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Ann Thorac Surg 2005;80:2422
© 2005 The Society of Thoracic Surgeons
a Department of Research and Development, The Cardiothoracic Centre, Liverpool, L14 3PE United Kingdom
b Department of Cardiothoracic Surgery, The Cardiothoracic Centre, Liverpool, L14 3PE United Kingdom
(Email: tony.grayson{at}ctc.nhs.uk).
We enjoyed reading the article by Kapetanakis and colleagues [1] that examined the impact of aortic manipulation on neurological outcomes after coronary artery bypass surgery (CABG). However, although they concluded that aortic manipulation was a contributing factor for the development of postoperative stroke, they failed to show a significant difference between their off-pump CABG groups with or without aortic manipulation.
This finding is similar to work previously carried out within our own institution by Patel and associates [2]. The conclusion from this study was that off-pump CABG, with or without aortic manipulation, reduces neurological outcomes compared with on-pump CABG.
As Kapetanakis and colleagues [1] correctly point out in their discussion, the study by Patel and associates [2] is limited by the small sample size and low event rates (off-pump with aortic manipulation was 2 of 520 vs off-pump without aortic manipulation was 3 of 597; p > 0.99 [Fisher's exact test]). Although the study by Kapetanakis and colleagues [1] has a large sample of patients who underwent off-pump with aortic manipulation (40 of 2,527), this study is also limited by a small sample and low event rate within the off-pump without aortic manipulation group (4 of 476). The percentage of patients with a postoperative stroke fails to reach a statistically significant difference between the groups even though the off-pump with aortic manipulation is double that of the other group (1.6% vs 0.8%; p = 0.30 [Fisher's exact test]).
Therefore, the question of whether a surgeon should avoid aortic manipulation when avoiding cardiopulmonary bypass is still unclear. However, a recent study by Calafiore and colleagues [3] did find a significant difference between these two groups with the off-pump group whose aortic manipulation had a significantly higher incidence of stroke (5 of 460 vs 3 of 1,533; p = 0.019 [Fisher's exact test]).
After combining these three studies together, the evidence in favor of avoiding aortic manipulation during off-pump CABG is quite clear, with a large reduction in the incidence of postoperative stroke (47 of 3,507 [1.3%] vs 10 of 2,606 [0.4%]; p < 0.001 [
2 test]).
However, the stroke rates quoted from these studies are crude outcomes and do not take into account differences in case-mix. Kapetanakis and colleagues [1] do show within their study that the case-mix is similar between these two groups as measured by the Northern New England stroke risk score [4] (off-pump with aortic manipulation was 1.5 vs off-pump without aortic manipulation was 1.1). Also Patel and associates [2] found that their groups were similar with respect to the additive EuroSCORE [5] with both having scores of 2. Calafiore and colleagues [3] did not show any case-mix comparisons between the groups.
We believe that there is sufficient evidence to conclude that avoidance of aortic manipulation adds significant benefit to patients undergoing off-pump CABG with respect to a further reduction in neurological outcomes.
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