Correspondence Article Type Letter by Salzberg 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 presenting his personal opinions about off-pump coronary surgery (OPCAB) and concluding that it should be abandoned. It is our belief that these conclusions are based on several factual errors and multiple inaccurate statements. First, the statement “Retrospective nonrandomized, prospective randomized, and meta-analyses trials have failed to show any significant improvement in short-term morbidity or mortality with OPCAB techniques” is erroneous. Numerous large retrospective studies and meta-analyses have shown significant short-term improvements after OPCAB and comparable long-term outcomes.2–4 A recent risk-adjusted analysis of the national Society of Thoracic Surgeons database assessing 876 081 patients demonstrated a significant reduction in death and stroke (11% and 34% reduction, respectively) after OPCAB, seen in both low- and high-volume centers. Börgermann and colleagues2 performed propensity matching on 1282 patients who underwent either a clampless OPCAB or an on-pump approach. A significant benefit for OPCAB was seen for mortality and stroke that remained visible at the 2-year follow-up, whereas the need for revascularization was comparable. Indeed, randomized, controlled trials have failed to demonstrate a significant mortality benefit for OPCAB. However, the available randomized, controlled trials were underpowered to detect significant differences between rarely occurring parameters such as stroke or death and importantly suffered from high selection and exclusion biases. Even more important is the fact that available randomized, controlled trials so far have primarily focused only on low-risk (Randomized On/Off Bypass [ROOBY; NCT00032630] or Coronary Artery Bypass Surgery Off or On Pump Revascularization Study [CORONARY; NCT00463294]) or elevated-risk (German Off Pump Coronary Artery Bypass in Elderly Study [GOPCABE; NCT00719667]) but not high-risk patients in whom the benefits of OPCAB have been repeatedly reported to be most apparent.3 The high conversion rates (12% in ROOBY, 7.9% in CORONARY, and 5% in GOPCABE) may suggest that some of the participating surgeons were inexperienced because expert centers report conversion rates between 2% and 4%,2–4 which significantly affects long-term outcome. Second, Dr Lazar points out the important relation between incomplete revascularization and worse long-term outcomes. However, incomplete revascularization is not a shortcoming of OPCAB. This is a technical issue overcome by experience, as demonstrated by several reports.4 Third, and most important, we disagree with the statement that “OPCAB does not completely eliminate the need for clamping.” It is well documented that standardized application of no-touch, clampless strategies significantly eliminates the risk of calcific embolism from the ascending aorta resulting from clamping or declamping maneuvers.2,5 Moreover, we must emphasize that stroke can occur with any type of aortic manipulation, including cross-clamping, partial clamping, and aortic cannulation and during cardiopulmonary bypass. Only OPCAB offers the opportunity to perform surgical coronary revascularization without aortic manipulation, providing the best hope of achieving periprocedural stroke rates that are competitive with those of percutaneous intervention. Importantly, in none of

the randomized, controlled trials are any details on the technique for proximal anastomoses (partial clamping versus clampless devices) mentioned because these were left to the discretion of the surgeon. Finally, we do not agree with the statement that “OPCAB has made surgeons lose their focus in regard to the goals of surgical revascularization.” Indeed, the SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries (SYNTAX; NCT00114972), Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes (FREEDOM; NCT00086450) trials, and ACCF and STS Database Collaboration on the Comparative Effectiveness of Revascularization Strategies (ASCERT) studies all showed that coronary artery bypass grafting was superior to percutaneous coronary intervention for the majority of patients with multivessel coronary artery disease; however, these trials also reported higher stroke rates after coronary artery bypass grafting. It should be the focus of skilled coronary surgeons to reduce that stroke rate; clampless OPCAB offers our best hope. We appreciate Dr Lazar’s insights and his point of view on this matter. The aim of our letter is to emphasize the other side of things.

Disclosures None. Sacha P. Salzberg, MD HeartClinic Hirslanden Hospital Zurich, Switzerland John D. Puskas, MD Department of Cardiac Surgery Emory Hospital University of Atlanta Atlanta, GA Maximilian Y. Emmert, MD, PhD Clinic for Cardiovascular Surgery University Hospital Zurich Zurich, Switzerland

References 1. Lazar HL. Should off-pump coronary artery bypass grafting be abandoned? Circulation. 2013;128:406–413. 2. Börgermann J, Hakim K, Renner A, Parsa A, Aboud A, Becker T, Masshoff M, Zittermann A, Gummert JF, Kuss O. Clampless off-pump versus conventional coronary artery revascularization: a propensity score analysis of 788 patients. Circulation. 2012;126(suppl 1):S176–S182. 3. Polomsky M, He X, O’Brien SM, Puskas JD. Outcomes of off-pump versus on-pump coronary artery bypass grafting: impact of preoperative risk. J Thorac Cardiovasc Surg. 2013;145:1193–1198. 4. 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. 5. Emmert MY, Seifert B, Wilhelm M, Grünenfelder J, Falk V, Salzberg SP. Aortic no-touch technique makes the difference in off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2011;142:1499–1506.

(Circulation. 2014;129:e388.) © 2014 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org

DOI: 10.1161/CIRCULATIONAHA.113.005825

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Letter by Salzberg et al Regarding Article, ''Should Off-Pump Coronary Artery Bypass Grafting Be Abandoned?'' Sacha P. Salzberg, John D. Puskas and Maximilian Y. Emmert Circulation. 2014;129:e388 doi: 10.1161/CIRCULATIONAHA.113.005825 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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