Off Pump CABG is Dead. Hopeman Lecture Debate T. Brett Reece, MD September 10, 2007

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1 Off Pump CABG is Dead Hopeman Lecture Debate T. Brett Reece, MD September 10, 2007

2 OPCAB Potential Pitfalls Technically Demanding Steep learning curve Incomplete revascularization Intraoperative ischemia Suboptimal anastomosis Mediastinitis in Diabetics Excessive Operative Times/Costs Denton Cooley, Ann Thorac Surg 2001

3 Step Backwards Prior to the pump, cardiac surgeons could only work on the surface of the heart 1950 s (no pump) Murray and Longmire coronary endarterectomy and resection Demhikov LIMA to LAD, Murray repeated (canines) 1960 s (limited pump) Sabiston coronary bypass in trauma Garret vein graft Kolesov LIMA to Circumflex OPCAB is not a new idea, felt to be outmoded with the availability of the almighty pump

4 Why stop there? If we are going back to techniques of the before cardiac surgery was viable, why stop there? Pericardial well Systemic hypothermia Cross circulation Ether

5 Nothing to Debate Gold Standard Bloodless field Stationary field Proven outcomes Complete revascularization Fall Back Superior Myocardial preservation Applicable to all patients Off Pump Subtotal revascularization Proximal targets unavailable Short term patency suspect Long term patency not known Niche surgery Propaganda Minimally Invasive?

6 OPCAB Trials Several very well done studies Randomized controlled Skilled centers BUT Excellent outcomes with CABG and OPCAB All 100 patients per arm No long term data Longest 3 years

7 Long-term Off Pump Results All start with Early results End with one year results

8 OPCAB Benefits over CABG Myocardial Infarction Myocardial Injury Neurocognitive Renal Dysfunction Atrial Fibrillation Denied On paper, significant? Denied Denied Maybe, affect outcomes?

9 OPCAB Benefits over CABG Transfusion Requirements Inotrope Requirements Ventilator Time ICU Time Hospital Stay Congrats, you got one Maybe Maybe, but 3hours? Maybe, <8 hours Maybe, <1 day

10 Unique Hospital Complications Avulsion of the IMA Even 5 days out, more anecdotal experience Mcmahon Ann Thorac Surg 1997 Reports of graft occlusion within 24 hours One series reported 1/3 of patients Ancalmo Ann Thorac Surg 2007

11 OPCAB Disadvantages vs CABG Fewer Targets Grafted Especially lateral wall Circumflex ignored Fewer proximal targets Due to positioning Current data is suboptimal to support conclusion on OPCAB suitability Data comes from 3369 patients in 37 trials Trial would require >10,000 patients to show significant results based on published meta-analyses

12 Intraoperative Conversion Reasons Hemodynamic instability Diseased Targets Low EF, Large Heart Calcified ascending aorta Doesn t sound good to me

13 Intraoperative Conversion Outcomes Increase mortality Increases complications Impairs long term graft patency/need for reintervention

14 1 Year Graft Patency CABG OPCAB Gundry JTCVS % 49% Khan et al NEJM % 88% Lingaas et al HSF % 83%

15 1 year Reintervention Rate CABG OPCAB Gundry et al JTCVS % 20% Cardiac mortality 9% 12% Guadino et al Ann Thor Surg % Smaller studies despite being RCT show now difference No study has more than 300 patients total Type II Error?

16 Longterm Results CABG IMA patency 90+% 10 yrs Vein patency 60+% 10 yrs OPCAB Um We got a new stabilizer So This snare is better Duh, Well There is nothing

17 Argument Short term benefits of OPCAB have been stated and overstated We have heard all this before in coronary disease PTCA better than CABG Bare Metal Stents better than CABG Drug Eluting Stents better than CABG If arguing short term results, then

18 OPCAB Slippery Slope CABG OPCAB DES

19 OPCAB = DES

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27 If OPCAB is not dead yet, it should be

28 Get back to the Basics CABG is the gold standard because of Complete revascularization Optimal field and positioning Long term results keep us in business Possible short term benefits are not replacement for long term results