Ann Thorac Surg 1999;68:911-912
© 1999 The Society of Thoracic Surgeons
Commentary
Piet Boonstra, MD, PhD
a Thoraxcentre, Groningen University Hospital, PO Box 30.001, 9700 RB Groningen, The Netherlands
e-mail: p.w.boonstra{at}thorax.azg.nl
Invited commentary
The advantages of off-pump coronary surgery, with respect to conventional coronary surgery with the pump, are the avoidance of the damaging side-effects of the pump and the avoidance of the midline sternotomy, like in the left anterior small thoracotomy (LAST) operation. However until recently, this technique has been limited to one-vessel disease. Nowadays also patients with two- or three-vessel disease can benefit from the advantages of off-pump coronary surgery, for example by combining the LAST operation with angioplasty for revascularization of the remaining coronary arteries called "the hybrid revascularization." The results presented in this study are indeed encouraging although we have to realize that the total number of patients studied is small, follow-up is short (mean 6 months), and is complete in only 9 of 18 patients. This technique is in particular advocated for redo surgery where a midline sternotomy has to be avoided or where coexisting pathology increases the risk associated with cardiopulmonary bypass. Moreover, in primary coronary surgery, off-pump surgery for two- and three-vessel disease via a midline sternotomy is expanding rapidly and is performed routinely now in many cardiac centers.
The main point in "hybrid revascularization" is timing of the procedures. The first option is angioplasty preceding surgery. In case of any interventional complication, surgery can effectively treat the underlying coronary disease. However, certain complications after percutaneous transluminal coronary angioplasty (PTCA) such as intimal disruption might require extensive anticoagulation with increased risk of bleeding complications and will delay the following surgery. Although failures of PTCA with urgent need for surgery are rare nowadays, the authors report one patient suffering this complication. The second option is surgery preceding angioplasty. By doing so, a safe angioplasty can be performed on a coronary system that is "protected" by a graft to the LAD and furthermore, the patency of the coronary anastomosis can be assessed immediately after surgery. Just like in the first option, a disadvantage is the fact that the patient has to be confronted with two procedures, performed by two different specialists and separated by one or two days. The third and maybe ideal option is surgery and angioplasty performed in the same operative session under general anesthesia. Whether it should be performed in the cathlab or in the operating room, mostly depends on the availability of in-hospital resources and the operators preferences. In general, the sequence with surgery first would represent the common practice in both interventional cardiology and surgery, to treat the culprit lesion first.
The future of "hybrid revascularization" is still an open question that can be answered only by results of prospective trials comparing hybrid revascularization with multiple PTCA or with conventional coronary artery bypass grafting (CABG) or with off-pump CABG, performed in patients with two- or three-vessel disease.
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Integrated left anterior small thoracotomy and angioplasty for coronary artery revascularization
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Ann. Thorac. Surg. 1999 68: 908-911.
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