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Sunday, November 8, 2009

Which Bypass Surgery is Best

The Final Word on Bypass Surgery?

Coronary artery bypass surgery, abbreviated CABG and pronounced like the vegetable, is necessary when someone's coronary arteries, those that supply the heart muscle itself with blood, become so extensively blocked that they must be replaced. The traditional way to do this is to crack open the patient's chest, harvest blood vessels from elsewhere in the body (yet another controversy we'll leave alone for today) and stitch them into place on the heart, thereby bypassing the blocked vessels.

Also traditional in this operation is stopping the person's heart. A dandy machine we'll call a heart lung bypass machine circulates the blood and provides oxygen to it while the heart is stopped. Once the new vessels are in place the heart is restarted, and voila! It now has enough blood to do its work. So what is the problem?

Lots of folks have complained that following this big operation, they had trouble thinking and remembering. The speculation was that stopping the heart was the cause, so a new operation was developed where the heart was left beating. A nimble surgeon stitched the new vessels into place on this moving target. But alas, problems existed with this operation as well, and now a big study in the New England Journal of Medicine has compared the two: On Pump Versus Off Pump Coronary Artery Bypass Surgery.

Over 2200 people were randomized, which means assigned to one group or the other essentially by a flip of a coin, to either on pump or off pump surgery. They were assessed at 30 days and again at a year, and the take home message is this: those who underwent the traditional surgery where their heart was stopped did better. There was no discernible difference between the two groups in thinking, or cognition, but those who had on pump surgery had a better blood supply to their heart and other superior outcomes.

Rick gives kudos to the VA Medical System for doing this study and adds the following caveats: choose a facility and a surgeon with experience. We reiterate this point again and again in the podcast but it bears repeating: experience matters greatly when it comes to better outcomes in the majority of interventions.

Other topics this week include the best way to quit smoking in the Archives of General Psychiatry, which doctors are overusing Pap smears in Annals of Internal Medicine, and the best mask for preventing transmission of the influenza virus in JAMA. Until next week, y'all live well.

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