he older method of doing open-heart surgery, in which the heart is stopped and a pump circulates blood through the body, leads to higher survival rates than a newer method of operating while the heart is beating, which doesn’t require use of the pump, according to a new study.
Why it matters:
Coronary-artery bypass surgery is the most common open-heart surgery in the U.S. It’s used to treat heart disease by rerouting blood around a blockage. Traditionally, the patient is kept alive by virtue of a heart-lung pump, which allows surgeons to stop the heart during surgery. However, in the 1990s, spurred by concerns that the use of pumps might increase patients’ risks of neurocognitive issues or stroke, surgeons developed an alternative approach, performing the surgery on a beating heart. However, there hasn’t been conclusive research showing which technique is better for patients in the long term.
Between 2002 and 2007, Dr. Frederick Grover, a cardiothoracic surgeon at the University of Colorado, and his colleagues enrolled roughly 2,000 veterans at 18 VA medical centers who needed coronary-artery bypass surgery, randomly assigning them to on-pump or off-pump surgery groups.
Grover and his team followed the patients for five years after surgery. In their recent New England Journal of Medicine report, they found that on-pump patients had significantly lower death rates (11.9 percent vs. 15.2 percent in the off-pump group), and also had a lower rate of major adverse cardiovascular events such as death from any cause, a repeat procedure to open or bypass a coronary artery, or a nonfatal heart attack.
“The takeaway is that the off-pump should be used with caution, unless you have a … very high-risk patient who you think would benefit from not having to be on a heart-lung machine,” like a calcified aorta or someone with impaired organ function, Grover said. He said that personally, he would opt for an on-pump surgery where his heart would be completely still and bloodless “so every stitch can be seen perfectly,” adding that it is more difficult to operate precisely on a heart that is beating and filled with blood.
But keep in mind:
The study group was composed entirely of veterans, and was over 99 percent male, though according to Dr. Harold Lazar, a cardiothoracic surgeon at Boston Medical Center and editor-in-chief of the Journal of Cardiac Surgery who was not involved in the study, “if anything, women tend to have worse outcomes after coronary bypass surgery,” which could translate into even poorer outcomes after off-pump surgeries.
What they’re saying:
Lazar said the study not only confirms a growing body of evidence that the newer method does not offer any advantages over surgery using a heart pump, but suggests that the newer method may actually lead to worse long-term outcomes in many people.
He considers it telling that off-pump coronary bypass surgeries in the U.S. dropped from 23 percent in 2002 to 17 percent in 2012.
“The vast majority of cardiac surgeons don’t want to hurt their patients, and while they want to be innovative, I think when they stop doing this operation, you know that there’s got to be a problem,” he said.
The bottom line:
Survival and long-term health both seem to be better for those patients who undergo a more conventional approach to open-heart surgery than ones using the newer off-pump technique.