Correspondence Article Type Letter by Edelman et al Regarding Article, “Should Off-Pump Coronary Artery Bypass Grafting Be Abandoned?” To the Editor: We read with interest the article by Dr Lazar1 and agree with his conclusion that off-pump coronary artery bypass (OPCAB) surgeons unable to demonstrate outcomes comparable with those with coronary artery bypass grafting (CABG) should abandon the technique. We believe, however, that the benefits of OPCAB performed by surgeons expert in the technique are underestimated in this review. The significant benefits of surgical revascularization over percutaneous coronary intervention for the treatment of multivessel disease have been overshadowed by the increased risk of stroke. We believe OPCAB has the potential to reduce the rate of stroke to a rate comparable with that of percutaneous coronary intervention while maintaining lower rates of major adverse cardiac events.2 This is best achieved with complete avoidance of aortic manipulation, the anaortic technique. In a meta-analysis of >10 000 patients, we have demonstrated a reduction in stroke at 30 days when an aortic side clamp (used for partial occlusion of the aorta for proximal anastomosis of the aortocoronary graft) is avoided (OPCAB with side clamp, 1.34%; anaortic OPCAB, 0.29%; P=0.006).3 The large trials comparing CABG and OPCAB have not reported the rate of side-clamp use. We believe these studies have missed the opportunity to demonstrate the benefit of anaortic OPCAB. Complete revascularization with the use of total arterial grafts avoids the need for an aortocoronary anastomosis. Should one be required, devices are available that avoid the need for a side clamp. We agree with Dr Lazar that the ability of the OPCAB technique to significantly reduce clinical events associated with inflammation has been less than anticipated, primarily because of the underestimation of the relative influence of surgical trauma.4 There has been a focus on cardiopulmonary bypass as the source of morbidity in the debate of CABG versus OPCAB. We believe that avoiding cardiopulmonary bypass should be viewed primarily as a step toward avoiding aortic manipulation. Despite the long-term benefits of surgery, some patients may choose percutaneous coronary intervention for the treatment of complex multivessel disease to avoid the morbidity associated with CABG, of which stroke is the most feared. Expert OPCAB surgeons can offer equivalent durability of graft patency as in CABG,5 with a lower rate of stroke if aortic manipulation is avoided. We believe that not every surgeon should be expected to perform the challenging OPCAB

procedure, just as not all surgeons are expected to perform minimally invasive mitral valve repair, valve-sparing aortic root surgery, or complex aortic surgery. Patients requiring surgical revascularization who are most at risk of stroke (the elderly, those with cerebrovascular disease, and patients with multiple comorbidities) may best be served undergoing OPCAB performed by an expert OPCAB surgeon. We believe OPCAB remains an important technique for the improvement of coronary surgery. A trial comparing anaortic OPCAB with CABG (or indeed a subgroup analysis of those large trials already performed) is required to assess the true benefits of OPCAB.

Disclosures None. J.J.B. Edelman, PhD, MBBS(Hons) P. Joshi, FRACS Department of Cardiothoracic Surgery Sir Charles Gairdner Hospital Nedlands, Western Australia M.P. Vallely, PhD, FRACS Cardiothoracic Surgical Unit Royal Prince Alfred Hospital Sydney, Australia

References 1. Lazar HL. Should off-pump coronary artery bypass grafting be abandoned? Circulation. 2013;128:406–413. 2. Edelman JJ, Yan TD, Padang R, Bannon PG, Vallely MP. Off-pump coronary artery bypass surgery versus percutaneous coronary intervention: a meta-analysis of randomized and nonrandomized studies. Ann Thorac Surg. 2010;90:1384–1390. 3. Edelman JJ, Yan TD, Bannon PG, Wilson MK, Vallely MP. Coronary artery bypass grafting with and without manipulation of the ascending aorta: a meta-analysis. Heart Lung Circ. 2011;20:318–324. 4. Edelman JJ, Fung YL, Pennings GJ, Reddel CJ, Bannon PG, Bayfield MS, Kritharides L, Fraser JF, Vallely MP. Off-pump coronary artery bypass surgery induces prolonged alterations to host neutrophil physiology. Shock. 2013;39:149–154. 5. Puskas JD, Williams WH, O’Donnell R, Patterson RE, Sigman SR, Smith AS, Baio KT, Kilgo PD, Guyton RA. Off-pump and on-pump coronary artery bypass grafting are associated with similar graft patency, myocardial ischemia, and freedom from reintervention: long-term follow-up of a randomized trial. Ann Thorac Surg. 2011;91:1836–1842.

(Circulation. 2014;129:e386.) © 2014 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org

DOI: 10.1161/CIRCULATIONAHA.113.006399

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Letter by Edelman et al Regarding Article, ''Should Off-Pump Coronary Artery Bypass Grafting Be Abandoned?'' J.J.B. Edelman, P. Joshi and M.P. Vallely Circulation. 2014;129:e386 doi: 10.1161/CIRCULATIONAHA.113.006399 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539

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