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Over the last 20 years, off-pump coronary artery bypass surgery (OPCAB) has evolved as a standard technique for surgical myocardial revascularisation, and although it is used routinely in many centres around the world, there is still debate over its safety and efficacy. Proponents point to extensive research demonstrating superior outcomes in terms of death, stroke, myocardial infarction, intraoperative blood loss and need for transfusion, with benefits particularly magnified in high-risk groups of patients. In stark contrast, critics of OPCAB surgery claim that it has no benefit on clinical outcome and is accompanied by a tendency for incomplete revascularisation and inferior bypass graft patency rates. Consequently, while OPCAB is performed in up to 90% of patients in some Asian countries, in Europe, the rate varies between 10% and 30%. The performance among individual surgeons and centres is very heterogeneous, ranging from a zero to 95% penetration rate. While in some centres OPCAB is already the default approach for all patients requiring surgical coronary revascularisation, in some, it is reserved for ‘high-risk’ patients only. Apart from the obvious problem of defining high risk, which in the context of coronary surgery may refer to the haemodynamic status of the patient, the severity of coronary disease, the impairment of cardiac function, urgency and the presence of comorbidities, the various approaches to the use of OPCAB reveal a fundamental ‘application bias’.
This year, the National Institute for Health and Clinical Excellence (NICE) has issued an updated Interventional Procedure Guidance on Off-Pump Coronary Artery Bypass (IPG 377) that replaces the 2004 version (IPG 35). Specifically, the 2011 NICE review “was precipitated by recent evidence of higher graft occlusion rates in the longer term after off-pump CABG”. Based on a “thorough literature review including approximately 531 000 patients” and an expert hearing, NICE concluded that “current evidence on the …