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Ann Thorac Surg 2006;81:2095-2096
© 2006 The Society of Thoracic Surgeons
300 Health Park Blvd, Suite 5000, St. Augustine, FL 32086
(Email: dmuehrcke{at}aol.com).
The report [1] is a perspective randomized trial comparing on-pump surgery and off-pump surgery in 120 patients with angiography being performed intraoperatively at 3 and 12 months. Global myocardial function determined graft patency and was estimated by magnetic resonance imaging preoperatively and 12 months postoperatively.
After 12 months, there was no difference in the internal mammary artery patency rate. There was no difference in the vein patency rate. The authors conclude that at 12-month follow-up off-pump surgery provided the same angiographic patency as on-pump technique. Functional status and exercise capacity was the same in both groups. No mention is made of any additional interventions in the conclusions.
Based on this study, it seems that by all accounts, on-pump and off-pump surgery are equivalent. However, I would point out that this is a select group of patients and that patients with ejection fractions less than 30% or with renal failure were excluded. During the early part of this study the patients with circumflex lesions were not done in the off-pump group, because they did not have a tilting table.
Also not mentioned in the conclusions by the authors, was the higher incidence of events in the off-pump group. Specifically, 7 of the off-pump patients had to be converted to on-pump cases. One of these died from a postoperative myocardial infarction. Ten patients had to have grafts immediately revised because of unsatisfactory intraoperative angiographic findings. Two in the on-pump group and 8 in the off-pump group, which was significant (p = 0.03). Moreover, long-term follow-up showed a trend toward a lower patency rate among the vein grafts with 80% of off-pump grafts open versus 87% if they were done on pump. Furthermore, 7 patients in the off-pump group required reintervention at 12 months with percutaneous interventions and 3 in the on-pump group required interventions.
If the patients requiring revised grafts at the time of surgery and those requiring percutaneous intervention at 12 months are combined, 15 in the off-pump group and 5 in the on-pump group required revision, or 3 times as many in the off-pump group.
Clearly, there is a difference in the outcomes of off-pump versus on-pump surgery. As previously mentioned, although the mortality rates are 1.6% in both groups within 30 days of surgery, 1 patient who died was done off-pump and postoperatively had a myocardial infarction after being converted to an on-pump surgery. Interestingly, this study does not show a difference in the number of grafts done between the off-pump and on-pump surgery, but typically this has been found in other off-pump studies, which in general show an average of one less graft being done in patients off-pump.
Overall I disagree with the authors conclusions that there is no difference between on-pump and off-pump surgery. Clearly this is an inferior procedure given the number of revascularizations that have to be performed immediately and at 12 months, as well as the number of people who have to be converted to on-pump surgery. If off-pump surgery was equivalent to on-pump surgery, both techniques would be able to compete with each other and one technique would not have to convert one to the other.
This is yet another study which claims that off-bypass surgery is equivalent or in some instances better than on-pump surgery. Not stated however is the fact that this is a preselected group that as in all such series can be done off-pump. Those that cannot be done off-pump (ie, intramyocardial vessels, small vessels, calcified vessels, lower ejection fraction, and concomitant valve surgery) have to be done on-pump. Only when all patients can be done by either technique can the techniques be compared. Therefore the gold standard for the foreseeable future will be on-pump surgery, as not all cases can be done off-pump.
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