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J Thorac Cardiovasc Surg 2006;132:211-212
© 2006 The American Association for Thoracic Surgery
Letter to the Editor |
Aga Khan University, Stadium Rd, Karachi 74800, Pakistan
(Email: warraicch{at}yahoo.com).
I read with interest the article by Stamou and colleagues,
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wherein they compare the early outcomes in nonelective myocardial revascularization in patients undergoing on-pump and off-pump bypass. However, it is arguable as to whether the conclusions drawn from this report will have an endearing and widespread influence on this issue.
First, even though recent studies are increasingly documenting better outcomes among patients undergoing off-pump procedures, a number of well-designed trials in the past and present (including both elective and urgent cases) have yielded conflicting results in this regard. Also, it is unclear as to why the urgent cases should be handled on a separate basis because the inflammatory effects associated with cardiopulmonary bypass are likely to be the same in both elective and nonelective scenarios, and the greater risks faced by these patients might solely be a result of their emergency nature of presentation, not having anything to do with cardiopulmonary bypass use.
Second, the authors state the superiority of off-pump surgery in urgent cases on the basis of the former decreasing the rate of intra-aortic balloon pump placement and renal failure. As regards intra-aortic balloon pump placement, studies have shown that off-pump surgery reduces the need for its use in elective cases. However, even as this evidence might tilt the balance toward off-pump surgery in elective cases, the argument is unlikely to have a significant influence on decision making in urgent cases, in which hemodynamic instability is often an issue and balloon pump placement is frequently mandated on purely clinical grounds. Also, although cardiopulmonary bypass is shown to have a detrimental influence on renal function in this report, recent propensity score study with univariate and multivariate analysis shows that off-pump grafting itself might not have any influence in reducing the rate of postoperative renal dysfunction in patients at risk for nephrologic compromise, raising doubts regarding the validity of using the kidney-sparing argument in support of off-pump surgery.
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Finally, before off-pump surgery is adapted as the primary approach in urgent coronary revascularization, it must be kept in mind that a small but significant percentage of patients undergoing off-pump procedures do require conversion to cardiopulmonary bypass, and in case of urgent conversion, disastrous consequences are recorded at a significant level, marking the scope for urgent off-pump use in a selected group of coronary artery bypass grafting patients.
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