A cirurgia de revascularização miocárdica com e sem circulação extracorpórea: o impacto do custo no sistema de saúde

Abstract

Currently, the increase in health care costs is undeniable, and that is a reason for concern to all third-part payers in the world. Since health care budgets in most countries are considerably limited, cost-benefit and cost-effectiveness analyses of several medical interventions are essential, not only for physicians, but also for public and private health care systems, inasmuch as they are equally relevant for both. Therefore, new procedures which provide quality, efficiency and clinical results similar or superior to those provided by ordinary therapies, with better cost-benefit and cost-effectiveness ratios, are needed and beneficial. Consonant with this reality, the study by Girardi et al. 1 , published in this issue, which analyzes comparatively the cost of on-pump and off-pump coronary bypass surgery, is extremely relevant and pertinent. Although this issue has already been analyzed by international studies, there were no specific data concerning the Brazilian reality; therefore, this study is particularly important to clarify the issue of comparative costs of on-pump and off-pump revascularization techniques in our country. Off-pump coronary artery bypass surgery (OPCAB) is gaining great acceptance and has become a widely used procedure in the treatment of coronary artery disease, as an effort to reduce the morbity attributed to and related to cardiopulmonary bypass (CPB) 2 . This trend has been guided by scientific evidences, randomized controlled studies, systematic reviews, meta-analyses and retrospective registries of large data bases, which have shown that off-pump surgery is associated with an incidence of perioperative complications lower than that of conventional myocardial revascularization surgery. Since the early 90s, there has been a gradual change in the demographic and risk profiles of patients referred for myocardial revascularization surgery, mostly related to old age and the presence of more serious comorbities which increase the incidence of complications that may lead to a greater operative mortality. It was demonstrated that offpump surgery reduces the systemic inflammatory response and the neurological alterations associated with the use of on-pump surgery which contribute to the incidence of perioperative complications. Up to now, 41 randomized controlled trials involving 3,996 patients were published, and four recent meta-analyses compared the results of on-pump versus off-pump coronary artery bypass surgery. The results of the meta-analyses demonstrated that offpump surgery, in comparison to traditional technique, was associated with a reduction in the incidence of cerebrovascular accidents (CVA), respiratory infections, atrial fibrilation, blood transfusions and the use of inotropic agents, as well as a reduction in the duration of mechanical ventilation and hospitalization, and lower direct costs. Two meta-analyses demonstrated a reduction in mortality at 30 days, in off-pump surgery technique, but also there were less grafts, and more late reinterventions were required 3-6 . The difference between offpump surgery and traditional technique in the number of grafts and late patency rates, which had been observed in previous studies, was not confirmed by subsequent studies, since no statistically significant difference was demonstrated 7