Response to Letter by Tourmousoglou et al

Abstract

Response: In the response to our article entitled “Off-pump surgery is associated with reduced occurrence of stroke and other morbidity as compared with traditional coronary artery bypass grafting,” Dr Tourmousoglou and colleagues mention important issues concerning the applicability/generalizibility of the randomized clinical trials of less invasive surgery. I would add that learning curve/surgical skill and inability to mask patients and surgeons are 2 important methodological issues that can potentially limit the generalizibility of the results found in this evidence synthesis and surgical evidence in general. Surgeons cut and sew heart chambers and coronary vessels. It is not a surprise that surgical skill is a critical contributor to good outcomes. There is a long learning curve to achieve excellence in off-pump coronary bypass surgery (CABG), and it has a great impact on the outcomes of this procedure. It is therefore understandable that trials of this new way of operating are hotly debated. But there is a good solution to this problem when conducting clinical trials: consider embarking on a clinical trial of less invasive surgery only after mastering this procedure. …