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J Thorac Cardiovasc Surg 1997;114:419-420
© 1997 Mosby, Inc.
SURGERY FOR ACQUIRED HEART DISEASE |
Received for publication June 19, 1997; accepted for publication July 9, 1997. Address for reprints: Michael J. Reardon, MD, Department of Surgery, Baylor College of Medicine, 6550 Fannin, No. 2435, Smith Tower, Houston, TX 77030.
Minimally invasive coronary artery bypass (CAB) surgery has catapulted into prominence in the past several years in the eyes of many cardiac surgeons, cardiologists, the lay press, and patients. Minimally invasive CAB is generally divided into two groups: (1) beating heart CAB, the most prominent form of which appears to be the minimally invasive direct coronary bypass (MIDCAB) and (2) port-access CAB done with femoral-femoral cardiopulmonary bypass (CPB) and cardioplegic arrest. Both approaches have been chronicled in the lay and medical literature, often reporting quite favorable early results. A huge industry is developing around these procedures, and out experience would suggest an increasing pressure from company representatives, patients, referring physicians, and hospital administrators to use these procedures as being "better" than conventional CAB surgery.
The December 1996 journal article, "Video-Assisted Minimally Invasive Coronary Operations Without Cardiopulmonary Bypass: A Multicenter Study," by Benetti and associates,
1 is remarkable both for its excellent results and for its call for careful patient selection and long-term follow-up. These results, however, appear to be in variance with some of our personal observations from MIDCAB teaching courses and local referrals of failed MIDCAB procedures. Attendance at MIDCAB conferences invariably involves a question to the "expert" panel concerning whether MIDCAB is as easy and accurate as conventional CAB with CPB, and the answer usually is, "yes, it is." The impression gained at most of these meetings is that the participants can go home and immediately initiate a MIDCAB program, and often that they should go home and initiate a MIDCAB program or they will "fall behind."
We have four concerns regarding these attitudes that we believe the thoracic surgery community should carefully consider: (1) the accuracy and patency of the anastomosis vis-à-vis conventional CAB, (2) issues of incomplete revascularization, (3) the ability to teach the procedure in a consistent fashion to the residents, and (4) long-term outcome.
The issue of consistency of anastomotic accuracy and patency is critical to the short- and the longterm success of CAB. The article by Benetti and associates suggests excellent graft patency. However, our experience includes referrals of a number of patients with early failure of the left internal thoracic artery graft for redo CAB or percutaneous transvenous coronary angioplasty after MIDCAB. Two of these patients have had extensive anterior wall myocardial infarctions, with one currently on the cardiac transplant list and another having already had a successful transplant after isolated MIDCAB procedures. Improved and improving methods of myocardial stabilization are indeed facilitating the accuracy of the anastomosis. Increased understanding of proper patient selection is also upgrading results. However, on the basis of our experience, the procedure does not seem to allow comparable accuracy and anastomotic patency for the community cardiac surgeon.
The rush to participate in the MIDCAB procedure, often to build a "market niche," appears to have led some of our colleagues to purposely or inadvertently ignore lesions other than those in the left anterior descending system and forget the well-learned lesson of the need for complete revascularization. In multivessel coronary artery occlusive disease, incomplete revascularization has been extensively shown to be a marker for increased cardiac events and death 2-7 We should therefore echo the call by Benetti's group for careful patient selection for this procedure.
As academic cardiac surgeons, we are involved with thoracic surgery residency education. Currently, single-vessel CAB is easily taught to our cardiac surgical residents with excellent and reproducible results. We find the MIDCAB procedure is still best done by our faculty and, although improving in ease of performance and reproducibility, this is not a procedure with which our residents can currently achieve consistently excellent results. To be a truly successful procedure, it must be easily mastered by our surgical residents.
Finally, we must remember that CAB is the most extensively studied surgical procedure in history, and its current success has been built on the reproducibility of good long-term results. The assumption is made that the long-term results of a successful MIDCAB will equal or exceed the long-term results of standard CAB. For a simple anastomosis between the left internal thoracic artery and the left anterior descending coronary artery, this ideally is true if the initial results are good. However, again in an attempt to overcome problems associated with this approach, some groups have used techniques such as extension of the internal thoracic artery with the inferior epigastric artery to increase the length of the graft. 8 The long-term results of this and other techniques remain to be seen.
