Versus On-Pump Coronary Artery Bypass Research Articles

10-Year Mortality of Off-Pump Versus On-Pump Coronary Artery Bypass Grafting: An Updated Systematic Review, Meta-Analysis, and Meta-Regression

The longstanding debate on off-pump coronary artery bypass grafting (OPCAB) versus on-pump coronary artery bypass grafting (ONCAB) has primarily focused on short-term and mid-term outcomes, with limited attention to long-term survival. This study aims to address this gap by providing an updated analysis of 10-year mortality rates after OPCAB versus ONCAB. We have conducted a systematic review and meta-analysis, incorporating 22 studies comprising 69,449 patients. The primary end point was all-cause mortality at 10 years. Meta-regression analysis explored sources of heterogeneity. The meta-analysis revealed no significant difference in long-term all-cause mortality between OPCAB and ONCAB (hazard ratio 1.000, 95% confidence interval 0.92 to 1.08, p = 0.95). Although substantial heterogeneity existed across studies, meta-regression identified older age as a significant factor favoring OPCAB. However, patient characteristics like gender, co-morbidities, and graft numbers did not significantly influence the choice of surgical technique. In conclusion, this study challenges historical concerns regarding OPCAB's quality of revascularization and long-term survival demonstrating comparable outcomes to ONCAB in well-selected patients when performed by experienced surgeons. The results emphasize the importance of surgeon proficiency and advocate for recognizing surgical revascularization as a subspecialty.

Off-Pump Versus On-Pump Coronary Artery Bypass Grafting In Patients With Left Main Coronary Artery Disease: A Randomized Controlled Trial.

To compare the outcome of off-pump and on-pump coronary artery bypass graftsurgery in patients with left main coronary artery disease. The randomised, controlled, prospective, multicentric study was conducted in 2020 during the period from January 2020 to December 2020 at Kafrelsheikh University Hospital, International Cardiac Centre and Alexandria New Medical Centre, Egypt, and comprised patients with left main coronary artery disease who underwent coronary artery bypass graftsurgery. The patients were randomised to on-pump surgery group I (Control Group) and off-pump surgery group II(Interventional Group). All patients were assessed pre-operatively for the presence of comorbid conditions and post-operatively for myocardial infarction, acute kidney injury, pneumonia, sternal dehiscence and 3-month mortality. Data was analysed using SPSS 20. Of the 60 patients, 44(73.3%) were men and 16(26.6%) were women. The overall mean age was 66.4±9.2 years. There were 30(50%) patients in each of the two groups. There were 2(6.7%) cases of myocardial infarction in group I and 1(3.3%) in group II. There was 1(3.3%) case of acute kidney injury in group I and none in group II. There were 3(10%) cases of pneumonia in group 1 compared to 1(3.3%) in group II. There was 1(3.3%) case of sternal dehiscence in group I and none in group II. Mortality at 3 months was 2(6.7%) in group I and 1(3.3%) in group II. There was no significant difference with respect to outcome between the groups (p>0.05). Off-pump coronary artery bypass graft surgery was found to be efficient and non-inferior to on-pump procedure in patients with left main coronary artery disease. The RCT was registered retrospectively at the Pan African Clinical Trials Registry (PACTR) (Trial #: PACTR202301506140749 Date of Approval: 06/01/2023). Link: https://pactr.samrc.ac.za/Search.aspx.

The Effect of Female Sex on Short-Term Outcomes of Patients Undergoing Off-Pump Versus On-Pump Coronary Artery Bypass Grafting.

According to the American Heart Association guideline for coronary artery bypass grafting (CABG), female patients undergoing on-pump CABG (ONCAB) are at higher risk of short-term adverse outcomes than male patients. However, whether off-pump CABG (OPCAB) can improve the short-term outcome of female patients compared to ONCAB remains unclear. We conducted a meta-analysis to study the effect of the female sex on short-term outcomes of OPCAB vs. ONCAB. A total of 31,115 patients were enrolled in 12 studies, including 20,245 females who underwent ONCAB and 10,910 females who underwent OPCAB. The in-hospital mortality in female patients who underwent OPCAB was significantly lower than in those in the ONCAB group with (2.7% vs. 3.4%; odds ratio [OR] 0.76; 95% confidence interval [CI] 0.65-0.89) and without (OR 0.68; 95% CI 0.52-0.89) adjustment for cardiovascular risk factor. The incidence of postoperative stroke in female patients who underwent OPCAB was lower than in those in the ONCAB group (1.2% vs. 2.1%; OR 0.59; 95% CI 0.48-0.73) before cardiovascular risk factor adjustment but was not significant (OR 0.87; 95% CI 0,66-1.16) after adjustment. There was no significant difference in the incidence of postoperative myocardial infarction between women who underwent OPCAB and those in the ONCAB group (1.3% vs. 2.3%; OR 0.88; 95% CI 0.54-1.43). In contrast to the American Heart Association CABG guideline, female patients who had OPCAB don't have unfavorable outcomes compared with the ONCAB group.

