| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
J Thorac Cardiovasc Surg 2009;137:302-303
© 2009 The American Association for Thoracic Surgery
Invited Commentary |
This article is certainly the extension of a previously published randomized clinical trial called the BHACAS 1 and 2 conducted almost 10 years ago, and today, the chief researchers again demonstrated that OPCAB, as compared with on-pump CABG, can yield a similar level of long-term survival and quality of life based on the similar long-term graft patency evaluated by using 16-array MDCTA.
Your group reported in 2002 and 2004 that OPCAB provided significant reduction in postoperative morbidity compared with that seen after conventional on-pump CABG, such as a 25% reduction in postoperative atrial fibrillation, a 31% reduction in blood transfusion, fewer chest infections, shorter intensive care unit stay, and so on. Also, a midterm follow-up study showed that randomized patients had a similar generic and disease-specific quality of life. However, OPCAB remains in only 15% to 20% of total practice in Western countries, you said.
On the contrary, in Japan surgeons have adopted this technique for about 60% of patients undergoing isolated CABG, and in my institution, the National Cardiovascular Center, 98% of isolated CABG procedures have been performed using the OPCAB technique, probably because in Japan angiographic follow-up is rather routine, which can allow surgeons and cardiologists to evaluate and confirm their own results. Very interestingly, once surgeons are trained and accustomed to do it, they are reluctant to go back to on-pump CABG because they are more comfortable with this technique because of easy hemostasis and easy adjustment of the graft length for complicated graft arrangement. I believe the basic reason for this technology not being popularized well, regardless of less use of resources and reduction of early postoperative morbidity, is the surgeons' attitude anesthesiologists' attitude, or both and the training system.
My first question is this: Why has reduction in postoperative morbidity contributed very little to the wide application of this technique? You mentioned that this was probably because of the concern about long-term graft patency and clinical results. What would you think about the importance of a training system, change of attitude, or both for OPCAB rather than evidence demonstrated by a handful of surgeons who are used to doing it?
Dr Angelini. Thank you, Dr Kitamura, for your kind remarks and your very appropriate question, which is not easy to answer. I have visited Japan on many occasions, and I have always been surprised by the skill and level with which you have adopted OPCAB surgery and also arterial revascularization, 2 techniques that are very poorly used in the Western world.
I think we have plenty of evidence on the benefits of OPCAB surgery. To say, as I heard this morning, that a reduction in blood loss is not such important evidence is a very feeble excuse. I think this is a technique that requires an institution's commitment to it and not just the surgeon and anesthetist but the whole team, and you have to be prepared to go through a learning process, which can be painful. Perhaps this is one of the reasons why surgeons are not prepared to adopt OPCAB surgery.
Maybe there is another explanation. I was reading an editorial written 5 or 6 years ago by Lawrence Bonchek, a very well-known, now retired, American surgeon, who asked, "Is off-pump for everybody?" After all, not all of us can perform mitral valve repair, extensive arterial revascularization, or aortic valve sparing. Therefore perhaps we should see the off-pump procedure as a specialized procedure and to think that everybody will be able to adopt it is perhaps just not feasible.
Dr Kitamura. Well, if I am correct, you are planning to conduct a new randomized trial of OPCAB versus CABG–CPB in patients with poor left ventricular function. Conversion from OPCAB to on-pump CABG in a hasty situation has been reported to result in high mortality. Urgent conversion occurs more often in patients with poor and large left ventricles. At present, would you think OPCAB should be limited for the patients with a low probability of conversion until new evidence comes out?
Dr Angelini. Thank you, again, for this question. We are indeed going to carry out a large study supported by the Medical Research Council in the United Kingdom. The plan is to enroll 5000 patients (EuroSCORE >5). Therefore these will be patients with poor ventricular function but also redo operations, patients with renal impairment, lung dysfunction, and so forth.
As far as conversion is concerned, our experience was reported about 2 years ago in the European Journal of Cardio-Thoracic Surgery; for the period 1995 to 2005, we had an overall conversion of 1.1%, going from 5.2% in the 1995 to 1996 period to less than 0.4% in the most recent years. I think in institutions in which OPCAB surgery has been adopted, after a proper learning curve, the risk of conversion is very small.
Dr Kitamura. I once again congratulate you and your associates on this excellent clinical research, and I hope this evidence can significantly contribute to the prevalence of the OPCAB technique. Thank you very much.
| ||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
