Letter by Salzberg et al regarding article, "Should off-pump coronary artery bypass grafting be abandoned?".

406 O ne of the most controversial areas of cardiac surgery has been whether off-pump coronary artery bypass graft (OPCAB) surgery is superior to traditional on-pump coronary artery bypass graft (CABG) surgery. On-pump CABG surgery has been an effective, safe, and time-proven technique and is the gold standard with which all other surgical revascular-ization methods have been compared. However, performing coronary revascularization on cardiopulmonary bypass (CPB) can result in myocardial ischemic injury, neurocognitive deficits , and strokes and activate inflammatory pathways that contribute to pulmonary, renal, and hematologic complications. OPCAB offered a promising alternative strategy that had the potential to decrease perioperative morbidity, mortality, and cost by eliminating CPB. In fact, throughout Asia and particularly in India, 95% of CABG surgery is performed off-pump. In North America, OPCAB procedures peaked at 25% in 2004 and have declined steadily since that time. 1 It is a more technically demanding procedure and results in less complete revascularization. There is growing concern that OPCAB is associated with reduced long-term graft patency and increased need for revascularization procedures and results in inferior long-term survival compared with traditional on-pump CABG surgery. In view of these concerns, should OPCAB be abandoned? The purpose of this review is to examine clinical data that most accurately compare the advantages and disadvantages of OPCAB to determine what, if any, role it should have in the practice of surgical coronary artery revascularization. To reach these conclusions, retrospective nonrandomized, prospective randomized, and meta-analyses trials will be reviewed. The effect of incomplete revascularization and conversion to conventional CABG will be examined. The relationship between OPCAB and the inflammatory response, neurological and cognitive changes, and quality of life will be studied, and the impact of OPCAB on sex, renal transplant recipients, and elderly patients will be determined. Retrospective studies were largely single center and lacked randomization. Surgeons who were more skilled in OPCAB were more likely to perform these procedures. Hence, there was a significant selection bias. In most studies, the intention-to-treat principle was not honored. Therefore, if a patient was converted to an on-pump CABG, an adverse outcome associated with this patient would be attributed to the on-pump CABG and not the originally planned OPCAB. Earlier studies may have lacked proper stabilizing equipment and intracoro-nary perfusion devices. Many trials reported only short-term outcomes. The retrospective studies discussed in this section generally involve >1 surgeon, had larger sample sizes to detect statistically significant …