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Ann Thorac Surg 2004;78:684-685
© 2004 The Society of Thoracic Surgeons
Mount Sinai Medical Center, Department of Cardiothoracic Surgery, 1190 Fifth Ave, New York, NY 10029, USA
e-mail: david.adams{at}mountsinai.org
| Dr Borst discloses that he has a financial relationship with Medtronic.
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Early efforts at beating heart surgery were decidedly low-tech, utilizing at most a simple stabilizer, a few pericardial sutures, and conventional anastomotic techniques [1]. These critical early steps represented more of a philosophical advance and paradigm shift than a technologic breakthrough. More importantly, a door was opened, and the imagination of surgeons and engineers were stimulated to develop new enabling technologies that would reinvent coronary artery bypass surgery. Starting with the original Octopus stabilizer, Drs Gründeman and Borst and colleagues from the Utretcht group have been pioneers in developing such technologies. Enabling technologies are now available to facilitate all aspects of off-pump coronary artery bypass (OPCAB) surgery, including positioning the heart with hemodynamic stability (apical suction devices), coronary stabilization (vacuum and rigid stabilizers), coronary visualization, and hemostasis (intracoronary shunts), as well proximal and distal anastomotic devices.
The first, and often most challenging, step in performing a beating heart anastomosis is positioning the heart so that the coronary target is well visualized and accessible, while maintaining hemodynamic stability. The ideal system permits access to all targets, especially on the lateral wall, with a normal blood pressure and cardiac output for as long as is necessary to perform a technically precise anastomosis. In a recent study, hemodynamic compromise during cardiac positioning was the most common obstacle to achieving complete revascularization during OPCAB [1]. The introduction of apical suction devices in large part eliminates this issue, allowing motivated surgeons with appropriate training and experience to now perform complete revascularization off-pump in most patients.
In this well-executed animal study, Gründeman and colleagues formally document what most OPCAB surgeons understand intuitively—that apical suction devices allow cardiac displacement and exposure of coronary targets while minimizing hemodynamic compromise. We previously documented similar benefits using the XposeTM (Guidant Corporation) apical suction device instead of pericardial sutures in a porcine model [2]. A unique finding in their study is the preservation of coronary perfusion. Imprecise manipulation of an ischemic heart during OPCAB can lead to hemodynamic compromise, which likely leads to decreased coronary perfusion and subclinical ischemia that further compromises hemodynamics in a vicious cycle. Maintaining adequate coronary perfusion is critical in preserving hemodynamic stability during OPCAB, and may be the most important benefit of apical suction devices. Broader acceptance of OPCAB will be facilitated by further technologic advances.
References
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