Ann Thorac Surg 2001;72:781
© 2001 The Society of Thoracic Surgeons
Invited commentary
George L. Hicks, Jr, MDa
a Division of Cardiothoracic Surgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14642, USA
This article by Magee and associates is a study aimed at evaluating the impact of a coronary revascularization using off-pump and traditional cardiopulmonary bypass techniques in both diabetic and nondiabetic patients. This study is a nonrandomized retrospective analysis of 9,965 patients having cardiopulmonary bypass by 22 cardiac surgeons over a 5-year period.
This study is timely as the most recent literature demonstrates coronary artery bypass surgery is the preferred method of revascularization in diabetic patients as compared to angioplasty and stent placement; and attempts to provide answers regarding both populations and their preferred surgical treatment. The univariant analysis of diabetics and nondiabetics undergoing coronary surgery concludes that there is a survival advantage in nondiabetics treated with off-pump techniques which is not apparent in the diabetic population. Further it agrees with other studies of off-pump surgery showing fewer blood transfusions, decreased incidence of atrial fibrillation, decreased duration of postoperative ventilation and decreased length of stay.
Although the study presents significant data analyzing both techniques and study populations, the reader is left with some confusion as to which technique is best for which population. Most importantly, the study represents two groups with differing risk factors operated upon by multiple surgeons over a 5-year period. It is unclear whether the year of operation, the surgeon doing the surgery, or the technique utilized is the more important factor. The comparison of the four study groups is both confusing and complex with the off-pump group having fewer grafts, better ventricular function and more elective operations. The study is unfortunately subject to the bias of 22 operating surgeons with different selection criteria and operative mortalities. Thus although the paper attempts to provide answers regarding off-pump versus traditional cardiopulmonary bypass surgery in the diabetic and nondiabetic population it falls short of providing us with the answers necessary. Length of stay may be a function of patients operated upon more recently versus the technique utilized. Extubation time likewise may be subject to recent improvements in fast track techniques versus the use of off-pump or traditional cardiopulmonary bypass. Clearly, off-pump techniques are being utilized more frequently in all medical centers throughout the country, and it remains the responsibility of cardiothoracic surgeons to utilize the most effective techniques in a wide range of patients to insure the lowest mortality and morbidity. Further studies in a prospective fashion using better population analysis should provide these answers.
Related Article
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Influence of diabetes on mortality and morbidity: off-pump coronary artery bypass grafting versus coronary artery bypass grafting with cardiopulmonary bypass
- Mitchell J. Magee, Todd M. Dewey, Tea Acuff, James R. Edgerton, James F. Hebeler, Syma L. Prince, and Michael J. Mack
Ann. Thorac. Surg. 2001 72: 776-781.
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