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Ann Thorac Surg 1997;64:1-2
© 1997 The Society of Thoracic Surgeons

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Editorial

Didn't They Do Well?

Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong

The concept that the trauma of access is often worse than that of the surgical correction per se has become widely accepted in various surgical disciplines. The latest extension of this principle has been into the treatment of heart disease, where "minimally invasive" cardiac surgery is currently undergoing rapid evolution [1, 2]. The most significant experience to date is with minimally invasive direct coronary artery bypass grafting (MIDCABG), where the heart is approached via a left anterior minithoracotomy through which the left internal mammary artery (LIMA) is harvested and anastomosed to the left anterior descending coronary artery under direct vision. Several recent reports presented the favorable clinical outcome of patients managed with this procedure [3, 4]. Indeed, MIDCABG seems to have received wide acceptance among cardiac surgeons rapidly [1].

Although we applaud all authors for their creativity and technical abilities, a word of caution is necessary. Before MIDCABG is accepted as "established" practice, such a newly developed therapeutic modality must be shown at least to duplicate the efficacy of the conventional surgical procedure, and preferably promise some added benefits. Neither of these has been credibly demonstrated yet.

Conventional (single-vessel) surgical revascularization is associated with a very low risk and an extremely high LIMA graft patency rate. It would be very difficult, therefore, for a more demanding technique, such as that of MIDCABG, to reproduce these results universally. Indeed, the few MIDCABG series that report routine angiographic studies of LIMA grafts uniformly present a less than ideal picture [5, 6]. The overall graft patency rate is around 85% to 90%, and abnormalities in the anastomoses or the positioning of the LIMA (even kinking) are common [5, 6]. There is little doubt that a learning curve is involved, and these results are likely to represent the early phase of this process. However, improvements in graft patency rate with experience cannot be taken for granted but should be actively demonstrated. Yet, such feedback is largely absent, for data concerning the patency of such grafts remain very scarce, with the majority of surgeons contented with the good "clinical" outcome of their patients [7, 8], a very insensitive marker indeed!

The success of grafting through MIDCABG (or indeed any such new modality), therefore, is a pressing topic that has to be kept at the forefront of our minds. Routine angiographic assessment of grafts should be considered vital for the critical appraisal of the procedure in every practicing institution. Such data are essential to help individual surgeons in their own process of learning. The length of the LIMA pedicle and its position in relation to the lung would be judged more accurately [5, 6], and the success in performing the anastomoses and the usefulness of stabilizing devices would become clear [9]. Collectively, these data will provide the necessary information about the patency of LIMA grafts beyond the "learning zone." We should not disregard the fact that an 85% patency rate is far inferior to that with conventional bypass grafting and almost similar to what can currently be achieved with coronary stenting [10]. Unless improvement in MIDCABG results can be convincingly demonstrated, it will be difficult to present MIDCABG as a credible contender for the treatment of single-vessel disease, and MIDCABG will be at risk of losing the vote of confidence from our cardiology colleagues [11].

Not only has MIDCABG not been shown to duplicate the efficacy of the conventional operation, but also no added benefits, besides cosmesis, have been demonstrated. Would smaller incisions necessarily equate with less patient morbidity? There are no scientific data yet that prove that this is the case, even though most of us believe this to be true [1]. It must be remembered that the morbidity is very low anyway in cases of single-vessel disease, even when median sternotomy and cardiopulmonary bypass are used.

The prophecy of MIDCABG becoming established as standard practice can already be seen to be realized, and over the next few months we are likely to be bombarded with many reports of patients "doing very well" after MIDCABG procedures. Yet, we should seek lessons from the "gold standard" angiography in every case before we all convert to MIDCABG in a St. Paul-on-the-road-to-Damascus style. Results should not be readily compromised for the benefit of a smaller scar or the yet-doubtful pledge of reduced short-term morbidity.

Footnotes

Address reprint requests to Dr Izzat, Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, Shatin, NT, Hong Kong (e-mail: b865721{at}mailserv.cuhk.edu.hk).

References

1. Izzat MB, Yim APC. Minimally invasive cardiac surgery, a fleeting fancy or a lasting prospect? [Editorial]. Int J Cardiol (in press).
2. Izzat MB, Yim APC. Minimally invasive intracardiac surgery. In: Mack M, Landreneau R, Cohen R, eds. Minimally invasive cardiac surgery. St. Louis: QMP (in press).
3. Acuff TE, Landreneau RJ, Griffith BP, Mack MJ. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;61:135–7.[Abstract/Free Full Text]
4. Calafiore AM, Di Giammarco G, Teodori G, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658–65.[Abstract/Free Full Text]
5. Schaff HV, Cable DG, Rihal CS, Daly RC, Orszulak TA. Minimal thoracotomy for coronary artery bypass: value of immediate postoperative graft angiography. Circulation 1996;94(Suppl 1):51.
6. Nataf P, Lima L, Jault F, et al. Video-assisted coronary bypass surgery with internal mammary artery: results of a new minimally invasive surgical alternative for single vessel disease [Abstract]. J Am Coll Cardiol 1997;29(Suppl A):465A.
7. Boonstra PW, Grandjean JG, Mariani MA. Improved method for direct coronary grafting without CPB via anterolateral small thoracotomy. Ann Thorac Surg 1997;63:567–9.[Abstract/Free Full Text]
8. Robinson MC, Gross DR, Zeman W, Stedje-Larsen E. Minimally invasive coronary artery bypass grafting: a new method using an anterior mediastinotomy. J Card Surg 1995;10:529–36.[Medline]
9. Shennib H, Lee AGL, Akin J. Safe and effective method of stabilization for coronary artery bypass grafting on the beating heart. Ann Thorac Surg 1997;63:988–92.[Abstract/Free Full Text]
10. Versaci F, Gaspardone A, Tomai F, Crea F, Chiariello L, Gioffre PA. A comparison of coronary artery stenting with angioplasty for isolated stenosis of the proximal left anterior descending coronary artery. N Engl J Med 1997;336:817–22.[Abstract/Free Full Text]
11. Frankel DH. Cardiac surgeons peer through the coronary keyhole. Lancet 1996;348:1437.

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Anthony P. C. Yim Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Izzat, M. B. Articles by Yim, A. P. C. Search for Related Content PubMed PubMed Citation Articles by Izzat, M. B. Articles by Yim, A. P. C.