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Off-pump coronary artery bypass surgeries (OPCAB), in which surgeons operate on a beating heart without the use of a heart lung machine, have been performed nationally only in the last 15 years yet now account for 25 percent of all cardiac bypass surgeries in the United States.
That statistic, however, does not mean that all OPCAB procedures are distributed equally across hospitals. As little as 14 months ago, ABC News reported that the disparity included Vanderbilt University Medical Center in Nashville which at that time performed 95 percent of all bypass surgeries off-pump compared with Northwestern Memorial Hospital in Chicago where more than 90 percent of the bypass procedures during that period used the heart lung machine.
While OPCAB has gained widespread use and acceptance it is still a relatively new procedure and there has not been enough time to study long-term patient outcomes nor a sufficient quantity of studies comparing coronary artery bypass grafting and OPCAB to draw definitive conclusions. Moreover, only 20 percent of heart surgeons worldwide have developed the skills required to do off-pump heart surgery.
What can’t be disputed is the role that experience plays in cardiac surgery. It is important for hospitals to have surgeons who have developed skills in both procedures so that patients can be the beneficiaries of whichever approach is most appropriate for their individual condition. The patient’s underlying condition and the surgeon’s experience will ultimately determine the type of surgery to be performed.
Holy Cross Hospital in Fort Lauderdale is one of a select group of medical centers nationwide performing beating heart bypass surgery. As a surgeon who has performed more than 1,000 off-pump surgeries, I believe that there are some patients and conditions for which off-pump procedures should be considered:
• Women: OPCAB shows promise in reducing the gender gap in outcomes following bypass surgery. In a seven-year study representing more than 11,000 patients and 14 surgeons, researchers Emory University School of Medicine concluded OPCAB benefits women disproportionately and was associated with fewer major adverse cardiac events such as heart attack and stroke in women.
• The elderly: Older patients at risk for strokes and those with advanced heart disease may be suitable candidates for OPCAB. There is conflicting evidence in the early studies of the efficacy of on-pump vs. off-pump concerning whether OPCAB reduces the incidence of cognitive dysfunction following surgery yet this complication is a prime consideration for this age group and should be considered.
• Patients with compromised renal and kidney functions: studies have indicated that OPCAB may lessen the risk of perioperative renal damage.
• Patients with other underlying conditions: OPCAB results in decreased trauma for the patient and beating heart patients require fewer blood transfusions and less medication than with traditional bypass surgery. In addition, beating heart bypass surgery patients are awake earlier, breathe on their own more, and have a shorter recovery time allowing them to resume their normal activities faster than traditional bypass surgery patients.
• OPCAB allows minimally invasive (i.e. smaller incisions rather than large sternal incisions) surgery, particularly in patients requiring a second or third re-operation.
Just as there is no blanket recommendation for on-pump vs. off-pump, hospitals must offer a full range of cardiovascular services and options. I am proud to say that the Jim Moran Heart and Vascular Center at Holy Cross was the first Broward County hospital to offer induced hypothermia, which has been shown to increase the odds of surviving a cardiac arrest and also has been shown to improve neurologic outcomes after such an event. Holy Cross also was the first in the state to use the Prime ECG Vest which, in select patients, may give physicians additional data beyond a traditional electrocardiogram.
