Human papillomavirus vaccine for cancer prevention.

n engl j med 361;19 nejm.org november 5, 2009 1899 served procedural mortality rates for both offpump and on-pump CABG were excellent and well below those predicted according to standard risk models. Third, neurocognitive testing was performed in only half the survivors and, in contrast with the results of a previous study,7 did not show any longitudinal deficits in either surgical group. Finally, some will argue that newer off-pump techniques and improved medications for secondary prevention make the findings of the trial less applicable for contemporary care. However, several trials comparing off-pump with on-pump CABG are currently under way that can broaden our understanding.8,9 In summary, the ROOBY trial did not support off-pump procedures as an advance that should generally supplant traditional techniques. As such, it will probably remain a technique reserved for selected patients and skilled surgeon advocates. However, the trial should truly be seen as a very positive one. It clearly showed the feasibility and willingness of surgeons to subject new surgical innovations to large-scale rigorous evaluation. Investigators in future trials involving CABG will need to consider other proposed innovations, including the evolving use of endovascular vein-graft harvesting methods, hybrid PCI–CABG techniques, and even robotic procedures. Although the results of such studies will not always show that the new approach is an advance, much can be learned from this type of systematic study. Through this process of innovation and evaluation, cardiac surgery will continue to evolve and lead to improved outcomes for its recipients. Dr. Peterson reports being principal investigator for the Society of Thoracic Surgeons National Adult Cardiac Surgery Database Warehouse, Duke Clinical Research Institute, Durham, NC. No other potential conflict of interest relevant to this editorial was reported.