Author + information
- aDepartment of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
- bDepartment of Surgery, Stony Brook University, New York, New York
- ↵∗Address for correspondence:
Dr. David H. Adams, Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, 1190 Fifth Avenue, New York, New York 10029.
In a recent attempt to resolve a 4-decade debate over the benefits of off-pump versus on-pump coronary artery bypass surgery (CABG), 12 surgeons including 10 predominantly off-pump surgeons conducted a systematic literature review following American College of Cardiology and American Heart Association standards for the development of clinical guidelines (1). Based on their analysis of 102 randomized trials, they concluded that off-pump surgery may improve short-term outcomes such as renal failure and stroke, but “off-pump may be associated with reduced graft patency, and increased risk of cardiac reintervention and death.” The paucity of long-term data contributed to uncertainty over whether late outcomes differed significantly after on-pump versus off-pump surgery. That remaining question is addressed in a meta-analysis published in this issue of the Journal, which analyzed 6 randomized trials including 3 large multicenter studies and 8,145 participants, reporting a small but persistent survival benefit with on-pump CABG surgery compared with off-pump CABG surgery at 5 years (2).
Here are 5 key points to consider when referring your patient for surgical coronary revascularization:
1. It is time for the debate to move on. Decades of facile arguments based on personal practice and methodologically flawed data have demonstrated that well-designed randomized trials are essential, representing the only means to completely account for unmeasured confounders and selection bias: no multicenter randomized trial has shown off-pump CABG to provide superior early or long-term mortality (1–5). The discussion needs to be reframed in terms of which patients may benefit more from one approach or the other.
2. Randomized data are essential but, with the exception of elderly patients who were shown to have equivalent outcomes with on- and off-pump CABG surgery in a large multicenter trial, information on the patient subgroups who may benefit from one approach over the other is limited to post hoc analysis and non-randomized data (4). This includes patients with severe atheromatous aortic disease, in which a “no-touch” aortic technique can be safely used to minimize the risk of embolic stroke (6). Additionally, patients with very severe lung disease may have a lower risk of postoperative respiratory failure with off-pump compared with on-pump techniques (1). Sternal sparing techniques, where the left internal mammary artery is harvested and grafted off-pump to the left anterior descending coronary artery without a midline sternotomy, sometimes combined with interval percutaneous coronary intervention to other territories, is an appealing option for selected patients and the subject of a multicenter randomized trial (7). In the absence of these characteristics, patients will benefit most from referral to a surgeon with experience and documented excellent outcomes, rather than a targeted on- or off-pump technique preference.
3. The overarching trend in CABG procedures is one of impressive and consistently improving safety and quality, despite the increasing age, comorbidity, and coronary pathology of patients who meet criteria for surgical revascularization. Here is where the value of randomized trials, characterized by their highly selected patients, surgeons, and centers, is superseded by insights from comprehensive, clinical registries—which represent the best means of evaluating outcomes in broader clinical practice. In a national registry-based comparison of 103,549 patients with multivessel coronary disease undergoing surgical revascularization versus 86,244 patients undergoing percutaneous coronary intervention, there was no difference in adjusted mortality between treatment groups at 1 year, with a long-term survival advantage with surgical revascularization at a median follow-up of 2.7 years (8). Surgical revascularization in the modern era has clearly established an exceptional safety record.
4. This remarkable safety record has been driven by incremental advances in technology and clinical practice. In 2018, CABG patients can and should expect to be on optimal medical therapy pre- and post-operatively, have effective perioperative blood conservation and glycemic control strategies in place, undergo intraoperative transesophageal echocardiography and epiaortic ultrasound to assess the ascending aorta, benefit from the evolution of cardiopulmonary bypass support that is almost unrecognizable from the technology of even 10 years ago, and receive care from multidisciplinary teams that bring a level of experienced sophistication and safety that was primarily available in only select centers until relatively recently (9).
5. These advances have all progressively addressed the limitations of on-pump CABG surgery, more so than they have off-pump CABG surgery, the latter of which remains far more dependent on the technical experience of the surgical team. As the occurrence of early post-operative adverse outcomes dwindles to a number that necessitates randomized trials to recruit thousands rather than hundreds of patients to identify a significant difference, emphasis is now appropriately shifting toward potential long-term outcome differences between on- and off-pump CABG approaches. The Smart et al. (2) current meta-analysis now confirms a statistically superior long-term survival with on-pump versus off-pump CABG surgery at 5 years.
In summary, given the equivalent short-term safety of both approaches and the superior long-term outcomes now reported, an on-pump approach to coronary surgical revascularization continues to stand the test of time.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Dr. Adams has reported that the Icahn School of Medicine at Mount Sinai receives royalty payments from Edwards Lifesciences for intellectual property related to the development of two mitral valve repair rings, and from Medtronic for intellectual property related to the development of a tricuspid valve repair ring. Dr. Chikwe has reported that she has no relationships relevant to the contents of this paper to disclose.
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