Response to Letters Regarding Article, “Should Off-Pump Coronary Artery Bypass Grafting Be Abandoned?”
I thank the authors for their comments regarding my recent clinical review.1
All the authors commented on the reduced incidence of stroke with the use of techniques that avoid aortic manipulation. However, this can be achieved with both on-pump and off-pump coronary artery bypass (OPCAB) techniques. Edelman and colleagues are correct in stating that large trials comparing on-pump and OPCAB have not reported the incidence of aortic side-biting clamp techniques. Our own incidence of perioperative strokes has decreased to <0.5% with the single clamp technique in a population of elderly, high-risk patients with cerebrovascular disease and multiple comorbidities that these authors feel should be performed only by experienced OPCAB surgeons. When required, an aortosaphenous vein or aortoarterial graft anastomosis can be performed on-pump in an atraumatic fashion with the single clamp technique. However, when this type of anastomosis is done in OPCAB patients, to avoid aortic manipulation, connecting devices must be used, which have been shown to decrease graft patency, still result in aortic trauma, and add to the cost of the procedure.
Saha discusses the timely use of the intra-aortic balloon pump to achieve a nearly zero conversion rate to avoid the increased mortality associated with emergent conversion to on-pump surgery. However, the use of the intra-aortic balloon in these patients adds another expense and is not without its own complications.
With regard to the comments by Salzberg and colleagues about the superior short-term outcomes with OPCAB, as I noted in my review, even in those studies in which OPCAB did result in a small improvement in early postoperative outcomes, these improvements were no longer apparent on long-term follow-up and in some series were actually worse.1
I agree with Saha that it is the technique and experience of the surgeon that determine graft patency. That being said, even in the best of hands, the results of OPCAB surgery are no better than those that can be achieved with on-pump CABG performed by all cardiac surgeons.
Cardiac surgeons are always motivated to adopt new techniques that will result in improved outcomes for their patients. The continuous decline in the use of OPCAB by surgeons in the United States is 1 indication that OPCAB is not such a technique. In the history of surgery, no operation that can be performed only by a select group of “experienced, talented” surgeons has ever achieved the test of time. As noted in my review, coronary artery bypass surgery must be performed expertly under all circumstances, on all patients, at all institutions, regardless of their cardiac volume. These goals can be best achieved with on-pump CABG, which remains the gold standard for coronary artery revascularization.
Harold L. Lazar, MD
Division of Cardiac Surgery
Boston Medical Center and Boston University School of Medicine
- © 2014 American Heart Association, Inc.