Ann Thorac Surg 2003;76:776-777
© 2003 The Society of Thoracic Surgeons
Original article: cardiovascular
Invited commentary
Lawrence L. Creswell, MDa
a Division of Cardiothoracic Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216 USA
e-mail: lcreswell{at}surgery.umsmed.edu
We are often confronted with the patient who requires surgical revascularization early after acute myocardial infarction (MI). As we all know, operation in this setting can be associated with high morbidity and mortality rates. The optimal timing of coronary artery bypass (CAB) has received much attention, but no concensus has emerged. Studying the issues related to CAB early after acute MI is difficult because of the many variables (ie, patient-related, surgeon-related, and institution-related) that influence the clinical outcome.
The report by Locker and colleagues [1] is the third report from this group that describes their experience with off-pump coronary artery bypass (OPCAB) for patients with acute MI. The authors have made careful observations and report a significantly lower operative mortality rate for patients having OPCAB, rather than standard on-pump CAB within the first 48 hours after acute MI. Beyond 48 hours, there was no difference in the operative mortality rate for the two operative approaches. The actuarial 5-year survival rate and the frequency of recurrent angina were similar for the two groups. Interestingly, patients in the on-pump CAB group were less likely to require re-intervention (surgical or interventional) during late follow-up. This finding suggests there may be a trade-off in which OPCAB is associated with better early but worse late results. Could this finding be due to a sacrifice in the technical quality of OPCAB bypasses and reduced graft patency over time?
The authors’ observations in this report are important, but in a retrospective study design we must always ask if the two study groups are similar in all regards other than the operative approach. The authors note several differences between the two groups in their report; and there are undoubtedly other, unmeasured, differences as well. At this point, how should we choose the best operation for our patient who needs CAB early after acute MI? The answer is not clear. Retrospective reports such as this continue to provide guidance and OPCAB may well be a better approach for these patients. What we really need, however, are randomized trials with careful long-term follow-up to provide a definitive answer.
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References
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- Locker C., Mohr R., Paz Y., et al. Myocardial revascularization for acute myocardial infarction: Benefits and drawbacks of avoiding cardiopulmonary bypass. Ann Thorac Surg 2003;76:771-777.[Abstract/Free Full Text]
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