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Ann Thorac Surg 2002;73:1020
© 2002 The Society of Thoracic Surgeons
a Research Center and Department of Surgery, Montreal Heart Institute, University of Montreal, 5000 Belanger St East, Montreal, Quebec H1T 1C8, Canada
e-mail: lpperrau{at}icm.umontreal.ca
To the Editor
We read with interest and concern the case report from Dogan and colleagues [1]. Although we are well aware and supportive of the trend and of the principles towards a less invasive approach in coronary artery bypass graft (CABG) surgery, as well as the growing role of computer enhancement in enabling a totally endoscopic technique, several issues in this report are cause for concern.
First, the exact place of hybrid revascularization (PTCA + minimally invasive direct coronary artery bypass) in the armamentarium of myocardial revascularization remains blurry, especially in young patients with no significant comorbidities, as reported here (patient 1), and this strategy should still be viewed with a healthy amount of skepticism.
Secondly, the use of 7-0 polypropylene suture with the larger needle used for the anastomosis appear suboptimal for performance of internal thoracic artery to coronary anastomosis, especially for side-to-side anastomosis, as we believe that technology should not modify the accepted surgical principles of microvascular anastomosis.
Lastly and most importantly, the operative times and specifically the ischemic times of 100 and 126 minutes (even with cardioplegic arrest) appear disproportionate compared with the classical approach of full sternotomy and cardioplegic arrest or beating heart surgery revascularization techniques currently available and carry, in our opinion, an unnecessarily high risk of ischemic injury to the myocardium. Another issue related to the Heartport system and the long cardiopulmonary bypass times is the moderate reperfusion injury to the cannulated leg of the 48-year-old patient that is part of the spectrum of vascular and groin complications which would be easily avoided by use of the more accepted approaches. Taken altogether, these issues make us question whether, even though "we have the technology," we should submit patients with straightforward coronary insufficiency to risks out of proportion to classical approaches. We fully agree with the closing statement of the authors that developments in the computer system, instrumentation, and the Heartport system are needed, and believe that such advances should be implemented, studied, and tested before ethically exposing patients with low surgical risks to complex procedures of questionable benefits. The integrity of our profession is at stake as well as our capacity to safely and rationally implement new technology in the clinical arena. Are we the only ones thinking that way?
References
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