Off-Pump Versus On-Pump Coronary Artery Bypass Graft Surgery, prospective cohort study

Introduction: Coronary artery bypass grafting is a surgical operation that bypasses atherosclerotic coronary vessels and restores blood flow to the ischemic zone of hearts. And two different conventional methods are ON-pump CABG, and Off-pump CABG. Altogether, the efficacy and safety of these two types of surgical procedures are still under debate. In this study, we aim to compare the efficacy, safety, and cost-effectiveness of these two different methods in admitted patients to Imam Reza Hospital in Mashhad in Iran during 2006 to 2016. Materials and Method: In this prospective cohort study, 533 patients who underwent CABG in Imam Reza hospital in Mashhad during 2006 to 2016 were identified. The data was collected using hospital records including demographic data, chief complaint, history of previous disease, ejection fraction, number of graft, blood transfusion, time of anesthesia, time of surgery, days of hospitalization, days of ICU stay, needs for reoperation, post-operative complication, expenses of hospitalization. Results: Of 533 patients were 347 patients of whom male. The mean age was 59.53±10.21 and the mean BMI was 26.38±5.4. The most common chief complaint of the patients was chest pain. 38 patients of 533 cases underwent on-pump surgery and 495 underwent off-pump technique. There were no significant differences for age, and gender. The prevalence of HTN, diabetes, MI, and hyperlipidemia had no differences among two groups. Renal failure was more common in on-pump group; whereas, pulmonary disease was more common in off-pump group. On-pump surgery required significantly longer hospitalization and ICU care. Also needs for reoperation was more common among on-pump surgery. Total expenses were significantly higher in on-pump group.10.5% of those who underwent on-pump surgery died after surgery. This rate was only 3.1% among off-pump group. Conclusion: In this study we showed that, the patients who underwent on-pump surgery, required longer hospitalization, and ICU care. Total expenses were significantly higher in on-pump group. In addition, the mortality rate of on-pump group was significantly higher than the off-pump group. Also needs for reoperation was more common among on-pump surgery. Altogether, it seems that off-pump surgery is safer with low expenses than on-pump CABG.

Mortality Following Off-Pump Versus On-Pump Coronary Artery Bypass Grafting at Five-Year Follow-Up: A Meta-Analysis

Mortality Following Off-Pump Versus On-Pump Coronary Artery Bypass Grafting at Five-Year Follow-Up: A Meta-Analysis

Long-Term Outcomes After Off-Pump Versus On-Pump Coronary Artery Bypass Grafting by Experienced Surgeons

BackgroundLong-term benefits of off-pump versus on-pump coronary artery bypass grafting (CABG) are controversial. ObjectivesThe authors sought to compare long-term survival and morbidity after on-pump versus off-pump CABG. MethodsMandatory clinical and administrative registries from New Jersey Department of Health were linked to identify patients who underwent CABG between 2005 and 2011, by surgeons who had performed at least 100 off-pump or on-pump CABG operations. Survival, stroke, myocardial infarction, repeat revascularization, and new dialysis requirement were compared using Cox modeling, propensity scores, and instrumental variable analysis. Median follow-up was 6.8 years (range: 0 to 11.0 years); last follow-up date was December 31, 2015. ResultsAmong 42,570 CABG patients, 6,950 who underwent off-pump CABG and 15,295 who underwent on-pump CABG met study criteria. Off-pump CABG was associated with higher mortality (33.4% vs. 29.6% at 10 years; hazard ratio [HR]: 1.11; 95% confidence interval [CI]: 1.04 to 1.18; p = 0.002) compared with on-pump CABG. Off-pump CABG was associated with a higher risk of incomplete revascularization (15.7% vs. 8.8%; p < 0.001), which was a predictor of late mortality (HR: 1.10; 95% CI: 1.03 to 1.17; p = 0.006); and higher rates of repeat revascularization (15.4% vs. 14.0% at 10 years; HR: 1.17; 95% CI: 1.01 to 1.37; p = 0.048). There were no significant differences in the rate of stroke, myocardial infarction, or new dialysis. ConclusionsIn this mandatory clinical registry, off-pump was associated with increased incomplete revascularization, repeat revascularization, and mortality at 10 years compared with on-pump CABG, suggesting that on-pump CABG may be the appropriate choice for most patients undergoing surgical revascularization.

