Coronary artery bypass.

Coronary artery bypass grafting as a means of myocardial revascularisation is a remarkably successful operation. Over 25,000 procedures are carried out each year in the UK with an operative mortality of the order of 2% achieved despite an ageing surgical population. Over the last decade, a remarkable increase in the number of patients treated percutaneously by angioplasty and stenting has lead to a levelling off, or even a decline, in the number of patients treated surgically. In an attempt to reduce further the operative morbidity and mortality by excluding that attributable to the extracorporeal circulation, several surgical groups have pioneered performing the procedure without the heart-lung machine (off-pump or OPCAB). Although not a new concept there has been a dramatic increase in its use, lead by the development of sophisticated and disposable devices for stabilising the heart to enable the demanding anastomotic technique required to suture vessels of 1-2 mm often containing degenerative plaque. Concerns remain about the completeness of revascularisation and about the quality of the anastomoses obtained, particularly in the right and circumflex territories which are less accessible than the anterior descending artery. Although some reduction in morbidity has been demonstrated, this has not been as marked as had been hoped. Davies and Wallwork from Papworth argue persuasively and colourfully in favour of the conventional operation and point out the difficulties in designing an appropriate, prospective, randomised,controlled clinical trial because of the apparently small differences in outcome between the two techniques. Amrani and colleagues from Harefield, leading proponents of off-pump surgery using it in virtually 100% of patients undergoing revascularisation, extensively review the comparative literature to date.