So we have another large study that suggests that doing coronary artery bypass surgery on a beating heart may be bad for patients. This time it is a study conducted by the Korean heart surgeons. Do we believe it or do we doubt the conduct of this study? I have just been at a meeting at Oxford, where all off the faculty apart from me are predominantly surgeons who operate on the beating heart. They show excellent results with their techniques and I have no doubt that they are honest about it. So why does the accumulation of evidence suggest that it may not be safe. Why does this operation that works clearly in certain peoples practice fail to stand up to the theory of evidence base accumulation?
One possibility is that this is a procedure that only shows benefits when offered to patients at a high risk of complications. This is a widely held belief and supported by some studies that have specifically looked at this subgroup of our patients coming to coronary artery bypass surgery. If that is the case then is it safe for surgeons to do this procedure only in high risk patients? That would be counterintuitive as most surgeons are best at doing things they do regularly. So how do we make sure that many low risk patients are not short changed for the benefit of the few high risk patients that will reap the benefits? This will be an interesting concept to deal with.
The other possibility is that not all surgeons can do this procedure safely. There is no doubt that beating heart surgery is more technically, physically and mentally demanding on the surgeon. It may be that this aspect translates into patient harm when large numbers of surgeons are expected to do a procedure that not everybody is comfortable with.
The final possibility is that beating heart surgery is not as good a procedure as it is intuitively presumed and passionately believed to be, by its enthusiasts. I do not think this is true as the results produced by enthusiasts are excellent and this may be a testament to their skill and, also their judgement, in selecting the right patient for this procedure. Both judgement and skill are hard to correct for in a large trial.
The truth will reveal itself over time but in the meantime we need to all agree that beating heart surgery is an important addition to the armamentarium of cardiac surgery in making it possible for us to help a proportion of patients who would otherwise suffer dreaded outcomes following heart surgery. Once we agree with this point, we as surgeons need to decide that in each team of cardiac surgeons we should have one or two individuals who are able to offer this procedure safely. They should attend regular courses on how to do this better and safer, and work with industry partners in continuing to teach future surgeons this technique so that it is continued to be offered. We should then agree that in a low risk group of patients it does not matter that these patients get operated on pump, by surgeons, who are able to do the basic training of young surgeons.These surgeons may be older and closer to retirement but play a crucial role in developing the younger individuals coming into the speciality. We then identify a large group of low risk patients on whom we can offer a minimally invasive on pump coronary artery bypass operation. This will make it more appealing to patients who are unable to take the months off work while waiting for their sternums to heal. It will have an obvious cosmetic advantage. It will be easier to teach other surgeons, more reproducible and hopefully as safe. Once more, industry partners need to play a part in the safe dissemination of this approach.
I do hope the take home message from this recent trial, is not that surgeons should not be offering it to patients, rather beating heart surgery should be seen as the collaborative option it is, rather than a competitive option as it is viewed by many.
