16 Sep Coronary Artery Bypass Grafting: On-Pump vs Off-Pump Trends and Mortality
MedicalResearch.com Interview with:
Faisal G. Bakaeen, MD FACS
Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TexasThe Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, Texas
MedicalResearch.com: What are the main findings of the study?
Dr. Bakaeen: The relative use of off-pump CABG peaked at 24% in 2003, followed by a slow decline after that to about 19%. In addition, the conversion rate from off- to on-pump decreased with time and has stayed below 3.5% in recent years. Perioperative mortality rates decreased over time for both on- and off-pump CABG and have stayed below 2% since 2006. The mortality associated with converted cases was high regardless of the surgery year.
MedicalResearch.com: Were any of the findings unexpected?
Dr. Bakaeen: No, we speculated that after an initial hype associated with off-pump surgery, enthusiasm has dampened and that the utilization rate declined in recent years. Our current study served to confirm and document this trend.
MedicalResearch.com: What should clinicians and patients take away from your report?
Dr. Bakaeen: Taken into context and in conjunction with reports from recent randomized trials that show no real advantage to off-pump over on-pump CABG, one can expect an even “tougher sell” for off-pump in the future. In fact, there are concerns relating to a higher risk of incomplete revascularization and the need for subsequent revascularization when CABG is performed off-pump. In a separate study that is based on the same database analyzed here, our group has demonstrated that off-pump CABG may be associated with decreased long-term survival.
Having said that, the off-pump CABG is useful in select anatomic and physiologic scenarios, such as in patients with porcelain aortas, those with advanced liver or pulmonary disease. In addition, there are surgeons at high volume off-pump centers with necessary infrastructure and resources that have reported matching (or even improving upon) on-pump outcomes.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Dr. Bakaeen: I think follow-up studies from the ROOBY, CORONARY, and GOCABE trials will shed interesting light on longer-term outcomes of the two revascularization strategies. Could off-pump CABG compromise long-term survival?
I don’t think that there will be any new large scale randomized trials comparing on- and off-pump CABG in the future, but I do think that there is a real need for studies to evaluate how to best teach off-pump techniques to future generations in the face of declining off- (and on-) pump CABG volumes. It is undeniable that the off-pump technique is a useful skill in the armamentarium of cardiac surgeons.
Bakaeen FG, Kelly RF, Chu D, Jessen ME, Ward HB, Holman WL. Trends Over Time in the Relative Use and Associated Mortality of On-Pump and Off-Pump Coronary Artery Bypass Grafting in the Veterans Affairs System. JAMA Surg. 2013;():-. doi:10.1001/jamasurg.2013.3580.