Ann Thorac Surg 2004;77:580
© 2004 The Society of Thoracic Surgeons
Invited commentary
Ernst Wolner, MD,
Daniel Zimpfer, MD,
Michael Grimm, MD
Department of Cardiothoracic Surgery, University of Vienna, Austria Waehringer Guertel 18-20 Vienna 1090, Austria
e-mail: ernst.wolner{at}akh-wien.ac.at
e-mail: daniel.zimpfer{at}akh-wien.ac.at
e-mail: michael.grimm{at}akh-wien.ac.at
In this interesting article, the authors report on their experience with on-pump versus off-pump coronary artery bypass grafting (CABG) in patients with increased operative risk (Euroscore >5). The following findings are of particular interest.
The authors report that off-pump surgery only in the subgroup of high risk patients (EuroSCORE >8) was able to reduce operative mortality/morbidity as compared with on-pump surgery. It is important to note that in the whole study cohort the mode of death differed between the on- and off-pump groups. On-pump patients exclusively died due to systemic causes (7/7: 100%) most probably related to extracorporeal perfusion, whereas off-pump patients predominantly died of cardiac causes (7/12: 58%). However, the perioperative benefit of off-pump surgery is already offset at 16-month follow-up by a higher cardiac related mortality and a higher incidence of recurrence of myocardial ischemia in the off-pump group.
Despite all efforts in off-pump surgery, we have to be cautious with this technique until transparent mid- to long-term outcome data (in terms of survival as well as quality of life) are available. The potential impact of incomplete revascularization on ischemic hearts may not be underestimated in long-term outcome. On the other hand, it seems obvious that in patients with increased operative risk, the use of extracorporeal perfusion is the main trigger mode of adverse outcome. From these findings, we have to learn as surgeons to particularly focus on adaptation or improvement of extracorporeal circulation techniques especially devoted to those patients. This is important, since it increasingly seems likely that only full and perfect revascularization is able to achieve satisfying outcome in the face of an increasing number of incomplete revascularizations performed by definitely less invasive percutaneous interventions.
Therefore, off-pump surgery should only be offered whenever complete revascularization may be safely achieved, with the exception of those patients with a proven perioperative benefit from this procedure. Further studies are warranted to definitely define those particular patients.
