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• W2889898372 abstract "Central MessageIn patients with diabetes, off-pump and on-pump CABG result in similar long-term survivals. The use of skeletonized BITA may be more important to increasing longevity in patients with diabetes.See Article page 960. In patients with diabetes, off-pump and on-pump CABG result in similar long-term survivals. The use of skeletonized BITA may be more important to increasing longevity in patients with diabetes. See Article page 960. Diabetes mellitus is an epidemic, affecting millions of patients in the United States and worldwide, and its prevalence is constantly rising. Nearly 50% of patients currently undergoing coronary artery bypass grafting (CABG) have diabetes. Survival after CABG among patients with diabetes is considerably worse,1Raza S. Sabik III, J.F. Ainkaran P. Blackstone E.H. Coronary artery bypass grafting in diabetics: a growing health care cost crisis.J Thorac Cardiovasc Surg. 2015; 150: 304-312Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar mainly because of the severity of coronary disease, the inferior response to current myocardial revascularization methods, and the multiorgan impact of the disease. Any investigation seeking to define the treatments in this group of patients is therefore of vast importance. In this issue of the Journal, Huang and colleagues2Huang K.C. Wu I.H. Chou N.K. Yang Y.Y. Lin L.C. Yu H.Y. et al.Late outcomes of off-pump versus on- pump coronary bypass in diabetic patients: a nationwide study from Taiwan.J Thorac Cardiovasc Surg. 2019; 157: 960-969Abstract Full Text Full Text PDF Scopus (7) Google Scholar present their analysis of the outcomes of 13,441 patients with diabetes who underwent isolated CABG between 2000 and 2011, with data derived from the National Health Insurance Database in Taiwan. Of those patients, 9341 were operated on with the use of cardiopulmonary bypass (on-pump group); the remaining 4100 were operated on with the off-pump technique. Huang and colleagues2Huang K.C. Wu I.H. Chou N.K. Yang Y.Y. Lin L.C. Yu H.Y. et al.Late outcomes of off-pump versus on- pump coronary bypass in diabetic patients: a nationwide study from Taiwan.J Thorac Cardiovasc Surg. 2019; 157: 960-969Abstract Full Text Full Text PDF Scopus (7) Google Scholar were able to match 3796 patients in each group, and the median follow-up time was 5.4 years. They concluded that at 30 days and at 1 year after the operation, the on-pump group had significantly higher mortalities than those of the off-pump group (hazard ratio, 1.52; and hazard ratio, 1.50, respectively); however, both techniques had similar long-term event-free rates at 10 years for mortality, stroke, and myocardial infarction. Long-term repeat revascularization rates were substantially higher in the off-pump group, and there was a significant survival benefit in patients with end-stage renal disease operated on with cardiopulmonary bypass (hazard ratio, 0.68). A strength of this report is the large cohort of patients with diabetes, more than the combined number included in 3 recent randomized trials, the Randomized On/Off Bypass trial (ROOBY),3Shroyer A.L. Grover F.L. Hattler B. Collins J.F. McDonal G.O. Kozora E. et al.Veterans Affairs Randomized On/Off Bypass (ROOBY) Study Group. On-pump versus off-pump coronary-artery bypass surgery.N Engl J Med. 2009; 361: 1827-1837Crossref PubMed Scopus (887) Google Scholar the CABG Off or On-Pump Revascularization study (CORONARY),4Lamy A. Deveraux P.J. Prabhakaran D. Taggart D.P. Hu S. Paolasso E. et al.CORONARY InvestigatorsEffects of off-pump and on-pump coronary-artery bypass grafting at 1 year.N Engl J Med. 2013; 368: 1179-1188Crossref PubMed Scopus (330) Google Scholar and the Off-Pump versus On-Pump Coronary-Artery Bypass Grafting in Elderly Patients trial (GOPCABE).5Diegler A. Börgermann J. Kappert U. Breuer M. Böning A. Ursulescu A. et al.GOPCABE Study GroupOff-pump versus on-pump coronary-artery bypass grafting in elderly patients.N Engl J Med. 2013; 368: 1189-1198Crossref PubMed Scopus (354) Google Scholar Another strength is that the analysis is based on a comprehensive national database. This report could have been the ideal setup