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Ann Thorac Surg 2001;72:462-463
© 2001 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, University of Miami/Jackson Memorial Hospital, 1611 NW 12th Ave, ET 3072, Miami, FL 33136, USA
e-mail: tsalerno{at}med.miami.edu
The spectrum of referral of patients for surgical myocardial revascularization is changing. Surgeons are being asked to operate in patients who are at high risk due to underlying comorbidities or poor left ventricular function. Coronary artery bypass grafting (CABG) surgery without the use of cardiopulmonary bypass (CPB) is an alternative approach to conventional CABG using CPB and cardioplegic arrest, aimed at decreasing morbidity and mortality. Reports in the literature indicate that mortality in CABG with or without CPB is about the same. However, the morbidity associated with CPB such as stroke, neurocognitive dysfunction, bleeding and cardiac events continue to raise concerns. Mortality can no longer be considered an end point in assessing outcomes of surgical revascularization procedures. The article by Calafiore and colleagues evaluates a consecutive series of patients undergoing CABG with and without CPB by the same group of surgeons who use similar surgical strategies. Bias was introduced since patients were randomized and one group of patients (group A—off pump) was older, had higher ejection fraction, and lower incidence of reoperation compared to group B (CPB group). There was also a greater number of arterial and sequential grafts and bilateral internal mammary arteries and a higher number of lateral grafts performed in group B. This suggested that off pump surgery was associated with difficulties in marginal artery bypass grafting. Of interest, the authors utilized intermittent warm cardioplegia as a means of myocardial protection in group B, a technique that is not widely used in North America. The authors achieved the same mortality in redo patients compared to first-time operations, as well as the same incidence of myocardial infarction, cerebrovascular accident, and EMF rates. The incidence of off pump was 60.1% for all surgical approaches and 49.9% for multivessel bypass grafting via median sternotomy. In this study, CPB was identified as an independent risk factor for higher mortality. There was also higher incidence for acute myocardial infarction and early major events in the on-pump group. Calafiore and associates identified small arteries, intramuscular arteries, diffuse calcification, dilated hearts and marginal branches in redo cases as contraindications for off pump CABG. At our center we routinely perform this procedure in these types of patients, and do not consider these factors contraindication for off pump surgery. The number of reports in the literature on off-pump CPB CABG continues to grow and the patency rates appear to be similar to on-pump, at least in the intermediate follow up period. This finding is not addressed in this article. The authors question the need for randomization studies and clinical trials to determine the superiority of one procedure over another. I suppose Calafiore and associates and others who are now routinely performing CABG without CPB are hesitant to expose their patients to CPB. This view may be not shared by other surgeons who insist on clinical trials to determine benefits of a procedure.
It is important to recognize that CABG without CPB is an operation which requires new technology, different technical skills as compared to on-pump, and an associated learning curve. This is facilitated by the fact that current residents in training are being exposed to off pump CABG as part of their learning experience. The intraoperative and postoperative care of these patients is also different from conventional CABG using CPB. Furthermore, in the very high risk patient, different strategies can be used, such as the hybrid procedure, different incisions and, obviously, avoidance of CPB. This poses a problem for surgeons who, irrespective of the clinical situation, are determined to perform complete revascularization utilizing CPB. Surgeons interested in off pump CABG surgery should reflect on this article by Calafiore and colleagues, together with others, who have been able to achieve comparable, if not superior results, when CPB is not used. This eventually poses the question: is the heart lung machine really needed in routine coronary artery bypass surgery?
Related Article
Ann. Thorac. Surg. 2001 72: 456-462.
This article has been cited by other articles:
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  P.-G. Chassot, P. van der Linden, M. Zaugg, X. M. Mueller, and D. R. Spahn Off-pump coronary artery bypass surgery: physiology and anaesthetic management{dagger} Br. J. Anaesth., March 1, 2004; 92(3): 400 - 413. [Abstract] [Full Text] [PDF]
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