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Eur J Cardiothorac Surg 2005;28:515-516
© 2005 Elsevier Science NL

Letter to the Editor

OPCAB: time to call off the search for the Holy Grail! {star}

Shahzad G. Raja *

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

Received 20 March 2005; accepted 11 May 2005.

* Tel.:+44 141 201 0269; fax: +44 141 201 9204. (Email: drrajashahzad{at}hotmail.com).

Key Words: Off-pump coronary artery bypass • Cardiopulmonary bypass • Outcomes

The propensity score analysis by Frankel et al. [1] comparing hemorrhage-related reexploration rates and blood transfusion requirements after off-pump coronary artery bypass (OPCAB) surgery with a matched set of patients undergoing on-pump coronary artery bypass grafting (CABG) is a welcome addition to the already voluminous current medical literature containing a massive amount of research related to OPCAB. However, I tend to disagree with their suggestion that due to the lack of comparative data on long-term outcomes retrospective initial reports similar to their study need to be validated by further randomized trials.

For nearly three decades on-pump CABG has been regarded as the Holy Grail of myocardial revascularization. Any new or innovative technique for myocardial revascularization needs to demonstrate equivalence in outcomes (especially freedom from angina, long-term graft patency and survival) to this Holy Grail for its universal adoption and acceptance. Interestingly, during the last decade over 37 randomized trials [2] as well as several meta-analysis and systematic reviews [2–4] have rigorously scrutinized the safety and efficacy of OPCAB and have demonstrated that OPCAB improves short-term and mid-term clinical outcomes without measurable increased risk to the patient with reduction in resource utilization and potential reduction in in-hospital costs compared with on-pump CABG [2–4]. There is no denying the fact that we are still awaiting long-term outcomes of OPCAB but that does not warrant further trials to verify the long-term outcomes. Instead, undertaking cumulative meta-analysis [5] incorporating long-term outcomes of already published trials will perhaps be a much more logical way of proceeding further.

Finally for all those who vehemently support the need for more trials to conclusively prove the superiority of OPCAB, it is important to remember that randomized trials of impractical sizes will be required to prove whether statistically significant differences really exist between these two techniques of myocardial revascularization. Perhaps it will be more prudent to accept that OPCAB is as good as the Holy Grail and call off the search for the Holy Grail!

Footnotes

{star} The authors of the original paper [1] were invited to comment on this Letter to the Editor but declined the offer. Back

References

  1. Frankel TL, Stamou SC, Lowery RC, Kapetanakis EI, Hill PC, Haile E, Corso PJ. Risk factors for hemorrhage-related reexploration and blood transfusion after conventional versus coronary revascularization without cardiopulmonary bypass. Eur J Cardiothorac Surg 2005;27:494-500.[Abstract/Free Full Text]
  2. Cheng DC, Bainbridge D, Martin JE, Novick RJ, Evidence-based Perioperative Clinical Outcomes Research Group. Does off-pump coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with conventional coronary artery bypass? A meta-analysis of randomized trials. Anesthesiology 2005;102:188-203.[CrossRef][Medline]
  3. Bainbridge D, Martin J, Cheng D. Off pump coronary artery bypass graft surgery versus conventional coronary artery bypass graft surgery: a systematic review of the literature. Semin Cardiothorac Vasc Anesth 2005;9:105-111.[Abstract/Free Full Text]
  4. 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]
  5. Lau J, Antman EM, Jimenez-Silva J, Kupelnick B, Mosteller F, Chalmers TC. Cumulative meta-analysis of therapeutic trials for myocardial infarction. N Engl J Med 1992;327:248-254.[Abstract]




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