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Ann Thorac Surg 2000;69:710
© 2000 The Society of Thoracic Surgeons
Discussion
DR GLENN J. R. WHITMAN (Baltimore, MD): Doctor Arom, it is fabulous to see such a large experience with off-pump versus on-pump bypasses. At the University of Maryland we have been less aggressive with off-pump operation, performing approximately 30% of our coronary bypass operations in that way.
We have started measuring flow in all of our grafts, and furthermore, we are starting to measure the reactivity of the anastomosis and the recipient vessel by injecting papaverine down the graft. As you may know, there are ultrasound devices with which you can measure flow and evaluate the adequacy of your grafts. I wondered if your group was relying on ultrasound or evaluating its use, looking at graft flow immediately after performing the proximal anastomosis and relating this to short or long term results.
DR AROM: Thank you, Glenn, for your question. We have looked at the flow study but not the reactivity. We used the Transonic Flow Meter in the majority of the cases and only a few required revision of the anastomosis. However, I do not have data available at this time. As we all know angiograms are the most beneficial way to look at the anastomosis, but we still do not know the correlation between these two techniques. If your institution can conduct the study, a comparison between these two approaches, I am sure that the available data will be very helpful to all of us.
DR ALAA Y. AFIFI (Gulfport, MS): I too, enjoyed your paper very much. One of the striking findings, as you clearly outlined, was the mortality data in the high risk group. There was a four-fold increase in mortality in the conventional cardiopulmonary bypass group versus the off-pump group. I was hoping that perhaps you would clarify this, looking at two of the variables, about 75% of your off-pump cases were done electively versus 50% of patients operated on electively with the conventional cardiopulmonary bypass technique. The other variable, of course, involves the number of distal anastomosis performed. There was a two-fold increase in the number of distal anastomosis performed on the conventional cardiopulmonary bypass group versus the off-pump group.
Do you think, based on these two variables, that is, a higher percentage of emergency, urgent cases versus elective cases, as well as, a higher number of distal anastomosis may have contributed to a higher mortality among the conventional cardiopulmonary bypass group, or how do you justify such a high differential between the off-pump and the on-pump coronary artery bypass graft patients?
DR AROM: I agree with you to a certain degree, it is not quite matched as far as the two groups of patients are concerned. But this represents what we have to date. With more patients in the future, we should be able to make a better matching. However, all of these patients were consecutive and done within the same time frame. The selection of the patients was done as per surgeon’s preferences.
There is definite trend that the results of OPCAB is better than CCAB in many categories. They had less blood loss, shorter ICU stay, recovered and went home sooner. As far as high-risk group is concerned, in spite of different number of the grafts, the data strongly suggested that OPCAB is better, and I feel that, if it is possible, this technique should be offered to any high-risk patient.
DR JOHN H. CALHOON (San Antonio, TX): Doctor Arom, this was a very nice paper, Despite its limitations of not being a randomized study, and the clear blatant attempt at being a repeat Tiki Award winner with that one slide. I have one question, how do you select these patients? For those of us who do not have this experience, how do you decide if you are going to do an off-pump coronary artery bypass or do it the old way?
DR AROM: John, thank you for your comment. No, there was no attempt here for a second Tiki Award! To answer your question, all the cases presented this afternoon were done mainly by 4 surgeons in our group. The selection may vary somewhat, but roughly we prefer no calcified, no intramuscular artery and size should not be smaller than 1.5 mm. Severe left ventricular hypertrophy giving me more difficulty while application of the "Octopus" and exposure of the vessels near the A-V grove, I tried to avoid the patient as well. In general, the more number of vessels required bypass is not contraindicated for OPCAB surgery.
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