Experts Weigh in On the Better Bypass

Use of heart-lung machine depends on surgeon's skill, AHA concludes

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HealthDay Reporter

TUESDAY, May 31, 2005 (HealthDay News) -- Whether patients undergoing coronary bypass surgery do better if their hearts keep beating or if a heart-lung machine takes over is a long-running debate that should end, at least as far as the American Heart Association is concerned.

Either method -- "off-pump" or "on-pump" -- works fine, as long as the surgeon and the hospital have the required expertise, concludes a report in this week's issue of the AHA's journal Circulation. The report was drafted by a committee that reviewed more than 53 studies comparing the two procedures.

"It's always been controversial which one is better," said the lead author, Dr. Frank M. Sellke, chief of cardiothoracic surgery at Beth Israel Deaconess Medical Center in Boston and chair of the association's council on cardiovascular surgery and anesthesia. "The off-pump procedure felt better to some because there was less confusion for the patient after surgery. Others liked the on-pump method because they could stop the heart and do the operation in a relaxed manner."

"We looked at various studies to see if there is a major advantage of one or another and concluded that other factors far outweigh this one," he added.

Those factors include the quality of the hospital in which the bypass is done, the ability of the surgeon doing the operation and whether a patient has other medical problems, Sellke said.

"There are some slight differences between the off-pump and the on-pump procedure," he said. "But the differences are very slight."

Only about 20 percent of bypass operations are done with the heart still beating, the report noted, mainly because that procedure is more technically demanding for the surgeon and requires a longer learning curve.

"It's better to have an off-pump procedure done by someone who is experienced and comfortable with it, because it is a little more demanding of the surgeon," said Dr. Timothy J. Gardner, medical director for heart and vascular surgery at the Christiana Health Care System in Wilmington, Delaware, another author of the report.

There are some benefits associated with the beating-heart method, Gardner added, including quicker recovery, less need for blood transfusions and a shorter hospital stay. But the most important factor is "the expertise of the surgeon and the comfort level of the surgeon with the technique," he said.

Someone who faces bypass surgery can get information about the quality of the surgeon and the hospital, at least in some states, Sellke said.

"In certain states, such as New York and Pennsylvania, you can go to the Internet and look at surgeon-specific information provided by the state health department," he said. "In Massachusetts, you can find hospital-specific information."

But the value of that information is limited, Sellke and Gardner agreed.

"It is not always the lowest mortality associated with the operation that is essential," Sellke said. "A surgeon with a higher mortality rate may be doing procedures on a larger number of high-risk patients."

And state health department statistics don't distinguish between procedures done off-pump and on-pump, Gardner said, so "you couldn't tell what a surgeon's expertise has been with regular vs. off-pump procedures."

More information

The whys and hows of bypass surgery are explained by the American Heart Association.

SOURCES: Frank M. Sellke, M.D., chief, cardiothoracic surgery, Beth Israel Deaconess Medical Center, Boston; Timothy J. Gardner, M.D., medical director for heart and vascular surgery, Christiana Health Care System, Wilmington, Del.; May 31, 2005, Circulation

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