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Eur J Cardiothorac Surg 2005;27:930
© 2005 Elsevier Science NL

Letter to the Editor

OPCAB and the incidence of atrial fibrillation: ignoring the current best available evidence

Department of Cardiac Surgery, Royal Hospital for Sick Children, Yorkhill NHS Trust, Dalnair Street, Glasgow G3 8SJ, UK

Received 20 December 2004; accepted 4 January 2005.

^* Corresponding author. Tel.: +44 141 201 0269; fax: +44 141 201 9204. (E-mail: drrajashahzad{at}hotmail.com).

Key Words: OPCAB • cardiopulmonary bypass • atrial fibrillation • evidence

I read with interest the recent article in EJCTS by Enc and colleagues [1] in which they have attempted to tackle the controversial issue of impact of off-pump coronary artery bypass surgery (OPCAB) on the incidence of postoperative atrial fibrillation (AF). Based on the results of their retrospective study they have concluded that there is no reduction of AF rate with OPCAB. Interestingly, their study is conspicuous not because they have attempted to verify a hypothesis with a study design marred with inherent weaknesses but because they have ignored the current best available evidence while trying to justify their conclusion.

OPCAB is fast becoming a safe alternative to conventional myocardial revascularization. By avoiding cardiopulmonary bypass (CPB), OPCAB is a potentially more physiologic method to maintain the functional integrity of major organ systems with the possibility of reducing mortality and morbidity [2]. In recent years a large body of evidence has been presented in the medical literature on the safety and efficacy of OPCAB. We are currently practicing in an era of evidence-based medicine where a logical and comprehensive approach to evaluating clinically relevant research incorporates many different types of evidence including randomised clinical trials (RCTs), nonrandomised clinical trials, and experimental data and analyses the information's content for its consistency, coherence and clarity [2]. In this era of evidence-based medicine double-blinded RCTs have been allotted the highest level of evidence [3]. Any research that ignores current best available evidence can only be termed biased.

I shall further take this opportunity to inform Enc and colleagues [1] and general readership of EJCTS that we have recently evaluated the current best available evidence on this topic taking into account all the published meta-analyses (Level Ia) as well as performed a meta-analysis of six RCTs published after these several meta-analyses [4]. The findings of our meta-analysis corroborated the findings of the already performed meta-analyses that found significant differences in the incidence of AF after OPCAB and conventional myocardial revascularization [2,5]. The skeptics might say that a meta-analysis is however only as good as the studies it includes and the factors it takes into account. Well if that's the case then perhaps it is time to undertake a large-scale multi-center RCT of OPCAB versus CPB with the development of post-operative AF as a primary endpoint. This may be the only definitive way to answer the question of whether OPCAB reduces the incidence of post-operative AF in patients undergoing coronary artery bypass surgery.

References

1. Enc Y, Ketenci B, Ozsoy D, Camur G, Kayacioglu I, Terzi S, Cicek S. Atrial fibrillation after surgical revascularization: is there any difference between on-pump and off-pump?. Eur J Cardiothorac Surg 2004;26:1129-1133.[Abstract/Free Full Text]
2. Raja SG, Dreyfus GD. Off-pump coronary artery bypass surgery: to do or not to do? Current best available evidence. J Cardiothorac Vasc Anesth 2004;18:486-505.[CrossRef][Medline]
3. von Segesser LK. Writing off evidence in evidence-based medicine?. Interact Cardiovasc Thorac Surg 2003;2:403-404.[Free Full Text]
4. Raja SG, Behranwala AA, Dunning J. Does off-pump coronary artery surgery reduce the incidence of postoperative atrial fibrillation?. Interact Cardiovasc Thorac Surg 2004;3:647-652.[Abstract/Free Full Text]
5. Athanasiou T, Aziz O, Mangoush O, Al-Ruzzeh S, Nair S, Malinovski V, Casula R, Glenville B. Does off-pump coronary artery bypass reduce the incidence of post-operative atrial fibrillation? A question revisited. Eur J Cardiothorac Surg 2004;26:701-710.[Abstract/Free Full Text]

This article has been cited by other articles:

				S. G Raja and G. D Dreyfus Current Status of Off-pump Coronary Artery Bypass Surgery Asian Cardiovasc Thorac Ann, April 1, 2008; 16(2): 164 - 178. [Abstract] [Full Text] [PDF]

				S. G. Raja and B. S. Rayen Levosimendan in Cardiac Surgery: Current Best Available Evidence Ann. Thorac. Surg., April 1, 2006; 81(4): 1536 - 1546. [Abstract] [Full Text] [PDF]

				S. G. Raja Drug-Eluting Stents and the Future of Coronary Artery Bypass Surgery: Facts and Fiction. Ann. Thorac. Surg., March 1, 2006; 81(3): 1162 - 1171. [Abstract] [Full Text] [PDF]

				S. G. Raja and G. D. Dreyfus Reply Ann. Thorac. Surg., January 1, 2006; 81(1): 406 - 406. [Full Text] [PDF]

				M. H. Aazami and M. Salehi Atrial fibrillation after off-pump versus on-pump: Are we not missing a common pathophysiological pathway? Eur. J. Cardiothorac. Surg., October 1, 2005; 28(4): 659 - 660. [Full Text] [PDF]

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