The "port-facilitated" approach to CAB surgery returns the surgeon to the familiar ground of cardioplegic arrest and CPB support but also requires careful prospective study. Two hypotheses need to be tested. The first is the hypothesis that femoral-femoral bypass and port-facilitated surgery can be performed with equal risk of morbidity and mortality to that seen with surgery performed by a median sternotomy. In our view, comparisons of aggregated anecdotal data with historical selected outcomes is probably invalid, and patients should not be presented with the alternative of this approach to cardiac surgery with the stated or unstated assertion that it is equivalent to surgery via sternotomy in terms of risk or expected technical outcome. Randomized prospective study is required. The second hypothesis that needs to be tested is the hypothesis that the use of this approach will result in less pain, shorter length of stay, and decreased costs. Multiple port sites, limited thoracotomy, and a groin dissection with femoral-femoral bypass do, of course, carry substantial morbidity. Whether this morbidity is significantly less than that of a sternotomy will require careful prospective study. The acknowledge increase in operating room time, complex monitoring requirements, and incremental cost of the associated devices raise significant questions regarding differential cost, and shortened length of stay is unproven. Careful randomized prospective study is required.
Resistance to the pressure from company representatives, patients, referring physicians, and hospital administrators is difficult at this juncture, and the usual refrain that "this is exactly what happened with laparoscopic cholecystectomy" requires a reasoned response and a commitment to progress based on responsible and expeditious study of the plethora of techniques that purport to reduce the morbidity of thoracic surgery.
References
This article has been cited by other articles:
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  T. Morota, F. G. Duhaylongsod, W. R. Burfeind, and C.-T. Huang Intraoperative evaluation of coronary anastomosis by transit-time ultrasonic flow measurement Ann. Thorac. Surg., May 1, 2002; 73(5): 1446 - 1450. [Abstract] [Full Text] [PDF]
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S. A. Oliveira, L. A. F. Lisboa, L. A. O. Dallan, S. O. Rojas, and L. F. Poli de Figueiredo Minimally invasive single-vessel coronary artery bypass with the internal thoracic artery and early postoperative angiography: midterm results of a prospective study in 120 consecutive patients Ann. Thorac. Surg., February 1, 2002; 73(2): 505 - 510. [Abstract] [Full Text] [PDF]
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 M. A. Chaney, M. Morales, and M. Bakhos Severe Incisional Pain and Long Thoracic Nerve Injury After Port-Access Minimally Invasive Mitral Valve Surgery Anesth. Analg., August 1, 2000; 91(2): 288 - 290. [Abstract] [Full Text] [PDF]
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 R. L. Singer Rationale and Surgical Techniques for Emerging Procedures in Cardiac Surgery Seminars in Cardiothoracic and Vascular Anesthesia, July 1, 1999; 3(2): 57 - 64. [Abstract] [PDF]
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T. M. McLoitghlin JR Complications of Minimally Invasive Cardiac Surgical Procedures Seminars in Cardiothoracic and Vascular Anesthesia, July 1, 1999; 3(2): 136 - 142. [Abstract] [PDF]
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 L. Noyez, D. P.B. Janssen, J. A.M. van Druten, S. H. Skotnicki, and L. K. Lacquet Coronary bypass surgery: what is changing?: Analysis of 3834 patients undergoing primary isolated myocardial revascularization Eur. J. Cardiothorac. Surg., April 1, 1999; 13(4): 365 - 369. [Abstract] [Full Text] [PDF]
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 T W Koh, G S Carr-White, A C DeSouza, F D Ferdinand, J R Pepper, and D G Gibson Effect of coronary occlusion on left ventricular function with and without collateral supply during beating heart coronary artery surgery Heart, March 1, 1999; 81(3): 285 - 291. [Abstract] [Full Text]
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 M. J. Reardon, G. V. Letsou, J. E. Anderson, H. J. Safi, R. Espada, and J. C. Baldwin ORTHOTOPIC CARDIAC TRANSPLANTATION AFTER MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS J. Thorac. Cardiovasc. Surg., February 1, 1999; 117(2): 390 - 391. [Full Text] [PDF]
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J. A. Goldstein, R. D. Safian, D. Aliabadi, W. W. O'Neill, F. L. Shannon, J. Bassett, and M. Sakwa Intraoperative angiography to assess graft patency after minimally invasive coronary bypass Ann. Thorac. Surg., December 1, 1998; 66(6): 1978 - 1982. [Abstract] [Full Text] [PDF]
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J. R. Elbeery, P. M. Brown, and W. R. Chitwood Jr Intraoperative MIDCABG arteriography via the left radial artery: a comparison with doppler ultrasound for assessment of graft patency Ann. Thorac. Surg., July 1, 1998; 66(1): 51 - 55. [Abstract] [Full Text] [PDF]
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R. L. Singer Minimally invasive coronary artery surgery--A word of caution J. Thorac. Cardiovasc. Surg., June 1, 1998; 115(6): 1392 - 1393. [Full Text]
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G. Possati, M. Gaudino, F. Alessandrini, M. Zimarino, F. Glieca, and N. Luciani Systematic clinical and angiographic follow-up of patients undergoing minimally invasive coronary artery bypass J. Thorac. Cardiovasc. Surg., April 1, 1998; 115(4): 785 - 790. [Abstract] [Full Text] [PDF]
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