Ann Thorac Surg 1997;63:1747
© 1997 The Society of Thoracic Surgeons
Invited Commentary
Albert J. Pfister, MD
Washington Hospital Center, 1706 New Hampshire Ave, NW, Washington, DC 20009
See also page 1742.
There are a number of issues that must be addressed by the surgeon when deciding to perform beating heart operations. Most of these have to do with judgment and technique. From a judgment standpoint, patient safety and benefit must be the first considerations. I strongly believe that there is a subset of patients for whom coronary revascularization is safer if done off pump. From a technical standpoint, each surgeon needs to consider whether the planned operation can be performed as successfully off pump as on. Technical considerations include immobilizing the anastomotic site and ensuring a dry operative field to allow the construction of a precise anastomosis. I am sorry that Rivetti and Gandra did not go into detail regarding their method for immobilizing the anastomotic site.
Theoretically, avoidance of ischemia is also a technical consideration, but in our experience it really seems to be a nonissue. In well over 500 anastomoses done off pump, we have never had to abandon an anastamosis because of ischemia. Consequently, we have found the entire concept of ischemic preconditioning to be unnecessary. In addition, we have not found the need to artificially slow the heart rate. Nevertheless, I certainly can envision ischemic problems when doing an anastomosis off bypass on a large, diseased, but patent right coronary artery. The availability of a shunt and its efficacy would be comforting in such a situation; however, I would not consider the use of a shunt to be routine.
An unsettling point of this article is the rate of less than optimal results. Of 63 patients, 21 had follow-up angiography, prompted by either angina or positive stress testing. Two patients had one of two grafts closed. An additional 2 patients had their single graft closed. One patient had sluggish flow in his graft secondary to a new distal lesion. In other words, 24% of the patients who underwent catheterization had a significant problem. One could say that really only 8% (5 of 63) of patients had a problem, although it is a bit of a leap of faith to assume that the 42 patients who did not undergo catheterization had flawless anastomoses.
Despite its widespread acceptance, significant concerns about beating heart surgery still remain. Almost all of these concerns could be put to rest with a well-designed study that includes 100% angiographic follow-up.
Related Article
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Initial Experience Using an Intraluminal Shunt During Revascularization of the Beating Heart
- Luiz Antônio Rivetti and Sylvio M. A. Gandra
Ann. Thorac. Surg. 1997 63: 1742-1747.
[Abstract]
[Full Text]