Comparison of Outcomes for Off-Pump Versus On-Pump Coronary Artery Bypass Grafting in Low-Volume and High-Volume Centers and by Low-Volume and High-Volume Surgeons

In terms of in-hospital outcomes, controversy still remains whether off-pump coronary artery bypass grafting is superior to on-pump coronary artery bypass surgery. We investigated whether the volume of off-pump coronary artery bypass procedures by hospital and individual surgeon influences patient outcomes when compared with on-pump coronary artery bypass surgery. Discharge records from the Nationwide Inpatient Sample were retrospectively reviewed for in-hospital admissions from 2003 to 2011, including 999 hospitals in 44 states. A total of 2,094,094 patients undergoing on- and off-pump coronary artery bypass surgery were included. In patients requiring 2 or more grafts, off-pump coronary artery bypass compared with on-pump coronary artery bypass was associated with increased risk-adjusted mortality when performed in low-volume centers (<29 cases per year) (odds ratio [OR] 1.32, 95% confidence interval [CI] 1.06 to 1.57) or by low-volume surgeons (<19 cases per year) (OR 1.26, 95% CI 1.02 to 1.56). In high-volume off-pump coronary artery bypass centers (≥164 cases per year) and surgeons (≥48 cases per year), off-pump coronary artery bypass reduced mortality compared with on-pump coronary artery bypass in cases requiring a single graft (OR 0.66, 95% CI 0.49 to 0.89 and OR 0.33, 95% CI 0.22 to 0.47, respectively) or 2 or more grafts (OR 0.82, 95% CI 0.66 to 0.99 and OR 0.63, 95% CI 0.49 to 0.81, respectively). In conclusion, the outcome of off-pump coronary artery bypass grafting procedures is dependent on volume at both the institution and the individual surgeon level. Off-pump coronary artery bypass should not be performed at low-volume centers and by low-volume surgeons.

TCT-73 Off-pump Versus On-pump Coronary Artery Bypass Surgery for Left Main Revascularization: Insights From the EXCEL trial

Whether off-pump CABG in patients with left main stem (LMS) disease is as safe and effective as on-pump surgery remains to be determined. The EXCEL trial compared PCI with everolimus-eluting stents vs CABG in 1905 patients undergoing left main revascularization. A total of 271 (29%) patients

PCV75 - Clinical Outcomes and Quality of Life After Off-Pump Versus On-Pump Coronary Artery Bypass Grafting in Armenia

PCV75 - Clinical Outcomes and Quality of Life After Off-Pump Versus On-Pump Coronary Artery Bypass Grafting in Armenia

