To beat or not to beat? From one size fits it all to an individual coronary revascularization strategy

This editorial refers to ‘Early graft patency after off-pump and on-pump coronary artery bypass surgery: a prospective randomized study’, by M. Sousa Uva et al. doi:10.1093/eurheartj/ehq210 For decades, coronary artery bypass grafting (CABG) was routinely performed with cardiopulmonary bypass support and cardioplegic arrest. A deloaded, non-beating heart, a bloodless surgical field, and an easy exposure were regarded to be essential for manipulations on vessel sizes of less than a pencil lead. Surgical results were excellent, mortality declined constantly, and conventional CABG (cCABG) became a success story and the ‘bread and butter’ for cardiac surgeons since it was the first-choice revascularization strategy in multivessel coronary artery disease. However, some adverse clinical consequences, such as stroke, myocardial infarction, and inflammatory response syndrome, complicated by acute lung and kidney injury have largely been attributed to cardiopulmonary bypass circuit, hypothermic cardiac arrest, and aortic manipulation. Consequently, several efforts were made in the early 1990s to reduce morbidity and mortality by looking for safer alternatives to cCABG including off-pump beating heart bypass surgery (OPCAB) in multivessel coronary artery disease. As is often the case when new technical innovations expand and become available for routine use, advocates and opponents of OPCAB raised their voice. Initial controversies within the cardiac surgery community, however, were based more on general convictions than on scientifically proven data.1 During the last decade more and more prospective randomized studies and meta-analyses comparing OPCAB and cCABG surgery in low-risk patients or mixed-risk populations have become available.2–4 They usually failed to demonstrate any significant benefit of OPCAB surgery on early mortality or perioperative major cardiac and cerebrovascular events, but OPCAB was superior regarding blood loss, transfusion requirements, re-thoracotomy rate, ventilation time, intensive care unit (ICU) and hospital stay, and subsequently resource utilization. Most of the large observational studies comparing OPCAB … *Corresponding author. Tel: +49 341 865 1421, Fax: +49 341 865 1452, Email: mohrf{at}medizin.uni-leipzig.de