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Ann Thorac Surg 1998;66:980-981
© 1998 The Society of Thoracic Surgeons
a Pacific Cardiothoracic Surgery Group, St. John’s Regional Medical Center, 700 N Rose Ave, #440, Oxnard, CA 93030, USA
To the Editor
We congratulate the group of Dr Reichenspurner and associates [1] for their efforts in Port-Access (Heartport, Redwood City, CA) coronary artery bypass grafting. The Port-Access technology has added to the field of cardiac surgery in tangible ways (refinement of endoaortic occlusion as a functional cross-clamp, for example) and intangible ways in making surgeons think about new alternatives in a broader scope. The technique is described as "minimally invasive" in terms of wound complications and hospital stay, while still permitting an accurate anastomosis.
But it still requires cardiopulmonary bypass and cardiac arrest. Does this constitute "minimally invasive"? Is minimally invasive local or systemic? To a given surgeon, the definition of minimally invasive depends on the patient, the audience, and what you are doing. To a media-sensitive public, small incisions are fashionable, and bandage-sized surgical scars are envisioned. Small incisions help the patient psychologically and physically (sternotomy avoidance for Port-Access, decreased pain(?), and ventilatory compromise). But what are we willing to risk or compromise to achieve such a goal? Does such "minimal wound" surgery constitute truly "minimally invasive" cardiac surgery? Port-hole endoscopic gallbladder surgery compared with open cholecystectomy is a physiologically poor analogy when applied to cardiac surgery, because the heart-lung machine adds a new level of physiologic derangement.
Generally, cardiopulmonary bypass is not good, and cardioplegic arrest is not good. They have their necessary place in cardiac surgery, and appropriate decompression and protection of the heart to optimize work/demand considerations cannot be underestimated. But cardiopulmonary bypass and cardioplegic arrest are still nonphysiologic, as attested to by the systemic inflammatory, coagulopathic, vascular resistance, and low-output postpump states, to mention nothing of pump-related neuropsychiatric events.
At present our group attempts to perform routine complete coronary revascularization without cardiopulmonary bypass. We generally perform a left internal mammary anastomosis to the left anterior descending artery first, then attempt the other vessels, usually successfully avoiding cardiopulmonary bypass. If cardiopulmonary support is required, we are usually still able to avoid cardioplegic arrest. We have performed 37 such cases in our early experience, of which 34 have been completely off pump, with 0% mortality.
In the work of Reichenspurner and associates, for single-vessel left internal mammary artery to left anterior descending artery grafting, the median pump and cross-clamp times were 59.5 and 28.5 minutes, respectively; the hospital stay was 5 days, and the mortality was 1/42 (2.4%). There were 2 cases of retrograde dissection. Is this "minimally invasive" for single-vessel coronary artery bypass grafting? Other reports likewise document a problem of morbidity in this type of minimally invasive surgery. Port-Access mitral valve operations in one study of 51 patients had a mean bypass time of more than 2 hours, many complications (6% perivalvular leak, 6% reexploration for bleeding, 4% aortic dissection), nearly 10% mortality rate, and a "high incidence of postoperative confusion" [2]. Is this "minimally invasive" mitral valve surgery? A corresponding editorial commented that the aim of the study was supposed to minimize surgical trauma, not surgical access [3].
For the medical profession 50 years ago, a "learning curve" when there was no alternative was acceptable, as it was ethically not only justified, but necessary to relieve human suffering. The same type of learning curve is not acceptable today. "Learning curves" can justify some types of surgical experiences, but we must ethically ensure that the end is worth the means required to achieve it.
Does Port-Access heart surgery constitute "minimally invasive" surgery? For a 25-year-old woman, probably yes. For an 80-year-old woman, probably not. The answer depends on the patient as well as the surgeon, and what we are willing to risk to "improve" on cardiac surgery as we know it.
References
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