To the Editor
Off-pump coronary artery bypass graft (OPCABG) surgery has been frequently reported for good early outcomes, including cost-effectiveness, in comparison to the on-pump surgery and it’s not surprising that surgeons from the Asian continent are performing large volumes of OPCABG surgeries. Various busy centres from Korea and Japan are regularly publishing their outcomes and these reports are mostly retrospective analyses of patients undergoing OPCABG using single or multi-arterial conduits, minimally invasive direct coronary artery bypass graft (MIDCABG), or hybrid coronary interventions [1].
Often non-Asian colleagues ask why Indian surgeons do not publish their long-term outcomes of OPCABG, especially of total arterial revascularization techniques, which are more frequent in India compared to many Western countries [2]. On extensive online search, quality meta-analyses and literature can be found which are correctly endorsing OPCABG technique, but finding large individual high-impact surgical series from India is uncommon and infrequent [3]. Mishra et al. published a series with 14,000 cases of OPCABG in year 2005 and was amongst one of the largest series from India [4]. Although their series reported in-hospital outcomes by dividing patients into three groups based on the era of surgery, it did not provide mid- or long-term outcomes and lacked insight into the follow-up sequels, which is important in the context of Indian population, where coronary artery disease is distinctly extensive. A cardiac surgical survey reported that relatively younger patients undergo coronary artery bypass surgery in India (30% cases were below 59 years of age) and nearly half of them were diagnosed type II diabetic [2]. Furthermore, a significant number of patients have diffuse atherosclerotic disease, frequently requiring coronary endarterectomies, have small size conduits and distal targets, and have a higher proportion of severe left ventricular dysfunction. These are reasons enough to closely follow-up and publish conclusions on the international platform, which could be a well-received support for proponents of the OPCABG, like me.
Cardiothoracic surgery in India is in an exciting phase, where tireless efforts of senior colleagues are bringing us on the international stage, with countless exchanges of mutual learning and innovations touching our shores [3]. As a result, our fraternity is striding forward from being OPCABG pundits to other sub-specialities like MIDCABG, heart and lung transplant, minimally invasive valve surgeries, and video-assisted thoracic surgery (VATS).
This is the best season to come up with advantageous ideas of national registry, so that various surgical groups can be enrolled, and outcomes can be reported on the regular basis. Out of many, few successful examples of registries are Society of Thoracic Surgeons (STS), Australia and New Zealand Society of Cardiothoracic Surgery (ANZSCT), International Registry of Aortic Dissection (IRAD), German Registry of Cardiothoracic Surgery, and International Society of Heart and Lung Transplant (ISHLT) registry.
Registries have an intention of improving patient care, providing comparison of standards, monitoring current practice, monitoring device durability and intervention performance, as well as engaging in guideline development. Other aims include future research, innovation, efficiency, transparency, and patient decision-making. Running a successful registry often faces challenges like voluntary data submission can result in reporting bias with under-reported complications and insufficient financial resources for registry development and maintenance, resulting in poor data quality and completeness.
But on the other side, collating data in the surgical registries can help in setting large meta-analyses, facilitate national comparisons between centres, as well as individual audit and revalidation. Mandavia et al. have reported immense utility of National Adult Cardiac Surgery Registry, thus bringing down risk-adjusted in-hospital mortality in the UK by 50% since the start of the registry, despite more elderly and high-risk patients [5].
In conclusion, with inseparable involvement of information technology (IT) and internet in the healthcare, it is the “time” for combined efforts to create a non-profitable unified national cardiothoracic registry to collate invaluable data for the present and future generation of surgeons.
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References
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