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Department of Biosurgery-Surgical Technology and Surgical Epidemiology Unit, Imperial College London, St. Mary's Hospital, London, W2 1NY United Kingdom
(Email: t.athanasiou{at}imperial.ac.uk; tathan5253{at}aol.com).
Minimally invasive harvesting (MIVH) of the great saphenous vein for coronary artery bypass grafting (CABG) has been shown to reduce patient-related morbidity in the postoperative period as compared with conventional vein harvesting (CVH), and can be considered to be a cost-effective option. Although the effect of MIVH on patient morbidity from wound-related complications has been extensively investigated in the literature, the effect on the quality of the harvested conduit is less clear [1, 2]. However, before attempting this comparison, it is important to consider the characteristics that would be expected of a high-quality conduit, namely its macroscopic appearance, histologic quality (with particular regard to endothelial continuity), functional characteristics, and mid-term and long-term patency [3]. The ultimate measure of quality of a conduit used for CABG is its long-term patency reassuring an optimal clinical outcome based on freedom from cardiovascular events avoiding disability, which can compromise a patient's quality of life. In their observational study, Ouzounian and colleagues [4] have demonstrated this effect. This is an important finding that also counteracts the recently published article from Lopes and colleagues [5], which concluded that it may be an increased risk of worse outcomes with endoscopic harvesting, and its adoption in the current clinical cardiothoracic practice should be weighed against its known short-term benefits.
There is no doubt that the validity of research findings increase as data accumulate. In the "Proteus phenomenon" between the first published studies [5] on a scientific question (mid-term patency after EVH), it may be shown to be the most extravagant effect size. This is followed by the publication of another study [4] that shows a large contradicting effect. Subsequent studies report effect sizes between these extremes.
In the past, we had limited research findings, and currently we have too many. This makes science exciting, but we do not know exactly what these findings mean and how we can make better use of them. Credibility of research findings looks like a pyramid where the base is broad (ie, many findings have low credibility) and the top is narrowed (ie, few findings have high credibility). Randomized trials can test findings that are somewhere between the middle to the top of this credibility pyramid. Selection of questions should be strategic and systematically evidence-based.
In summary we need to assess critically the following two important referenced studies [4, 5]. First, both studies had the following methodological drawbacks:
Second, apart from attention to design, power, and protection from bias, it is evident that careful strategic planning for designing research agendas and being able to make sense of the overall picture of all randomized controlled trials in the cardiothoracic field is required. Designing trials in isolation or with nonscientific priorities creates fragmented, irrelevant evidence. The more difficult challenge is to dismiss false discoveries and materialize some truly useful findings.
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  M. Ouzounian, K. J. Buth, and I. S. Ali Reply Ann. Thorac. Surg., September 1, 2010; 90(3): 1059 - 1060. [Full Text] [PDF]
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