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Ann Thorac Surg 2005;80:142-143
© 2005 The Society of Thoracic Surgeons

Original article: Cardiovascular

Invited commentary

Yves Louagie, MD, PhD

Division of Cardiovascular and Thoracic Surgery, Cliniques Universitaires UCL de Mont Godinne, 1 Ave Therasse, Mont Yvoir, B-5530 Belgium

(Email: louagie{at}chir.ucl.ac.be).


   Introduction
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 Introduction
Notice From the American...
 
This study by Lu and associates evaluates the feasibility of off-pump coronary artery bypass grafting in patients who have significant left main stem disease. The authors compared 259 patients undergoing the off-pump procedure with 938 patients operated on with the pump. They attempted to limit selection bias by constructing a propensity score and including it in the multivariate analyses. Risk-adjusted in-hospital outcomes showed a reduction in the requirement for inotropic support and a reduction in the incidence of prolonged length of stay (> 14 days) with the off-pump method. The risk-adjusted 2-year mortality rate showed no difference between the methods.

This study is interesting as it includes a large number of patients operated on for a very specific pathology and treatment selection bias was controlled by constructing a propensity score. Obviously the authors have good expertise in off-pump surgery, and they should be congratulated for a low conversion rate (3%). However, in my opinion, several weaknesses limit the impact of these data and leave the reader with unanswered questions.

The study includes 7 surgeons, 3 of whom performed all the off-pump cases. However, these 3 surgeons performed only a minority of the on-pump procedures. Thus, the study turns out to be a comparison of the results of two groups of surgeons, the off-pump cases being performed during the last 3 years of the study period. In addition, the selection criteria are not known. Because a description of the quality of the coronary arteries, (ie, preoperative angiogram or intraoperative assessment) is not included, one can suspect that worse coronary arteries were grafted on-pump rather than off-pump.

Prophylactic intra-aortic balloon counterpulsation is considered an interesting tool in high-risk patients, particularly in patients who have severe left main stem disease. Unfortunately this parameter was overlooked in the present study.

The detrimental effects of on-pump surgery are not related exclusively to cardiopulmonary bypass, but also to aortic manipulations, cross-clamping, and associated ischemia. During the last decade, techniques of myocardial protection designed to counteract these negative effects were refined considerably. Particularly the way cardioplegia is delivered seemed of importance in left main stem disease. Despite this, numerous studies comparing off-pump and on-pump surgery consider that on-pump surgery carries a uniform risk irrespective of the methods of myocardial protection used and the choice of the grafts. The present study is not an exception; the methods of myocardial protection in the on-pump group and the choice of grafts are largely ignored. We only know that myocardial protection in the on-pump cases was achieved with antegrade induction of blood cardioplegia followed by intermittent antegrade or continuous retrograde warm-blood cardioplegia. The exact proportions of antegrade and retrograde cardioplegia use are not stated. Thus, why should the higher incidence of inotropic support (this term was not defined) in the on-pump group not be related to the use of inadequate myocardial protection (antegrade cardioplegia) in the presence of severe left main stem disease? In addition, the nature of the grafts used (ie, arterial, venous, pediculated) and consequently the extent of aortic manipulations in the study groups are not mentioned. This is a major problem when stroke is included as a target variable. Is the trend toward a lower stroke incidence in the off-pump group due to pump avoidance or to a limitation of aortic manipulations associated with an increased use of pediculated arterial grafts?

The risk of death during the early postoperative period of coronary bypass surgery is a rather insensitive parameter by which to differentiate two groups of patients having similar preoperative risk factors. Unfortunately, parameters such as angina recurrence, myocardial infarction, and the need for angioplasty were not studied.

One can conclude from the present data that off-pump and on-pump coronary artery bypass grafting can be performed safely with similar immediate results in left main stem disease patients by an experienced team. However, the contention that morbidity is reduced with off-pump surgery is not supported by the data. Further large studies, including detailed long-term follow-up are required to assess the superiority of a technique in comparison with another.


   Notice From the American Board of Thoracic Surgery Regarding Trainees and Candidates for Certification Who Are Called to Military Service Related to the War on Terrorism
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 Introduction
 Notice From the American...
 
The Board appreciates the concern of those who have received emergency calls to military service. They may be assured that the Board will exercise the same sympathetic consideration as was given to candidates in recognition of their special contributions to their country during the Vietnam conflict and the Persian Gulf conflict with regard to applications, examinations, and interruption of training. If you have any questions about how this might affect you, please call the Board office at (312) 202-5900.

Timothy J. Gardner, MD

Chairman

The American Board of Thoracic Surgery


Related Article

On-Pump Versus Off-Pump Surgical Revascularization for Left Main Stem Stenosis: Risk Adjusted Outcomes
John C.Y. Lu, Antony D. Grayson, and D. Mark Pullan
Ann. Thorac. Surg. 2005 80: 136-142. [Abstract] [Full Text] [PDF]




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