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| Guest Commentary |
By Vinod H. Thourani, MD
Chief Resident
Emory University School of Medicine, Atlanta, Georgia, USA |
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Coming Full Circle
Coronary bypass surgery has truly “come full circle”. Rediscovering the work of our forefathers in coronary surgery, there is a trend towards abandoning the cardiopulmonary bypass (CPB) circuit in the pursuit of ameliorating its detrimental perturbations.
In 1996 at Emory University, OPCAB was in its infancy; only Drs. Joseph Craver and Robert Guyton, the two most experienced and busiest surgeons in our institution at the time, had dabbled in OPCAB surgery. Nevertheless, they performed the majority of their coronary cases on-pump. It was not until Dr. Guyton had given Dr. Puskas the arduous task of perfecting OPCAB surgery did we as an institution become quite proficient in OPCAB surgery. My first case in off-pump coronary artery bypass (OPCAB) was on my cardiothoracic surgical rotation as a 3rd year general surgery resident with John Puskas, MD in 1999, then a newly hired attending surgeon. I quite vividly remember that steep, and sometimes difficult, learning curve. At that time, I would have rather scrubbed on the on-pump CABGs since it allowed me practice on the art of cannulating the aorta and right atrium. It was my perception then and now that the actual construction of distal anastomoses during OPCAB is more difficult. However, passing the learning curve is feasible and quite attainable. It is without a doubt that at Emory University, Drs. Guyton and Puskas have simplified this difficult operation such that it can be applied for resident training.
At Emory University, we are fortunate as CT residents to have a quite varied experience between our two main hospitals. Emory University Hospital performs approximately 600-800 cases per annum of which approximately 20-30% are off-pump. Conversely, Crawford Long Hospital of Emory University currently performs approximately 1200 cases per annum of which >70% are off-pump; such that we now have performed over 3,000 OPCAB cases since 1997. Despite this huge experience, as CT residents there is no doubt that we perform fewer distal anastomoses in OPCAB cases during the first one and half years of training. Generally, these are cases in which our CT resident predecessors would have routinely performed. We do perform the majority of OPCAB distals in the second half of our second year and the third year of our CT training. There is no doubt that at Emory after completing three years of CT training, that we are quite comfortable performing OPCAB surgery.
While the performance of OPCAB surgery is more demanding and noted to be “more difficult for the surgeon than the patient”; it is an operation that can be technically performed on the majority of patient populations. The most important question to me still remains whether it is actually better than on-pump CABG for the patient. Which patient population is better served with off-pump techniques? We as a profession have not yet clearly defined this!! Yes, it may reduce 0.6 units of PRBC transfusion. Yes, it may reduce length of stay by 1 day. Yes, it may reduce the cost by $1,000 to $2,000. But have you performed the best operation for the patient? Are the distals constructed to perfection? Do the transient dips in blood pressure affect the kidneys? Does the extra volume administered to maintain preload (necessary for heart positioning) affect the lungs? Will the long-term (10 year) patency rate compared favorably with on-pump CABG? Despite my experience in a high-volume CABG center for both OPCAB and on-pump CABG, I continue to struggle with the answers to these questions.
I am a believer!! Although cardiac surgery is in what most of us call a “slump” in terms of job placement, recruiting the best general surgery residents, reimbursement, and diminishing case volume; I do believe that we will survive and eventually prevail. There is no doubt that the cardiologists have embraced OPCAB surgery. There is no doubt that OPCAB is tied intimately with the increase in volume at one of our hospitals (Crawford Long Hospital).
The art of performing OPCAB needs to be in the armamentarium of every CT resident in the world! After discussions with colleagues who have recently taken jobs in the USA, it is quite evident that OPCAB experience is one of the first questions that are discussed during the interview process. As we “come full circle” in the performance of coronary surgery, the care of our patients must remain in the forefront of our minds.
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