Off-Pump Versus On-Pump Coronary-Artery Bypass Grafting in Elderly Patients

Off-Pump Versus On-Pump Coronary-Artery Bypass Grafting in Elderly Patients

Invited Commentary

The 1-year outcomes of the CORONARY trial were published this past year and demonstrated no significant difference between on-pump and off-pump coronary artery bypass grafting (CABG) with regard to the primary composite endpoint or rate of repeat coronary revascularization. Combined with the recent outcomes of the GOPCABGE study [German Off-Pump Coronary Artery Bypass Grafting in Elderly Patients] demonstrating no difference in on-pump or off-pump CABG in elderly patients, much of the large, contemporary literature on off-pump CABG indicates that, unlike the results of the ROOBY [Randomized On/Off Bypass] trial, off-pump is at least noninferior to on-pump CABG [1Diegeler A. Börgermann J. Kappert U. et al.Off-pump versus on-pump coronary-artery bypass grafting in elderly patients.N Engl J Med. 2013; 368: 1189-1198Crossref PubMed Scopus (343) Google Scholar, 2Shroyer A.L. Grover F.L. Hattler B. et al.On-pump versus off-pump coronary-artery bypass surgery.N Engl J Med. 2009; 361: 1827-1837Crossref PubMed Scopus (874) Google Scholar]. In this growing era of comparative effectiveness research, however, we see a trend toward assessing new technologies not only with regard to their clinical effectiveness but also cost effectiveness [3Iribarne A. Russo M.J. Moskowitz A.J. Ascheim D.D. Brown L.D. Gelijns A.C. Assessing technological change in cardiothoracic surgery.Semin Thorac Cardiovasc Surg. 2009; 21: 28-34Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar]. Thus, while on-pump and off-pump techniques appear to have similar clinical outcomes, could one technique prove more effective through lower overall costs? Lamy and colleagues [4Lamy A. Tong W. Devereaux P.J. et al.The cost implications of off-pump versus on-pump coronary artery bypass graft surgery at one year.Ann Thorac Surg. 2014; 98: 1620-1626Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar] begin to address this question in their current analysis and demonstrate that after 1 year there was no significant difference in total cost per patient between on-pump and off-pump groups. However, this analysis does have some notable limitations. The CORONARY trial recruited 4,752 patients from 79 centers and 19 countries. Variability exists among countries in event costs used to calculate health care utilization costs, and furthermore the conversion of such event costs to standardized US dollars using purchasing power parties relies on several significant economic assumptions. More importantly, the authors do not include the cost for surgical supplies in their analysis. The high costs associated with disposables such as retractors and stabilizers have the potential to significantly alter the conclusions of the study, as demonstrated by the authors' sensitivity analysis. While Lamy and colleagues [4Lamy A. Tong W. Devereaux P.J. et al.The cost implications of off-pump versus on-pump coronary artery bypass graft surgery at one year.Ann Thorac Surg. 2014; 98: 1620-1626Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar] offer an important starting point for assessing the cost effectiveness of on-pump versus off-pump CABG, further research is necessary before drawing final conclusions. An ideal cost effectiveness analysis would be performed in 1 or more hospitals in the same country to limit economic assumptions, be high volume in both on-pump and off-pump techniques to eliminate operator bias, and account for differences in direct costs of surgical supplies such as disposables. The Cost Implications of Off-Pump Versus On-Pump Coronary Artery Bypass Graft Surgery at One YearThe Annals of Thoracic SurgeryVol. 98Issue 5PreviewThe purpose of this study was to determine the cost implications of the Coronary Artery Bypass Graft Off or On Pump Revascularization Study (CORONARY) at 1 year. Full-Text PDF

The Cost Implications of Off-Pump Versus On-Pump Coronary Artery Bypass Graft Surgery at One Year

The purpose of this study was to determine the cost implications of the Coronary Artery Bypass Graft Off or On Pump Revascularization Study (CORONARY) at 1 year. Country-specific healthcare costs were obtained from public databases or local experts from each country in the CORONARY trial. Purchasing power parities were applied to these costs of consumed healthcare resources. Analyses of subgroups included in the CORONARY clinical trial were also conducted. Costs are reported in US dollars. After 1 year, the total cost per patient in the off-pump coronary artery bypass graft surgery (CABG) arm was $9,650 ($9,216 to $10,285) compared with $9,583 ($9,239 to $9,988) for the on-pump CABG arm; that resulted in a nonsignificant increase of $68 (-$575 to $710). Similar findings were noted for various subgroups. There were also no differences due to late conversions. The CORONARY trial demonstrated that off-pump CABG was clinically as safe and effective as on-pump CABG with no difference in costs. Thus, the decision as to which method to choose is free from costs considerations and should be based on patient preference and surgeon expertise (Coronary Artery Bypass Graft [CABG] Off or On Pump Revascularization Study [CORONARY]; clinicaltrials.gov NCT00463294).

