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Puskas estimates that 95% of his CABG surgeries are performed off-pump. John Pepper, MChir, a cardiothoracic surgeon at Royal Brompton Hospital in London and coauthor of the English article, agreed that physician experience may have been a factor in the lower graft-patency rate in study participants who underwent offpump CABG. “It may reflect that we were still on a learning curve, despite more than 2 years of experience,” Pepper said. “The point of our study was to sound a word of caution against the wholesale abandonment of cardiopulmonary bypass for isolated coronary artery surgery, which has been advocated in some quarters.” Surgeon experience may also be a factor in results from a recent observational study, in which researchers followed shortand long-term outcomes for 59 044 patients undergoing onpump CABG and 9135 undergoing offpump between 1997 and 2000 in New York State ( J Am Coll Cardiol . 2004;43:557-564). Edward L. Hannan, PhD, a study coauthor, said the investigators concluded that on-pump patients had better long-term survival (at 3 years) and freedom from revascularization compared with off-pump patients. But the survival difference disappeared when looking only at patients undergoing the procedures in the last 2 years of the study. “The differences in the last 2 years disappeared possibly because the education curve had improved,” said Hannan, a distinguished professor and chair of the Department of Health Policy Management and Behavior at the University of Albany School of Public Health, in New York. However, when the researchers assessed the need for revascularization in patients who underwent the procedures during the last 2 years of the study, they found that those in the on-pump CABG group still fared better than those who had the offpump surgery, Hannan said.