HomeCirculationVol. 122, No. 17Letter by Miceli et al Regarding Article, “No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery: The Best Bypass Surgery Trial” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Miceli et al Regarding Article, “No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery: The Best Bypass Surgery Trial” Antonio Miceli, MD, Mattia Glauber, MD and Gianni D. Angelini, MD, MCh, FRCS Antonio MiceliAntonio Miceli Search for more papers by this author , Mattia GlauberMattia Glauber Search for more papers by this author and Gianni D. AngeliniGianni D. Angelini Search for more papers by this author Originally published26 Oct 2010https://doi.org/10.1161/CIRCULATIONAHA.110.944520Circulation. 2010;122:e497To the Editor:The results of the Best Bypass Surgery Trial (BBS), performed on 341 high-risk patients (European system for cardiac operative risk evaluation [EuroSCORE] >5) undergoing coronary artery bypass grafting with (on-pump coronary artery bypass graft surgery) or without (off-pump coronary artery bypass graft surgery) cardiopulmonary bypass, report no significant differences in the composite of adverse cardiac and cerebrovascular events or in any of the following outcomes: All-cause mortality, acute myocardial infarction, cardiac arrest, low cardiac output/cardiogenic shock, stroke, and coronary reintervention.1 However, in our opinion, the definition of high-risk patient should be interpreted carefully. Although the EuroSCORE identifies patients with a score >6 as high risk,2 the score is based on 18 independent variables, many of which were not considered in the study. Risk factors such as previous cardiac surgery, critical preoperative state, emergency operation, and poor left ventricular dysfunction were excluded. Furthermore, active endocarditis, pulmonary hypertension, other than isolated coronary artery bypass surgery, surgery on the thoracic aorta, and postinfarction septal rupture were not considered in the study because of the nature of the study. Chronic pulmonary disease and neurological dysfunction were not defined according to EuroSCORE, and there is no information on patients with unstable angina. Finally, it has been shown that the ability of the EuroSCORE to predict mortality is reduced in high-risk patients.3 Indeed, Puskas et al,4 using the Society of Thoracic Surgeons' predicted risk of mortality on 14 776 patients undergoing coronary surgery, showed that off-pump coronary artery bypass graft surgery disproportionately benefited high-risk patients.Antonio Miceli, MDMattia Glauber, MD Fondazione G. Monasterio CNR-Regione Toscana Massa, ItalyGianni D. Angelini, MD, MCh, FRCS Bristol Heart Institute University of Bristol Bristol, United KingdomDisclosuresNone.