Monday, 2 April 2012

The Pragmatic Cardiac Surgeon.

Off-Pump or On-Pump Coronary-Artery Bypass Grafting at 30 Days — NEJM
 This randomised trial compared 30 day outcomes between patients whose coronary bypass operation was done with a heart lung machine with those whose surgery was performed without i.e. OPCAB - Off Pump Coronary Bypass. 

This results were published this past week at ACC12, one of the 2 very large North American cardiology conferences and in the New England Journal of Medicine. This combined coordinated approach to the publication of cardiology trial results (conference and prominent hi impact journal) is now quite common and through the power of social media and a large number of internet based medical newsletters, one would have to be in a coma ( or not be bothered about medicine on the web at all!) not to be aware of the results. 
This study was large and methodologically robust enough to be a fair representation of the truth.  At 30 days, there were no differences between the numbers of patients who had attained the primary outcome (composite of death, stroke or new MI or dialysis). Fewer patients who underwent on pump CABG needed further revascularisation (PCI or CABG) and fewer patients who had undergone OPCAB needed a blood transfusion or sustained an acute kidney injury.   
As with other issues in cardiac surgery most notably the use of Aprotinin, enthusiasm for the use of OPCAB has swung pendulum like from one extreme to the other.  This wild swinging from being pro to being sceptical has occurred amongst individual surgeons, myself included. The findings of this study vindicates the approach I have adopted with the use of OPCAB surgery - i.e. the pragmatic approach. No surgeon, (not even the arch sceptics) will argue that completing a CABG operation without touching the aorta in someone whose ascending aorta is diseased is not associated with improved outcomes. This is only possible using OPCAB. This situation is still  however mercifully still quite uncommon and any surgeon would want to perform what is a challenging operation more often. My pragmatic approach is this  - I will perform OPCAB when I think it is definitely safer for the patient e.g. diseased ascending aorta or a Jehovah's witness (study showed fewer transfusions required with OPCAB) or when I think that I can complete the necessary bypass grafts quicker (and therefore easier) with OPCAB than with on-bypass CABG. This approach means that my OPCAB rate is around 30% of all CABGs I perform - often enough to remain proficient. This approach has served me well with good outcomes and I would recommend it to others. There is no doubt in my mind that all cardiac surgeons must learn the techniques of OPCAB if they want to be confident of the best outcomes for all  the coronary patients they operate on.