Heart doctors say off-pump or on-pump, no difference in bypass surgery

As far as the American Heart Association (AHA) is concerned, the long running debate over whether patients undergoing coronary bypass surgery do better if their hearts keep beating or if a heart-lung machine takes over should end.

They say either method works fine, as long as the surgeon and the hospital have the required expertise.

In a report published this week a committee that reviewed more than 53 studies compared the two procedures.

The study's 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, says it has always been controversial which one is better.

Sellke says the off-pump procedure felt better to some because there was less confusion for the patient after surgery, while others liked the on-pump method because they could stop the heart and do the operation in a relaxed manner.

He says after looking at various studies to see if there is a major advantage of one or another they came to the conclusion that other factors including 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, far outweigh this one.

He says there are some very slight differences between the off-pump and the on-pump procedure.

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

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, says it is 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.

He adds that there are some benefits associated with the beating-heart method, which include quicker recovery, less need for blood transfusions and a shorter hospital stay.

But the most important factor remains the expertise of the surgeon and the comfort level of the surgeon with the technique.

People facing bypass surgery can gain information about the quality of the surgeon and the hospital, and in certain states, such as New York and Pennsylvania, surgeon-specific information is provided by the state health department on the Internet.

Both Sellke and Gardner agree that the value of that information is limited, as it is not always the lowest mortality associated with the operation that is essential, a surgeon with a higher mortality rate may be doing procedures on a larger number of high-risk patients.

Also the state health department statistics do not distinguish between procedures done off-pump and on-pump.

The report is published in this week's issue of the AHA's journal Circulation.