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Ann Thorac Surg 1997;64:622
© 1997 The Society of Thoracic Surgeons
DR CARY W. AKINS (Boston, MA): You suggested that your philosophy has been not to treat just culprit lesions with this operation, yet in 12 years you performed only 12 LIMA-to-LAD grafts and then in 9 months you performed 23 MIDCAB procedures with LIMA-to-LAD grafts. Were these patients who otherwise would have undergone angioplasty? How did you get this increased group of patients for reoperation?
DR ALLEN: That is an excellent question. Because of the success we are having, the cardiologists no longer are performing high-risk angioplasty for stenotic LAD vein grafts. In addition, because of the reputation that our group has garnered in this field, we are experiencing a significant number of referrals from great distances, and I think that explains the additional cases.
DR RANDALL K. WOLF (Cincinnati, OH):I enjoyed your paper. We also have had a good experience with minimally invasive coronary artery bypass grafting in redo situations.
I would like to ask you two questions. First, would you agree that if minimally invasive coronary artery bypass grafting is a good technique in patients undergoing initial coronary revascularization procedures, it is a great procedure in patients undergoing reoperations because one can avoid manipulation of the aorta and atherosclerotic grafts? Second, would you agree that in selected patients undergoing either initial or repeated procedures, the key is an adequate target site, and that if one does not perform bypass to an adequate target site, the patency of the graft may be compromised?
DR ALLEN: I would concur with both those comments. We believe that MIDCAB grafting is a good operation in selected patients. However, it is not meant to replace CPB. Our philosophy is that MIDCAB procedures should not be used to treat so-called culprit lesions in patients who have multivessel disease who are acceptable candidates for CPB.
DR AKINS: What is your strategy, and presumably you have thought it out, for the patient in whom hemodynamic instability develops while you are performing this operation? It is one thing to open the sternum in a first-time patient to place him or her on cardiopulmonary bypass, but how do you plan to deal with hemodynamic instability in a reoperative setting when you are caught in a small incision in the left chest?
DR ALLEN: Interestingly, hemodynamic instability, unlike what you may think, is not a common problem during MIDCAB operations. Patients tolerate short periods of ischemia very well, as demonstrated by the percutaneous transluminal coronary angioplasty experience. We have not had to convert any of the 170 MIDCAB procedures we have performed to date for hemodynamic instability. I think it is important in the redo group, particularly when you are operating on a patient who you would not place on cardiopulmonary bypass, to talk with the patient and the family beforehand and explain to them that if problems do develop, you are not going to open their chest in a conventional manner.
Related Article
Ann. Thorac. Surg. 1997 64: 616-622.
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