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Ann Thorac Surg 1996;61:10-11
© 1996 The Society of Thoracic Surgeons

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Editorials

Look Ma, No Hands!

Cardiac Surgery, Peninsula Hospital, Burlingame, California

From time to time the surgical orthodoxy is challenged by asserting less is more and by questioning the need to employ the full available technological armamentarium. A number of such challenges come to mind during the evolution of coronary artery bypass grafting.

Loop and colleagues [1] argued that one could perform internal mammary artery anastomoses to coronary vessels 1 mm or larger in diameter without resort to high-power magnification, addressing themselves to work by Bailey and Hirose [2] and Green and associates [3], who reported internal mammary artery grafting with 2.5x magnification (optical loupes) and 16x magnification (operating microscope), respectively. Akins [4] and Bonchek and Burlingame [5] independently published clinical series showing that good results in myocardial revascularization could be obtained without using cardioplegia. In the early 1970s Ankeney [6] advocated coronary bypass grafting to the right coronary artery and left anterior descending coronary artery in the beating heart without extracorporeal circulation. Although none of these reports made a rigorous argument using prospective, randomized trial methodology, all offered an appealing simplicity with good clinical results and were championed by respected surgeons.

See also 63.

In this issue of The Annals Buffolo and colleagues [7] revisit the subject of coronary artery bypass grafting without cardiopulmonary bypass (CPB). They operated on 1,274 consecutive, carefully selected patients (patients with left main disease and those requiring posterior wall revascularization were excluded) without CPB. An average of 1.7 grafts per patient were placed, 44% of which were arterial conduits. The operative mortality in this series, which included reoperative and emergency cases, was 2.5%. Patency rates were identical (93.4%) in 60 patients catheterized before discharge from hospital, 30 of whom were operated on using CPB and 30 without. In a subgroup of patients, arrhythmic, pulmonary, and neurologic complications were lower in the no-CPB group; bleeding complications were similar in both groups.

What is new about Buffolo and colleagues' article is the emphasis on cost savings as the most important benefit of performing coronary bypass grafting without extracorporeal circulation. ``Most importantly, there was decreased cost when the procedure was used because no extracorporeal circulation, cardioplegia sets, or other cannulas were used'' [7]. Buffolo and colleagues claim a cost saving of US $3,000 per case by foregoing the use of extracorporeal circulation in coronary bypass grafting, and estimate that approximately 25% of their surgical patients are candidates to undergo myocardial revascularization without CPB.

Rigorous methodology, of course, would demand a study in which patients were selected preoperatively for coronary bypass grafting without CPB, and randomized to CPB and no-CPB groups to determine whether there are meaningful differences in early outcomes. One would like to have long-term and especially late angiographic data as well.

Notwithstanding the lingering questions about methodology, how are we to deal with the cost issue posed by this article? How much are we willing to alter the way we perform surgery in the name of cost containment? For patients with lesser extent of disease and accessible vessels, should we modify our use of technology to achieve a one-time cost savings?

In this era of cost containment surgeons have responded positively in a variety of ways. Same-day operations have become commonplace as have strategies for early extubation, accelerated transfer from the intensive care unit and early discharge from the hospital. The Society of Thoracic Surgeons National Database has documented a trend toward shortened lengths of stay despite increasing age and complexity of patients undergoing coronary bypass grafting [8]. No one can say that surgeons have failed to respond to the public's cry for good care, less expensively.

Where I part company with the thrust of Buffolo and colleagues' challenge is to potentially alter the product in the name of cost containment by abandoning the technology that gives us the ability to conduct a careful, meticulous, complete, and, yes, safe operation. The benefits of surgical revascularization are those of completeness, durability, and reproducibility, which in turn translate into prolonged relief of symptoms and, in most patients operated on today, a survival benefit compared with medical management.

Randomized studies comparing coronary artery bypass grafting and coronary angioplasty show higher initial costs for surgical management and then convergence of costs within 2 to 3 years thereafter. This cost advantage over time is due to the lack of subsequent interventions needed in the surgical cohort [9]. These favorable long-term cost effects are based on careful selection of sites for anastomosis as, for example, the intramyocardial left anterior descending coronary artery, a disposition to perform complete revascularization using arterial conduits when possible, optimal conditions for microvascular anastomosis, and minimal trauma to conduit or native coronary artery. Although coronary bypass grafting can be done snaring the coronary with a 5-0 suture and reducing blood pressure and heart rate pharmacologically as advocated by Buffolo and colleagues, at least one surgeon familiar with the technique warns that a number of his patients operated on without CPB died unexpectedly or had recurrent angina, and an ``inordinate'' number had graft stenoses at anastomotic sites, and stenoses at the sites of the stay sutures or loops placed around vessels [10].

