Off Pump Coronary Surgery (OPCAB) and the Evolution of My Pragmatism!

I have been observing and then performing coronary artery surgery since 1988. It was in 1992 when I first heard of Subramanian's first published accounts of LIMA to LAD coronary bypass done off pump i.e. without the aid of a heart lung machine.

How to link 5 stories to 1 Narrative or Why Cardiac Surgeons are not doing the right operation.

Reports of the death of the Coronary Artery Bypass Grafting Operation (CABG) are plentiful and exaggerated.

What kind of Evidence do we need in Surgery?

In percutaneous coronary intervention, the key to stent patency and therefore prevention of clinical events is inhibition of platelet function. Aspirin is the best know inhibitor of platelet function & has been around forever. Over the past 10 years, we have had many more - clopidogrel, abciximab, ticlopidine, pasugrel and now ticagrelor - each one shown to be superior to the last in good quality randomised controlled studies.

Who is being Referred for Cardiac Surgery ?

Man in his 60s for Coronary Artery Surgery

78 year old lady with mixed aortic valve and coronary disease

63 year old lady with pulmonary hypertension and severe mixed mitral valve disease secondary to rheumatic fever.

A 37 year old man with severe coronary surgery for CABG.

 

It's that Frailty Thing Again!

Every year for the past 10 years, the mean age of patients undergoing coronary artery surgery in the UK has gone up . There is a feeling now that we are possibly reaching the biological limits of the bodies that we subject to surgical trauma. Evidence for this perception is the increase in interest in using an index of frailty for pre operative risk assessment. At the recent joint annual meeting of the Society for Cardiothoracic Surgery and the Association of Cardiothoracic Anaesthetists in Manchester UK, a whole session was dedicated to the subject. I have been interested in this subject for a number of years and have posted about it on a number of occasions.

It is therefore not surprising that I feel the need to comment in this paper published recently in Circulation.

In this paper, researchers describe how the addition of various known scores of frailty to existing cardiac surgical risk scores improved the discriminatory power (the area under the curve for the Receiver Operating Characteristic or ROC curve) of the surgical risk score to predict death after a heart operation. Now prediction of early death after surgery is all well and good. What I think is even more important is the ability to predict whether a heart operation can improve the quality of life of these very elderly patients. What's the point of increasing the life years of 86 year old Ethel, who is suffering with critical left main stem stenosis, if she lives them in discomfort from her chest wounds attached to a VAC pump treating her wound infection. The good news is that PROMS or Patient Reported Outcome Measures may help us with the quality of life issue. They have been used routinely in the English NHS to measure quality of life after hip and knee surgery, and varicose vein and hernia surgery . There is now a pilot project looking at PROMS after coronary revascularisation and I get the feeling the findings form these could prove to be very interesting .

Who is being referred for Cardiac surgery?

3 men aged 55-78 for coronary artery bypass surgery

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. 

Financial Consequences of New Guidelines

This is a really interesting study for a number of reasons. When diagnosing the causes of angina, there has been a move away from exercise testing ((too many false positives and false negatives) and towards using CT coronary calcium scoring and CT coronary angiography.  These evidence based changes have appeared in NICE issued guidelines. 
This study suggest that such a strategy results in a greater number of invasive coronary angiograms and a greater number of revascularisations - both percutaneous (PCI/coronary stenting) and surgical CABG) - thus making it a more expensive strategy with no change in mortality.
In the UK , the number of revascularisation procedures (both PCI and CABG) for stable angina is plummeting. It will be interesting to see whether increased use of CT angiography might slow or reverse this decline.

NICE, ANGINA, SURGERY & TAGGART

The UK's NICE (National Institute for Health and Clinical Excellence) recently published guidelines for the management of stable angina. As the primary guideline setting body in the UK, what they advise is a big deal. Public health commissioning bodies look to this organisation before they decide to invest in any treatment.

PEOPLE RESEARCH A CAR MORE THAN THEIR CARDIAC SURGEON

Is this video, from Consumer Reports in the USA, a vision of the future for the UK? I suppose it should be - you just cannot argue against it. The Bristol Heart Surgery scandal and the endeavours of Sarah Boseley at the Guardian led to the eventual publication of individual surgeons' results. Today however, 6 years after the first publication of institutional results and the efforts of the then President of the Society of CT surgeons and the current medical director of the NHS, Sir Bruce Keogh, we are no further forward.

IS THE END NIGH?

I'm not talking about the rapture (was it not due to take place recently at 6:30pm wherever you were on the planet? does that mean it would have lasted 24 hours).

ANOTHER NAIL IN THE OPCAB COFFIN

Three-year follow-up in a subset of high-risk patients randomly assigned to off-pump versus on-pump coronary artery bypass surgery: the Best Bypass Surgery Trial -- Møller et al. 97 (11): 907 -- Heart

This study provides some more evidence for the non-inferiority and probably superiority of on pump coronary surgery when to compared to off pump CABG in higher risk patients.