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Off-Pump Versus On-Pump Bypass Surgery for Left Main Coronary Artery Disease

Friday, August 9, 2019

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Source Name: JACC


Umberto Benedetto, John Puskas, Arie Pieter Kappetein, W. Morris Brown III, Ferenc Horkay, Piet W. Boonstra, Gabor Bogáts, Nicolas Noiseux, Ovidiu Dressler, Gianni D. Angelini, Gregg W. Stone, Patrick W. Serruys, Joseph F. Sabik, David P. Taggart

The authors in this study performed a post-hoc analysis of the coronary artery bypass grafting (CABG) cohort in the multicenter randomized EXCEL trial, comparing patients undergoing on-pump versus off-pump procedures for left main disease. Of note, in both groups some of the most experienced CABG surgeons in the world participated. The 3-year outcomes of the two CABG groups were compared using inverse-probability-of-treatment weighting for treatment effect estimation. For the 923 CABG patients, 71% and 29% underwent on-pump versus off-pump CABG, respectively. 

Outcomes: Off-pump CABG was associated with a lower rate of revascularization of both the circumflex and right coronary artery territories in patients with obstruction of those territories. Moreover, the 3-year all-cause death was roughly double for the off-pump group as compared to the on-pump group (8.8% versus 4.5%, p = 0.02).


It seems the study is weighted toward on pump CABG on a 70% to 30% off pump. Seems like a true RCT is needed
How do you define the most experienced CABG surgeons in the world, and if so enrolled you should and at least match it to the world most experienced OPCAB surgeons in the 30% (against 70!) group
Totally agree with previous comments.. If to compare OPCABG to On Pump CABG so definitely we need to judge over according to real life.. Surgeons who are doing almost all CABGs as Off Pump are the most concerned physicians to talk about the experience..and outcomes when to come to comparing that to On Pump.. Otherwise all trials will be not as equal to practice..
The increased mortality was due to incomplete revascularization. If the surgeons performing OPCAB could not perform the needed revascularization, they should have converted to ONCAB to finish the procedure, or referred the patients to more experienced OPCAB surgeons.
Thank you all for your comments and critiques. I was hoping to generate controversy by my characterization, and it seems as if I succeeded. Of the authors on this publication, roughly 2/3 are cardiac surgeons. Of these, most are recognized for their expertise and experience in off-pump revascularization. As mentioned in the study, which is retrospective in nature, the decision to proceed with on-pump or off-pump revascularization was left to the discretion of the surgeon. Certainly a weakness of this study is that, to my knowledge, there is no breakdown on the proportion of the off-pump procedures that were performed by the more experienced surgeons among the participating centers. Nevertheless, I don't think one can make any generalizations based on the relative proportion of cases in the study performed as off-pump vs. on-pump, but a reasonable assumption is that the off-pump cases were performed by those surgeons more facile in its performance. As we are all aware, there remains quite a bit of controversy whether or not one technique over the other is superior in the long-term. Nonetheless, the degree of incomplete revascularization seen in the off-pump group is striking. Thanks, again, for your comments. I expect we will still be debating this issue a decade from now.
My Dear professors happy to share u ur great knowledge and experience , i am agree with dr Arie as i compare this to my results in last 4 years (2015-2019) despite my technique of preference is OPCAP but i found that rate of revascularization of LCX territories and RCA(specially if PDA or PL is the target ) is less during my OPCAB procedures ....... to my knowledge i explained this due to haemodynamic compromise that happened during grafting this targets so the decision was to decrease number of targets selected for grafting in those territories
There is something I cannot understand. Why OpCab is needed at all? I mean CABG is like a starting operation for a cardiac surgeon, why one must spend years in training just to become so good, to become non-inferior to others, who perform On pump revascularisation. There are no proven benefits that off-pump gives. So WHY our (as a cardiac surgeons) main weapon against "the stent them all movement" - Long term results, should be jeopardized by the egocentrism of Offpump surgeons? At the end is it worth the years and efforts to become an off-pump GOD and to have the same results as the cardiac surgeon with 5 years experience, who is working Onpump.

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