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Ann Thorac Surg 2000;69:1047
© 2000 The Society of Thoracic Surgeons
DR ALAA Y. AFIFI (Gulfport, MS): I enjoyed your presentation very much. Certainly you demonstrate excellent results on a fairly worrisome part of the population that undergo coronary artery bypass surgery. One of the interesting points you made is the incidence of atrial fibrillation. Many authors have previously demonstrated a lower incidence of atrial fibrillation on those patients that undergo minimally invasive procedures versus those that undergo conventional coronary artery bypass surgery. The incidence you demonstrated with both groups was about 20%. Many of the theories that have been discussed in relation to the lower incidence of atrial fibrillation without conventional bypass is due to lack of atrial manipulation. What are your thoughts and theories as far as why the incidence of atrial fibrillation is so significant in this off-pump bypass group?
DR KOUTLAS: We actually don’t know why other people are finding lower incidences. Dr Elbeery and I have talked about it and we feel if you age match the populations between OP-CAB and on-pump bypasses that the rates are probably similar, and actually Dr Cohn up in Boston recently wrote a paper showing essentially the same incidence of atrial fibrillation for on-pump and off-pump techniques. I don’t have a good answer why we see it as much.
DR KIT V. AROM (Minneapolis, MN): I congratulate Dr Koutlas and his associates for their very fine paper. However, I do not think you are comparing apples to apples. Many of your patients in the off-pump group had typical minimally-invasive direct coronary artery bypass (MIDCAB) approach via anterior thoracotomy. As we all know, MIDCAB is totally different from off-pump CABG with full sternotomy. It would be better, if you were comparing the full sternotomy off-pump CABG with conventional on-pump patients. Could you explain why you are including MIDCAB in the study?
My second question is about the number of grafts per patient in the off-pump group. I could have missed this during your presentation. I would expect, however, there would be significantly fewer grafts/patient in the off-pump group, since most of the time we can only do the LAD or diagonal arteries with the MIDCAB approach. Again I enjoyed your presentation.
DR KOUTLAS: The number of grafts per patient is about one and a half for the off-pump coronary artery bypass (OP-CAB) group and about two and a half for the coronary artery bypass graft (CABG) group. We included the MIDCAB patients in this study because a good percentage of them underwent hybrid procedures where they had more than just a single artery revascularized. Also in the elderly population oftentimes you see people that have either very small circumflex marginals or an occluded right where really their best revascularization is just a graft to the left anterior descending artery (LAD). Thus we included the MIDCAB patients in this group because we are looking at a way to treat elderly patients as well as possible based on their angiogram, not necessarily which operation we use.
DR W. ROBIN HOWE (Paducah, KY): I enjoyed your presentation. I have two questions. One, it looked as though about two-thirds of your patients were anterior thoracotomies, as Dr Arom mentioned. Were any of the neurologic complications in those patients who presumably had no manipulation of the aorta or anything?
And second, I am concerned that we are seeing a selection process. Whether consciously or subconsciously, we are taking those patients out of the pump group who would do better and would lower the mortality rate in the pump group. And whatever selection process we apply, are we in fact magnifying the difference in mortality because of that selection process? Thank you.
DR KOUTLAS: Those are both very good questions. The one patient that had a stroke was, I believe, an anterior thoracotomy, and I have also had another patient with a stroke after an anterior thoracotomy, MIDCAB. Both those patients had some LV thrombus on echoes after prior myocardial infarctions. So I don’t think a MIDCAB necessarily prevents intraoperative stroke. As far as selection, you obviously cannot eliminate that bias without doing a randomized trial. Dr Elbeery and I, actually we tend to pick sicker patients to do this operation because we worry about using cardiopulmonary bypass, for example, on somebody with a creatinine of 3. You are right, there can be some selection bias, but we go more by what the angiogram looks like for identifying a good candidate, whether their vessels are amenable to (OP-CAB), more than trying to just take the least sick patients for the (OP-CAB).
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