to obtain significant results that could clarify some of the current on-pump versus off-pump CABG controversies, especially after the recent publication of the 5-year outcomes of the ROOBY trial, which showed that off-pump CABG led to increased mortalities and lower 5-year event-free survival relative to on-pump CABG.6Shroyer A.L. Hattler B. Wagner T.H. Collins J.F. Baltz J.H. Quin J.A. et al.Veterans Affairs ROOBY-FS GroupFive-year outcomes after on-pump and off-pump coronary-artery bypass.N Engl J Med. 2017; 377: 623-632Crossref PubMed Scopus (45) Google Scholar Unfortunately, the study of Huang and colleagues2Huang K.C. Wu I.H. Chou N.K. Yang Y.Y. Lin L.C. Yu H.Y. et al.Late outcomes of off-pump versus on- pump coronary bypass in diabetic patients: a nationwide study from Taiwan.J Thorac Cardiovasc Surg. 2019; 157: 960-969Abstract Full Text Full Text PDF Scopus (7) Google Scholar suffers from some shortcomings. First, we did not receive data about how experienced the surgeons involved in this study were in performing off-pump CABG, other than the inclusion of a variable in the propensity matching of “hospital volume of CABG” and the statement that a majority of cases (65%) were performed in high-volume centers (>200 CABG cases/y overall). Importantly, the major criticism about the ROOBY trial was the perceived high conversion rate from off-pump to on-pump CABG (12.4%), which was more than 3.4 times as high as the reported rate in the Society of Thoracic Surgeons database. It appears that this initially presented value was an intention-to-treat crossover rate, however, and the ROOBY authors7Shroyer A.L. Hattler B. Grover F.L. Five-year outcomes after on-pump and off-pump coronary-artery bypass.N Engl J Med. 2017; 377: 1898-1899Crossref PubMed Scopus (76) Google Scholar recalculated it to 6.3%, which is lower than that reported in the CORONARY study (7.9%).8Stevens L.M. Noiseux N. Avezum A. Aypati D.R. Chen X. Lucchese F.A. et al.CORONARY InvestigatorsConversion after off-pump coronary artery bypass grafting: the CORONARY trial experience.Eur J Cardiothorac Surg. 2017; 51: 539-546PubMed Google Scholar The high conversion rates implied another argument, that the surgeons participating in the ROOBY trial were relatively inexperienced in off-pump surgery, and that this inexperience resulted in the inferior off-pump outcomes observed. The GOPCABE trial, on the other hand, showed no differences in major adverse cardiac and cerebrovascular events between on-pump and off-pump CABG at 1 year, nor did the CORONARY trial show any differences at 1- and 5-year follow-up.9Lamy A.L. Deveraux P.J. Prabhakaran D. Taggart D.P. Hu S. Straka Z. et al.CORONARY InvestigatorsFive -year outcomes after off-pump or on-pump coronary-artery bypass grafting.N Engl J Med. 2016; 375: 2359-2368Crossref PubMed Scopus (259) Google Scholar These outcomes only partially support the study findings of Huang and colleagues.2Huang K.C. Wu I.H. Chou N.K. Yang Y.Y. Lin L.C. Yu H.Y. et al.Late outcomes of off-pump versus on- pump coronary bypass in diabetic patients: a nationwide study from Taiwan.J Thorac Cardiovasc Surg. 2019; 157: 960-969Abstract Full Text Full Text PDF Scopus (7) Google Scholar Perhaps more importantly, in the study of Huang and colleagues2Huang K.C. Wu I.H. Chou N.K. Yang Y.Y. Lin L.C. Yu H.Y. et al.Late outcomes of off-pump versus on- pump coronary bypass in diabetic patients: a nationwide study from Taiwan.J Thorac Cardiovasc Surg. 2019; 157: 960-969Abstract Full Text Full Text PDF Scopus (7) Google Scholar we were not presented with any details about the surgical technique and conduits used. The use of skeletonized bilateral internal thoracic artery (BITA) is crucial in patients with diabetes. Raza and colleagues10Raza S. Sabik III, J.F. Masabni K. Ainkaran P. Lytle B.W. Blackstone E.H. Surgical revascularization techniques that minimize surgical risk and maximize late survival after coronary artery bypass grafting in patients with diabetes mellitus.J Thorac Cardiovasc Surg. 2014; 148: 1257-1266Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar reported outcomes of 11,922 patients with diabetes undergoing CABG and showed that the largest impact observed was that of the