Ann Thorac Surg 2005;79:812-813
© 2005 The Society of Thoracic Surgeons
INVITED COMMENTARY
Paul Kurlansky, MD
Miami Heart Research Institute, 4770 Biscayne Blvd, Suite 500, Miami, FL 33137
(E-mail: doctorwu18{at}aol.com).
Revolutionary advances in surgical technique warrant reexamination of previous paradigms. We therefore welcome the work of the Leipzig group, as well as that of others, exploring the impact of off-pump coronary bypass graft surgery (OPCABG) on surgical outcomes in women. The finding of significantly lower mortality and morbidity rates among women with off-pump versus on-pump surgery has been reported by others and is indeed encouraging. However, caution must be exercised in concluding that the problem of increased mortality with bypass surgery among women has been solved. The women who underwent OPCABG in this (and other) studies constitute a highly select group, representing only 7% of the women in the study. The basis of selection is obscure, as are the risk profile (20 patients in cardiogenic shock, but only 1 operated on emergently; 77% in New York Heart Association class III or IV, but only 3.9% with a left ventricular ejection fraction less than 30%) and the reason for significantly fewer grafts (1.6 versus 2.5) per patient. The analyses performed are revealing, but severely constrained by the low number (152) of OPCABG patients. We have no information regarding the use of the internal thoracic artery, which has been reported to have a significant impact on reversing the negative impact of gender on mortality in coronary surgery. Moreover, we have no indication how the men in this center fare: do they enjoy a similar apparent benefit from the off-pump approach? In fact, do women in this database even suffer from the problems of increased mortality reported elsewhere? Is the off-pump experience described actually solving a problem that exists?
To better focus on this issue of mortality among women, we should, at some point, try to better understand the source of the problem: is it anatomy? Physiology? Associated risk factors? The well-documented correlation of mortality with body surface area, as well as the beneficial impact of internal thoracic artery grafting, would support a hypothesis that smaller coronary arteries may limit the effectiveness of bypass surgery. The impact of hormone withdrawal and other gender-specific issues on surgical outcome remains woefully underexplored. Risk profiles vary from one center to the next, and may not be gender-specific, nor broadly applicable.
It is hoped that future studies of the impact of the off-pump approach on the outcome of coronary bypass surgery in women will direct their attention to (1) defining the scope of the problem; (2) matching as carefully as possible in some meaningful way the on-pump and off-pump patients; and (3) defining as specifically as possible how one technique or the other seems to better solve the problems defined. We now know that off-pump bypass surgery can be safely performed in select female patients. Whether the technique will help to solve the illusive problem of gender-related morbidity and mortality remains a topic for future investigation.
Related Article
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Impact of Off-Pump Coronary Bypass Grafting on the Prevalence of Adverse Perioperative Outcome in Women Undergoing Coronary Artery Bypass Grafting Surgery
- Jan Bucerius, Jan F. Gummert, Thomas Walther, Michael A. Borger, Nicolas Doll, Volkmar Falk, and Friedrich W. Mohr
Ann. Thorac. Surg. 2005 79: 807-812.
[Abstract]
[Full Text]
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