Cost savings in coronary bypass grafting depend importantly on the avoidance of complications of operation [11]. Complications attributable to the use of CPB with today's technology are trivial. All of us doing these operations have had the experience of an untoward event causing temporary ``stunning'' of the heart, resulting in a prolonged postoperative course with unanticipated need for mechanical circulatory support, lengthy mechanical ventilation, and renal or central nervous system impairment. Invariably these events occur before or after, rarely during, CPB.

One of the ironies in this era of aggressive management of patients with coronary artery disease is that catheter intervention is moving in the direction of greater complexity and expense, while some surgeons are scrambling to make surgical revascularization simpler and cheaper. The use of coronary stents with increased peripheral vascular complications, complex anticoagulation regimens, and intravascular echocardiography to verify adequate stent placement, as well as proposed genetic and other manipulations to mitigate the smooth muscle proliferation in response to catheter-induced vascular injury, has jettisoned the advantages of simplicity and low initial cost, leading to greater expense and long hospital stays.

Coronary bypass grafting, as evidenced by Buffolo and colleagues' article, is vulnerable to the siren call of cost containment by circumventing some of the technology integral to its well-established reproducibility and beneficial long-term results. Tinkering with the fundamentals of coronary bypass grafting as practiced today, especially the use of cardiopulmonary bypass, in the name of cost containment should be resisted.

We applaud for the youngster who rides for a time without touching the handlebars, knowing, at the same time, that the big races are still won in classic style.

Footnotes

Address reprint requests to Dr Ullyot, 1828 El Camino Real, Suite 802, Burlingame, CA 94010.

References

1. Loop FD, Effler DB, Spampinato N, et al. Myocardial revascularization by internal mammary artery grafts. J Thorac Cardiovasc Surg 1972;63:674–80.[Medline]
2. Bailey CP, Hirose T. Successful internal mammary-coronary arterial anastomosis using a ``minivascular'' suturing technique. Int Surg 1968;49:417.
3. Green GF, Stertzer SH, Gordon RB, Tice DA. Anastomosis of the internal mammary artery to the distal left anterior descending coronary artery. Circulation 1970;41(Suppl 2):79.
4. Akins CW. Noncardioplegic myocardial preservation for coronary revascularization. J Thorac Cardiovasc Surg 1984;88:174–81.[Abstract]
5. Bonchek LI, Burlingame MW. Coronary artery bypass without cardioplegia. J Thorac Cardiovasc Surg 1987;93:261–7.[Abstract]
6. Ankeney JL. To use or not to use the pump oxygenator in coronary bypass operations. Ann Thorac Surg 1975;19:108–9.[Medline]
7. Buffolo E, de Andrade JCS, Branco JNR, Teles CA, Aguiar LF, Gomes WJ. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1996;61:63–6.[Abstract/Free Full Text]
8. Data analyses of The Society of Thoracic Surgeons National Cardiac Surgery Database, the fourth year-January 1995. Chicago: The Society of Thoracic Surgeons, 1995;6, 11.
9. Sculpher MJ, Seed P, Henderson RA, et al. Health service costs of coronary angioplasty and coronary artery bypass surgery: the randomised intervention treatment of angina (RITA) trial. Lancet 1994;344:927–30.[Medline]
10. Gundry SR. Discussion of Pfister AJ, Zaki MS, Garcia JM, et al. Coronary artery bypass without cardiopulmonary bypass. Ann Thorac Surg 1992;54:1092.
11. Mauldin PD, Weintraub WS, Becker ER. Predicting hospital costs for first-time coronary artery bypass grafting from preoperative and postoperative variables. Am J Cardiol 1994;74:772–5.[Medline]

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Daniel J. Ullyot Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ullyot, D. J. Search for Related Content PubMed PubMed Citation Articles by Ullyot, D. J. Related Collections Related Article