use of BITA, which increased the 20-year survival by 21%, followed by completeness of revascularization (10%). Again, there was no marked difference found in 10-year survival between the off-pump and on-pump groups.10Raza S. Sabik III, J.F. Masabni K. Ainkaran P. Lytle B.W. Blackstone E.H. Surgical revascularization techniques that minimize surgical risk and maximize late survival after coronary artery bypass grafting in patients with diabetes mellitus.J Thorac Cardiovasc Surg. 2014; 148: 1257-1266Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar In addition, the perception that graft patency is inferior in patients with diabetes has been recently questioned by an analysis showing that the 20-year patency rate of BITA was greater than 90%, that vein graft patency was declining to approximately 40%, and that those rates were similar for patients both with and without diabetes.11Raza S. Blackstone E.H. Houghtaling P.L. Rajeswaran J. Riaz H. Bakaeen F.G. et al.Influence of diabetes on long-term coronary artery bypass graft patency.J Am Coll Cardiol. 2017; 70: 515-524Crossref PubMed Scopus (39) Google Scholar These findings amplify the argument in favor of increasing the use of skeletonized BITA in CABG overall, and specifically in patients with diabetes. With the notion that the rates of both off-pump CABG (>60%) and arterial grafting in Asian countries are much higher than those in Western countries,12Park S.J. Ahn J.M. Kim Y.H. Park D.W. Yun S.C. Lee J.Y. et al.BEST Trial InvestigatorsTrial of everolimus-eluting stents or bypass surgery for coronary disease.N Engl J Med. 2015; 372: 1204-1212Crossref PubMed Scopus (344) Google Scholar the missing data regarding BITA use per group in the study of Huang and colleagues2Huang K.C. Wu I.H. Chou N.K. Yang Y.Y. Lin L.C. Yu H.Y. et al.Late outcomes of off-pump versus on- pump coronary bypass in diabetic patients: a nationwide study from Taiwan.J Thorac Cardiovasc Surg. 2019; 157: 960-969Abstract Full Text Full Text PDF Scopus (7) Google Scholar are even more important. There should be a consensus that the goal of every CABG operation is the appropriate selection and harvest of conduits13Locker C. To skeletonize the internal thoracic artery or not to skeletonize? To be or not to be!.J Thorac Cardiovasc Surg. 2018; 155: 229-231Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar and the completeness of revascularization, rather than the avoidance of cardiopulmonary bypass. These goals apply even more in patients with diabetes. The only exception would be in the case of a porcelain aorta, in which case the avoidance of cardiopulmonary bypass and aortic manipulation would be prudent.14Zhao D.F. Edelman J.J. Seco M. Bannon P.G. Wilson M.K. Byrom M.J. et al.Coronary artery bypass grafting with and without manipulation of the ascending aorta. a network meta-analysis.J Am Coll Cardiol. 2017; 69: 924-936Crossref PubMed Scopus (143) Google Scholar Future investigations are warranted to define better who could benefit from off-pump surgery. It seems that a change in the manner of tailoring and analyzing trials is also necessary.15Noiseux N. Stevens L.M. Chartrand-Lefebvre C. Soulez G. Prieto I. Basile F. et al.CORONARY InvestigatorsOff-pump versus on-pump coronary artery bypass surgery: graft patency assessment with coronary computed tomographic angiography. A prospective multicenter randomized controlled pilot study.J Thorac Imaging. 2017; 32: 370-377Google Scholar Late outcomes of off-pump versus on-pump coronary bypass in patients with diabetes: A nationwide study from TaiwanThe Journal of Thoracic and Cardiovascular SurgeryVol. 157Issue 3PreviewAlthough the benefits and risks of on- and off-pump coronary artery bypass have been compared in several clinical trials, large-scale studies regarding long-term outcomes in patients with diabetes are lacking. We compared long-term outcomes after on- and off-pump coronary artery bypass in patients with diabetes. Full-Text PDF Open Archive" @default.
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• W2889898372 title "Off-pump or on-pump coronary artery bypass grafting in diabetes: Is this the important question?" @default.
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