-pump technology will have on improving outcomes for women undergoing CABG surgery.
References
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