Comparison of Frequency of Postoperative Stroke in Off-Pump Coronary Artery Bypass Grafting Versus On-Pump Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention

The stroke rate after coronary artery bypass grafting (CABG) compared to percutaneous coronary intervention (PCI) is generally considered high because cardiopulmonary bypass and aortic manipulations are often associated with cerebrovascular complications. However, an increasing number of CABGs performed without cardiopulmonary bypass (OPCAB) may improve those outcomes. Of 6,323 patients with multivessel and/or left main coronary artery disease, 3,877 patients underwent PCI, 1,381 conventional on-pump CABG, and 1,065 OPCAB. Median follow-up was 3.4 years. Stroke types were classified as early (onset of stroke within 24 hours after revascularization), delayed (within 30 days), and late (after 30 days). Propensity score analysis showed that the incidences of early, delayed, and late stroke did not differ between PCI and OPCAB (0.65, 95% confidence interval 0.08 to 5.45, p = 1.00; 0.36, 0.10 to 1.29, p = 0.23; 0.81, 0.52 to 1.27, p = 0.72, respectively). In contrast, incidence of early stroke after on-pump CABG was higher than after OPCAB (7.22, 1.67 to 31.3, p = 0.01), but incidences of delayed and late stroke were not different (1.66, 0.70 to 3.91, p = 0.50; 1.18, 0.83 to 1.69, p = 0.73). In conclusion, occurrence of stroke was not found to differ in patients after PCI versus OPCAB regardless of onset of stroke. Occurrence of early stroke after OPCAB was lower than that after on-pump CABG, yet occurrences of delayed and late strokes were similar for the 3 revascularization strategies.

Impact of Preoperative Renal Dysfunction in Patients Undergoing Off-Pump Versus On-Pump Coronary Artery Bypass

The impact of the degree of renal dysfunction (RD) in patients undergoing coronary artery bypass grafting (CABG) ranging from normal to dialysis-dependence is not well defined. A retrospective review of 14,199 patients undergoing isolated, primary CABG from January 1996 to May 2009 at Emory Healthcare was performed. The estimated glomerular filtration rate (eGFR) was estimated by the Modification of Diet in Renal Disease formula: mild RD (eGFR 60 to 90 mL/min/1.73 m2), moderate RD (eGFR 30 to 59), severe RD (eGFR<30). A propensity scoring was used to balance the groups with 46 preoperative covariates. Multivariable logistic and Cox regression methods were used to determine the independent association of eGFR with mortality. Adjusted odds ratios were calculated for outcomes using the normal eGFR group as the reference. Kaplan-Meier curves were created to estimate long-term survival. A total of 8,086 patients (57.0%) underwent off-pump coronary artery bypass (OPCAB) while 6,113 (43.0%) underwent on-pump CAB. Preoperative RD was common: Normal eGFR (n=3,503/14,199 [24.7%]); mild RD (7,236/14199 [51.0%]); moderate RD (2,860/14,199 [20.1%]); severe RD (283/14,199 [2.0%]); and preoperative dialysis (317/14,199 [2.2%]). Moderate to severe RD or preoperative dialysis was associated with worse adjusted in-hospital mortality: mild RD (odds ratio [OR] 1.42; 95% confidence interval [CI] 0.93 to 2.16; p=not significant); moderate RD (OR 3.55; 95% CI 2.32 to 5.43; p<0.05]; severe RD (OR 8.84; 95% CI 4.92 to 15.9; p<0.05); and dialysis-dependent (OR 9.64; 95% CI 5.45 to 17.0; p<0.05). Adjusted long-term survival was worse across levels of RD. The OPCAB patients with moderate to severe RD had worse long-term survival than on-pump CAB patients; however, the surgery types were similar among normal, mild, and dialysis patients. Preoperative RD is common in the CABG population and is associated with diminished long-term survival. Improved early outcomes in patients with RD undergoing OPCAB diminished with worsening RD.

Midterm Angiographic Follow-up for Off-Pump Versus On-Pump Coronary Artery Bypass Grafting in a Randomised Controlled Study

Midterm Angiographic Follow-up for Off-Pump Versus On-Pump Coronary Artery Bypass Grafting in a Randomised Controlled Study

Postoperative Functional Outcome After Off-Pump Versus On-Pump Coronary Artery Bypass Grafting Using Gated Myocardial SPECT: A Comparison by Propensity Score Analysis.

