Ann Thorac Surg 2005;80:1360-1361
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Louis P. Perrault, MD, PhD
Department of Surgery, Research Center, Montreal Heart Institute, 5000 E Belanger St, Montreal, PQ, H1T-1C8 Canada
(Email: louis.perrault{at}icm-mhi.org).
The article by Choi and associates [1] raises numerous interesting issues concerning the subject of optimal surgical myocardial revascularization strategy in both diabetic and nondiabetic patients. The authors should first be commended for obtaining a very high rate of angiographic controls both immediately postoperatively (97.9%) and at 1 year (88.2%) in their cohort of 517 patients. Systematic control angiograms remain the gold standard when evaluating any approach for revascularization, whether its percutaneous coronary interventions, off-pump coronary artery bypass (OPCAB), robotic-assisted coronary artery bypass grafting, or other minimally invasive techniques as well as any technical innovations (eg, Connectors, U-clips, facilitated anastomosis, endoscopic radial or saphenectomy, and so forth). Choi and colleagues' study yielded very impressive results with patency rates of over 95% in both diabetic and nondiabetic patients at 1 year. It is with great anticipation and hope that we can await the presentation of long-term angiographic controls to see whether the apparent benefits of their current strategy of total arterial revascularization and OPCAB hold up at 5 years and beyond.
Although no statistical differences in late mortality were observed between diabetics and nondiabetics or insulin treated versus noninsulin treated patients, both rates were higher in the diabetic and insulin-treated patients. Because the study was not powered for proper evaluation of this end-point, as appropriately pointed out by the authors in the limitations section, their conclusions concerning mortality should be interpreted as speculative until further proper demonstration. Furthermore, I do concur with the authors that the results of this study are not applicable to other patients undergoing on-pump CABG or saphenous vein grafting as numerous technical and patient-related factors may influence the selection of patients toward total arterial OPCAB versus other strategies, and these selection biases were not addressed in the present study. In closing, I join voices with Choi and colleagues in support of the recommendations for tight glucose control in the perioperative and long-term postoperative period, as advocated by Furnary and colleagues of the Portland group, a strategy already proven to decrease infections and lower immediate mortality after CABG. Ongoing studies currently seek to demonstrate the superiority of this approach on long-term survival after CABG to finally curb the detrimental effect of diabetes mellitus on surgical results for the benefit of our patients.
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- Choi J-S, Cho KR, Kim K-B. Does diabetes affect the postoperative outcomes after total arterial off-pump coronary bypass surgery in multivessel disease Ann Thorac Surg 2005;80:1353-1361.[Abstract/Free Full Text]
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