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J Thorac Cardiovasc Surg 2006;132:212
© 2006 The American Association for Thoracic Surgery

Letter to the Editor

Reply to the Editor

Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 27562 Remington Circle, Westlake, OH 44145

(Email: cvsisfun{at}hotmail.com).

Reply to the Editor:

We appreciate the interest of Dr Ashraf in our article comparing the outcomes of nonelective on-pump with those of off-pump myocardial revascularization. Dr Ashraf is concerned that our results are not confirmed by well-randomized trials comparing the 2 techniques. However, we are not aware of any randomized controlled trials comparing the outcomes of patients having nonelective off-pump coronary artery bypass grafting (CABG) with those of historical control subjects. Such an endeavor might require randomized trials of impractical size to prove whether statistically significant differences really exist between these 2 techniques of myocardial revascularization in this subset of high-risk patients. The authors also question whether urgent or emergency cases should be handled on a separate basis compared with elective cases. The answer is yes, with the main reason being that urgent and emergency myocardial revascularization poses a greater challenge and has consistently been associated with worse outcomes compared with first elective CABG. ¹ Thus a separate and more focused analysis on this subgroup of patients is able to determine the factors that result in a better or worse clinical outcome.

In regard to the issue of decreased rate of postoperative intra-aortic balloon placement and renal failure after off-pump CABG demonstrated in our study, Dr Ashraf quotes a recent article not showing any benefit of off-pump compared with on-pump CABG in regard to the occurrence of postoperative renal function. The study he quotes, ² however, is a not well-balanced study, including only 158 patients in the off-pump arm and comparing those with 2869 patients having on-pump CABG in the same period of time. One might wonder whether the authors of the study were equally comfortable with both techniques because they performed only about one tenth the off-pump cases compared with on-pump cases. In contrast, our 2-institution study compared 2273 patients undergoing off-pump procedures with 3487 undergoing on-pump procedures and, after a robust statistical methodology, was able to document a lower rate of intra-aortic balloon pump placement and a decreased rate of postoperative renal failure, as well as a decreased length of stay after off-pump compared with on-pump nonelective CABG. Moreover, multiple previous studies, including some randomized controlled studies, ^3,4 have documented a lower rate of postoperative renal dysfunction after off-pump compared with on-pump CABG. ⁵ Finally, we tend to agree with Dr Ashraf that a conversion to cardiopulmonary bypass in cases of urgent myocardial revascularization will be associated with worse outcomes, and thus a careful selection of patients chosen for off-pump surgery by surgeons comfortable with both approaches would be necessary to optimize clinical outcome.

	References

Top References

 

1. Nakano H, Daimon M, Hayashi K, et al. Evaluation of value of CABG for emergency or subemergency case. Kyobu Geka 2001;54:298-304.[Medline]
   
2. Chukwuemeka A, Weisel A, Maganti M, et al. Renal dysfunction in high-risk patients after on-pump and off-pump coronary artery bypass surgery. a propensity score analysis. Ann Thorac Surg 2005;80:2148-2153.[Abstract/Free Full Text]
   
3. Ascione R, Lloyd CT, Underwood MJ, Gomes WJ, Angelini GD. On-pump versus off-pump coronary revascularization. evaluation of renal function. Ann Thorac Surg 1999;68:493-498.[Abstract/Free Full Text]
   
4. Celik JB, Gormus N, Topal A, Okesli S, Solak H. Effect of off-pump and on-pump coronary artery bypass grafting on renal function. Ren Fail 2005;27:183-188.[Medline]
   
5. Ascione R, Nason G, Al-Ruzzeh S, Ko C, Ciulli F, Angelini GD. Coronary revascularization with or without cardiopulmonary bypass in patients with preoperative nondialysis-dependent renal insufficiency. Ann Thorac Surg 2001;72:2020-2025.[Abstract/Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sotiris C. Stamou Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Stamou, S. C. Search for Related Content PubMed Articles by Stamou, S. C. Related Collections Cardiac - physiology Coronary disease Extracorporeal circulation Related Article