http://www.medpagetoday.com/Cardiolo...sease/tb1/1127
Survival after coronary artery bypass surgery (CABG) is more dependent on choice of surgeon or institution than on whether a cardiopulmonary bypass pump is used, says the American Heart Association.
MedPage Today Action Points
- Patients who ask about the relative merits of on-pump versus off pump surgery should be assured that both techniques can achieve excellent outcomes.
- Patients who ask for information about CABG outcomes for various surgeons and institutions should be provided data as well as assistance in interpreting the data.
Pump Use Isn't the Determinant of CABG Outcome
By Peggy Peck, Senior Editor, MedPage Today
Reviewed by
Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine.
May 31, 2005
Also covered by:
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DALLAS, May 31- Survival after coronary artery bypass surgery (CABG) is more dependent on choice of surgeon or institution than on whether a cardiopulmonary bypass pump is used, says the American Heart Association.
In a scientific statement by a blue-ribbon panel, the AHA says that excellent outcomes can be achieved with or without the use of cardiopulmonary bypass during CABG surgery.
The AHA says that its analysis of published studies of the two procedures answered some but not all questions about the hotly debated relative merits of on-pump versus off-pump CABG. The results of the analysis were published in a statement in the May 31 issue of
Circulation, Journal of the American Heart Association.
The AHA panel concluded that to "definitively answer the remaining questions of whether either strategy is superior and in which patients, a large-scale prospective randomized trial is required." The Department of Veterans Affairs is enrolling patients in such a large-scale trial.
Frank W. Sellke, M.D., of Beth Israel-Deaconess Medical Center in Boston, who is program committee chair of the AHA Council on Cardiovascular Surgery and Anesthesia and lead author of the statement, said that mortality rates for CABG vary from less than 1% to less than 6%. This range, he said, indicates that the skill of the surgeon and the quality of the institution "play a much greater role in determining outcome" than use of the cardiopulmonary bypass pump.
For almost a decade surgeons have been debating the merits of off-pump versus on pump surgery, and this latest analysis suggests that there are probably ample data to support each camp.
Based on the reviewed studies, off-pump CABG:
- Probably has less blood loss and less need for transfusion
- Less myocardial enzyme release during the 24-hours following surgery
- Probably has less early neurocognitive dysfunction after surgery, especially if the aorta is calcified
- Probably less renal insufficiency after surgery
- Possibly shorter overall length of stay
The same studies find that on-pump CABG is
- Less technically demanding
- Has a shorter learning curve
- Possibly has better long term graft patency
- Is easier to use when bypassing posterior vessels
- May be preferable when a greater number of bypass grafts are constructed
The authors also cautioned that "patients who require urgent or emergent conversion from off-pump to on-pump revascularization have a much greater risk of mortality, postoperative cardiac arrest, and multisystem organ failure than do patients initially undergoing on-pump CABG."
Related articles:
Primary source:
Circulation, Journal of the American Heart Association
Source reference:
Sellke FW et al. "Comparing On-Pump and Off-Pump Coronary Artery Bypass Grafting Numerous Studies But Few Conclusions An American Heart Association Scientific Statement from the Council on Cardiovascular Surgery and Anesthesia and the Working Group on Quality of Care and Outcomes Research."
Circulation. 2005; 111.
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