We evaluated the short-term and mid-term differences in perfusion and function after off-pump and on-pump coronary artery bypass grafting (CABG) using gated myocardial single photon emission computed tomography. A total of 70 patients with coronary artery disease who underwent CABG were included based on the propensity score matching results from 165 patients. Thirty-five patients underwent off-pump and 35 patients on-pump CABG. Rest (201)Tl/dipyridamole stress (99m)Tc-methoxyisobutylisonitrile gated single photon emission computed tomographies were performed preoperatively and postoperatively at short-term (103 ± 23days after surgery) and mid-term follow-up (502 ± 111days after surgery). Changes in left ventricular ejection fraction, end systolic volume, stress and rest segmental perfusion, and segmental wall thickening were compared between the two groups. The segments with preoperative rest (201)Tl uptake under 60% of maximum uptake were included in the segmental analysis. Left ventricular ejection fraction (P = 0.001) and end systolic volume (P = 0.008) showed significant improvement in both groups. There were no significant short-term and mid-term differences between the two groups in terms of left ventricular ejection fraction (P = 0.309) and end systolic volume (P = 0.938). Likewise, segmental rest (P = 0.178) and stress perfusion (P = 0.071), and systolic wall thickening (P = 0.241) showed significant improvement in both groups with similar time courses. Off-pump CABG resulted in significant improvements in left ventricular ejection fraction, end systolic volume, and regional myocardial perfusion and function that are comparable to on-pump CABG at short-term and mid-term. Gated myocardial SPECT successfully revealed that off-pump CABG is as good as on-pump CABG from the viewpoint of myocardial perfusion and function.

50 Cognitive Outcomes in High-Risk Patients 3 Months and 1 Year After Off-Pump Versus On-Pump Coronary Artery Bypass Grafting (CABG)

50 Cognitive Outcomes in High-Risk Patients 3 Months and 1 Year After Off-Pump Versus On-Pump Coronary Artery Bypass Grafting (CABG)

Cognitive and Cardiac Outcomes 5 Years After Off-Pump Versus On-Pump Coronary Artery Bypass Graft Surgery

Cognitive and Cardiac Outcomes 5 Years After Off-Pump Versus On-Pump Coronary Artery Bypass Graft Surgery

Effects of Off-Pump Versus On-Pump Coronary Artery Bypass Grafting on Early and Late Right Ventricular Function

Off-pump CABG (OPCABG) results in better preservation of left ventricular function in the perioperative period than conventional on-pump CABG (ONCABG); however, evidence is conflicting as to the effect of OPCABG and ONCABG on right ventricular (RV) function, possibly because of the complexity involved in measuring this. In a single-center randomized pilot study, 60 patients with normal left ventricular function undergoing CABG were randomly assigned to OPCABG or ONCABG. Patients underwent cardiac magnetic resonance imagine for assessment of RV function preoperatively, early postoperatively, and at 6 months after surgery. Fifty-one patients completed the first 2 scans, and 47 completed all 3 scans. Preoperative characteristics and RV function did not differ significantly between the 2 groups (mean+/-SD): RV stroke volume index was 49+/-10 mL/m(2) for OPCABG and 49+/-16 mL/m(2) for ONCABG. After surgery, RV stroke volume index fell to 36+/-7 mL/m(2) in the OPCABG group and 39+/-11 mL/m(2) in the ONCABG group, but this did not differ significantly between the 2 groups (P=0.41). All markers of RV function recovered to preoperative levels by 6 months, with no long-term difference between the surgical techniques. RV function is impaired early after surgery but recovers by 6 months. The changes were similar in both the OPCABG and ONCABG groups.

Response to Letter Regarding Article, “Off-Pump Versus On-Pump Coronary Artery Bypass Graft Surgery: Differences in Short-Term Outcomes and in Long-Term Mortality and Need for Subsequent Revascularization”

To the Editor: We read with great interest the recent report by Hannan et al1 on the short-term benefits of off-pump coronary artery bypass graft surgery compared with the standard on-pump approach on in-hospital/30-day mortality and perioperative complication rates. The 3-year follow-up proved comparable outcomes, excluding a lower rate of freedom from revascularization for the off-pump surgery group. The topic is certainly extremely interesting, especially nowadays, when less invasive approaches, such as off-pump coronary surgery and percutaneous coronary interventions, are acquiring dominant roles in the treatment of ischemic heart disease.2 However, we believe that this …