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Ann Thorac Surg 1997;64:285-286
© 1997 The Society of Thoracic Surgeons

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Correspondence

Minimally Invasive Coronary Artery Bypass Grafting

Cardiac Surgical Unit, Royal Victoria Hospital, Belfast BT12 6ba, Northern Ireland.

To the Editor:

I read with interest the article by Calafiore and associates [1] that recently appeared in your journal about "Minimally Invasive Coronary Artery Bypass Grafting," which seems to be the topic in fashion nowadays. I do believe that the use of cardiopulmonary bypass should be avoided whenever possible, and in my clinical practice I perform coronary artery bypass grafting on a beating heart via a median sternotomy in selected cases. The majority of the patients operated upon with this technique have received two grafts, to the left anterior descending artery and the right coronary artery. The numbers are small because very few patients require only two grafts. The number of patients requiring only a left anterior descending artery graft is even smaller.

I totally reject the technique described in the above-mentioned article for the following reasons: (1) Thoracotomy is more painful than a median sternotomy. (2) Median sternotomy allows the immediate institution of cardiopulmonary bypass if necessary. (3) To have the internal mammary artery dissected along its entire length with ligation of the branches makes more sense, even if a steal syndrome has not been demonstrated in internal mammary arteries with branches. (4) The sutures applied distally and proximally on the left anterior descending artery for occlusion may cause endothelial damage of the coronary with later consequences. (5) An early reoperation rate for graft failure of 4.5% as described by Calafiore and associates is unacceptable. (6) Similarly unacceptable is a survival rate of 92.2% at mean of 5.6 months of follow-up.

So I totally disagree with the prediction of Calafiore and associates that minimally invasive coronary artery bypass grafting will grow and will become popular among cardiac surgeons, patients, and institutions. I believe that coronary artery bypass grafting without the use of cardiopulmonary bypass via a median sternotomy is the technique that will become popular and will be taught to the future generation of cardiac surgeons.

Reference

1. Calafiore AM, Angelini GD, Bergsland J, Salerno TA. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;62:1545–8.[Abstract/Free Full Text]

Reply

Division of Cardiothoracic Surgery, The Buffalo GeneralHospital, 100 High St, Buffalo Ny 14203.
Department of Cardiac Surgery, Universita di Chieti, c/o Ospedale "San Camillo De Lellis", Via Forlanini 50, 66100 Chieti, Italy.

To the Editor:

Doctor Campalani's letter brings to the attention of cardiac surgeons important issues related to minimally invasive coronary artery surgery.

Like Dr Campalani, we also believe that cardiopulmonary bypass should be avoided whenever possible, and our definition of minimally invasive coronary artery surgery excludes the use of cardiopulmonary bypass. We would like to offer some specific comments on Dr Campalani's letter:

1. With appropriate therapy, thoracotomy pain in the minimally invasive coronary artery bypass grafting approach can be reduced to allow for extubation of the patient in the operating room.
   
2. It is true that when median sternotomy is used, cardiopulmonary bypass can be instituted immediately if needed. In our experience with more than 400 cases, emergency institution of cardiopulmonary bypass has never been necessary.
   
3. Steal syndrome from persistent left internal mammary artery branches remains controversial in our view. Theoretically such steal is not possible because left internal mammary artery branches have systolic flow, whereas left anterior descending artery flow is mainly diastolic. In such a situation, competition to blood flow is not possible.
   
4. Endothelial damage from sutures applied distally and proximally to control bleeding from the arteriotomy is an obvious concern. In our large experience with angiograms performed postoperatively, we have not observed such damage. An important technical detail is that snares must be placed deep in the myocardium to prevent direct compression of the vessel. We presently use intravascular occluders and a surgical blower to optimize visulization.
   
5. Occlusion of a graft can occur after bypass grafting with or without the use of cardiopulmonary bypass. A rate of 5% has been reported with cardiopulmonary bypass [1, 2]. Has Dr Campalani performed angiograms in all his bypass patients? What was or is his patency rate?
   
6. The figure 92.2% is not the survival rate, but the percentage of patients alive (only 1 patient died in the first 155 patients operated upon by Dr Calafiore) and free of symptoms without a cardiac event [3].
   

We continue to believe that minimally invasive direct coronary artery bypass grafting for single-vessel coronary artery disease will continue to grow. Multivessel coronary artery disease remains a challenge for the minimally invasive approach. Currently Drs Bergsland and Salerno are able to accomplish complete revascularization via median sternotomy in approximately 80% of recent patients operated upon without using cardiopulmonary bypass. We still have an open mind about new technology that will facilitate minimally invasive coronary artery bypass grafting for single-vessel and multivessel coronary artery disease. The integrated approach (minimally invasive coronary bypass followed by angioplasty/stent), popularized by Angelini and associates, is another addition to the minimally invasive direct coronary artery bypass grafting approach. As with any new procedure, truth will prevail and time will tell.

References

1. Hoffman O, Beyssen B, Pagny JY, Guermonprez JL, Gaux JC. Early angiographic evaluation of coronary bypass using arterial grafts. Arch Mal Coeur Vaiss 1993;86:1445–50.[Medline]
2. Van der Meer J, Hillege HL, van Gilst WH, et al. A comparison of internal mammary artery and saphenous vein grafts after coronary artery bypass surgery. No difference in 1-year occlusion rates and clinical outcome. Circulation 1994;90:2367–74.[Abstract/Free Full Text]
3. 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]

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