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Off-Pump Coronary Bypass Surgery: Another Brick in the Wall of Reduced Graft Patency

2009; Elsevier BV; Volume: 87; Issue: 2 Linguagem: Inglês

10.1016/j.athoracsur.2008.03.066

1552-6259

Alessandro Parolari, Elena Tremoli, Paolo Biglioli, Francesco Alamanni,

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Magee and colleagues [1Magee M.J. Alexander J.H. Hafley G. et al.Coronary artery bypass graft failure after on-pump and off-pump coronary artery bypass: findings from PREVENT IV.Ann Thorac Surg. 2008; 85: 494-499Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar] recently published an interesting article concerning a post-hoc analysis of the PREVENT IV trial that specifically addressed the question of whether graft patency differs in patients undergoing on-pump and off-pump surgery, and whether outcomes can be different at follow-up. We believe that the conclusions the authors draw in the “Abstract” section may be somehow misleading, as they give the impression that there is no difference in 1-year saphenous vein graft patency between on-pump and off-pump bypass surgery, whereas outcomes major adverse cardiac and cerebral events (MACCE) at follow-up are better for patients undergoing off-pump coronary surgery. The concept of equivalent vein graft patency that can be achieved with either technique, however, is in clear contrast with what is shown in the results section of the “Abstract” and in Table 8 of the article; these sections show that multivariable analyses identified off-pump bypass surgery as a risk factor for graft occlusion once adjustment for the other significant predictors of graft failure is performed. This is in line and further expands previous evidence [2Parolari A. Alamanni F. Polvani G. et al.Meta-analysis of randomized trials comparing off-pump with on-pump coronary artery bypass graft patency.Ann Thorac Surg. 2005; 80: 2121-2125Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 3Lim E. Drain A. Davies W. Edmonds L. Rosengard B.R. A systematic review of randomized trials comparing revascularization rate and graft patency of off-pump and conventional coronary surgery.J Thorac Cardiovasc Surg. 2006; 132: 1409-1413Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar] showing that reduced saphenous graft patency is an aspect that deserves special attention when choosing the technique for a surgical coronary revascularization procedure. The notion of better outcomes achievable with the adoption of the off-pump strategy that was documented to occur at 1-year follow-up is also somehow questionable and deserves caution, as the potential protective effect of off-pump coronary bypass surgery was no more evident 2 years after surgery when major adverse cardiac and cerebral events were reported to be similar between groups. Taken together, evidence coming from this subanalysis of the PREVENT IV trial are another “brick in the wall” of evidence showing reduced venous graft patency for this alternative surgical strategy (ie, off-pump coronary bypass surgery). As the competition with interventional cardiology is actually more intense in the field of efficacy and durability of revascularization procedures, we believe that a surgical strategy that may potentially jeopardize long-term patency is not the approach with the best chances to succeed in this contest. ReplyThe Annals of Thoracic SurgeryVol. 87Issue 2PreviewWe appreciate the interest that Parolari and colleagues [1] have shown in our subanalysis of off-pump and on-pump coronary artery bypass grafting (CABG) in the PREVENT IV trial [2]. However, we take strong exception to the points made in their communication. Specifically, they suggest that our analyses and conclusions drawn from data collected from the PREVENT IV study are fallacious and misleading, rather preferring to conclude that we have manufactured “another brick in the wall of evidence” supporting reduced graft patency in off-pump coronary artery bypass (OPCAB). Full-Text PDF