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Ann Thorac Surg 1999;67:503
© 1999 The Society of Thoracic Surgeons

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Commentary

^a Department of Surgery, Tulane University Medical School SL22, 1430 Tulane Ave, New Orleans, LA 70312, USA

e-mail: rshartzmd{at}aol.com

Invited commentary

Limited-access or minimally invasive direct coronary artery bypass grafting (MIDCAB) has assumed an increasing role in many surgical practices. The ideal candidate has not been defined, but very high risk patients seem to benefit most when cardiopulmonary bypass is avoided. Zenati and colleagues [1] observed no operative mortality in a group of 17 patients undergoing MIDCAB with a predicted mortality rate (for traditional coronary artery bypass grafting) of greater than 20%. Angiographic patency of internal mammary artery–left anterior descending coronary artery anastomoses was 100% in their series.

Lazzara and Kidwell have accurately pointed out the absolute necessity of documenting perfusion of the anterior wall of the heart, through the bypass graft, before the patient leaves the operating room. This principle holds true whether the graft is done with or without cardiopulmonary bypass or with a small or large incision.

If a limited-access procedure is performed in an institution where on-table angiography is available, the surgeon may elect such an approach. It is important to remember, however, that angiographic patency is not synonymous with coronary flow. It has been my practice for 15 years to measure flow in all vein grafts. Better machinery has also allowed duplex examination of arterial grafts as well. Luise and associates [2] recently described the flow patterns in patent and occluded internal mammary artery grafts after limited-access operation using a Doppler ultrasound probe. These physiologic data can be obtained by every coronary surgeon, in every institution, for a small investment. I recommend that it be performed routinely, with complementary angiography as the surgeon desires. Predischarge physiologic evidence of graft patency should be obtained (stress test) because factors contributing to early graft closure after off-pump operation (eg, whether heparin should be reversed) have not been elucidated.

References

1. Zenati M., Cohen H.A., Feldman M.D., et al. Improved results of minimally invasive coronary artery bypass in Parsonnet very high risk patients. Circulation 1997;96(Suppl):8.
2. Luise R., Teodori G., Di Giammarco G., et al. Persistence of mammary artery branches and blood supply to the left anterior descending artery. Ann Thorac Surg 1997;63:1759-1764.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Renée S. Hartz Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hartz, R. S. Search for Related Content PubMed Articles by Hartz, R. S.