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Eur J Cardiothorac Surg 2001;20:657
© 2001 Elsevier Science NL

Letter to the Editor

Reply to Ngaage

Department of Cardiac Surgery, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, UK

Received 31 May 2001; accepted 1 June 2001.

e-mail: mr.amrani{at}rbh.nthames.nhs.uk

We read with great interest the paper from D.L. Ngaage and thank him for his nice comments. We completely agree with the fact that complete myocardial revascularisation (CMR) should never be traded against an unsatisfactory ‘fashionable’ procedure. Off-pump coronary artery bypass (OPCAB) surgery will only be accepted if, at the very least, the outcome is comparable to cardiopulmonary bypass (CPB). We also believe that similar practice should be maintained. This is particularly true as far as the type of conduit and number of grafts is concerned. The patient who died in this cohort of patients had critical left main stem and a blocked right coronary artery. He also had a large posterior scar. As he received four grafts, incomplete myocardial revascularisation can be ruled out as a cause of death.

In our institution we have now performed over 300 consecutive OPCAB for multivessel disease with a morbidity, mortality, type and number of graft at least similar to what we used to achieve with CPB.

In our initial experience (first 50 patients) we converted eight patients to CPB because of unsatisfactory exposure of the lateral wall. With growing anaesthetic and surgical experience as well as additional personal modification of exposure technique we managed to avoid any conversion in the last 250 cases.

OPCAB surgery has somehow suffered from early and hasty criticism which we believe is unfair and unjustified for several reasons. Firstly, the issue of the learning curve is very rarely taken into consideration when OPCAB is compared to CPB. Secondly, whilst there are some broad guidelines about how coronary surgery should be performed with CPB, there are still no consensus regarding many aspects of OPCAB including the level of anticoagulation, the methods of hemodynamic assessment, the sequence of grafting, the indication for intracoronary shunt, the method of the vessels exposure etc. The lack of uniformity in the practice could explain some of the discrepancies reported as well as the difference of perception.

Finally, in a very short period there has been tremendous progress in the quality of stabilisation devices and other tools. The surgical comfort provided by the recent technology is by no means comparable to what was available only a year ago! Therefore some of the negative conclusions published in the mid nineties do not reflect what could be achieved nowadays. OPCAB surgery should be given the chance to mature. It is only the end of the beginning.

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 Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Amrani, M. Search for Related Content PubMed Articles by Amrani, M. Related Collections Mediastinum Coronary disease