What this study means
The way it's supposed to happen is: randomized studies are conducted in the best hospitals with the best surgeons, yielding favorable results, then every Tom, Dick and Mary Surgeon in the world quotes those statistics to their prospective patients, as if they generated the stats themselves. It's a great system.
The difficulty in this specific instance is that the surgeons doing the study didn't generate the expected favorable results. So how should we interpret this outcome?
There is no doubt in DrRich's mind that the results one obtains with off-pump bypass surgery will be strongly related to the ability and experience of the surgeon. Of course, this same statement can be made about conventional bypass surgery. Indeed, as a non-surgeon who has observed many bypass operations, DrRich can assert that there is clearly an art to sewing grafts into a coronary artery in such a way that they will stay open. Most cardiac surgeons develop the knack for making sucessful grafts over some period of time. Others, unfortunately, never seem to quite get the hang of it. In other words, individual surgeons will produce very different results.
Nonetheless, poorly done surgery does not appear to explain the results of this study. Despite the implications articulated by the editorialists, the surgeons who conducted this study are very good surgeons. This is plain from the 98% success rate obtained by these surgeons when doing conventional on-pump surgery - a result that would delight any surgical department in the world. Even with this highly competent group, however, results with off-pump surgery were much worse than with conventional surgery. So what's going on here?
Accomplishing equivalent graft patency rates with off-pump surgery, where the heart is constantly beating, new tools are required, and surgery is done through a smaller incision (which results in relatively less visibility and less room for maneuvering) will predictably be much more difficult than conventional surgery, and will predictably require a longer learning curve on the part of the surgeon. Even with the best surgeons in the world, then, it may not be reasonable to expect fully equivalent results with today's technology.
In other words, off-pump bypass grafting is just more difficult to do well, even for the good surgeons.
There is no doubt that with more experience, and with ongoing advances in technology, results of off-pump bypass surgery will continue to improve, and no doubt will some day be as effective as on-pump surgery. But we're not there yet. It will get better, but in the meantime off-pump surgery should probably be reserved mainly for individuals who are particularly at risk for pump-related complications such as those with generalized vascular disease, liver problems, severe lung problems, or bleeding problems.
Just one more thing: when you are talking to your surgeon about your prospective bypass surgery - whether off-pump or on-pump - make sure you ask the surgeon for the real statistics - the surgeon's own numbers, and not those transcribed from the medical literature. All good medical centers compile such data, and most are rightfully proud about sharing it. If they are not forthcoming, think thrice about having the surgery done there.
