Ann Thorac Surg 2001;72:775
© 2001 The Society of Thoracic Surgeons
Invited commentary
Irving L. Kron, MDa
a Thoracic & Cardiovascular Research Laboratory, Lane Rd, Medical Research Bldg 4, Rm 3111, Charlottesville, VA 22908-1359, USA
e-mail: ikron{at}virginia.edu
Ascione and colleagues have reported 42 patients who underwent combined "one-stage" coronary bypass and aortic surgery from 1990 to 1999. The first 20 patients were done on bypass and the subsequent 22 had surgery on the beating heart. The authors had excellent results. With the off-pump technique and the combined procedure there was only one death.
I applaud the authors for these excellent results. I am not convinced that off-pump versus on-pump makes as much difference as the authors would suggest. In fact, we have demonstrated mortality of 5% during these combined procedures using an on-pump approach. We differ somewhat in the technique that the authors describe. They tend to close their chest incisions prior to going onto the abdominal part of the procedure. We, in fact, do the entire incision at one time including aortic exposure. At this point, we heparinize and don’t reverse the heparin until the entire procedure is completed. Not only does this give you excellent exposure, but in the on-pump situation, we leave the cannulas in place which allows easy and quick transfusion of volume if required during the aortic exposure. We also will start the aneurysm surgery as we are rewarming and go off-pump as we are finishing the procedure. We found bleeding to not be an issue. The length of stay for the last 15 patients has been a mean of 6 days.
We have demonstrated an increased rupture rate of aortic aneurysms after coronary artery bypass. Therefore, we are in favor of combined procedures when required. However, technology continues to change. Aortic stent graft repairs are now available and may take the place of open procedures in many of these patients.
