Ann Thorac Surg 1997;64:114-115
© 1997 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
R. Scott Stuart, MD,
William A. Baumgartner, MD
Division of Cardiac Surgery, The Johns Hopkins Hospital, 600 N Wolfe St, Blalock 618, Baltimore, MD 21287-4618
See also page 110.
Doctor Shennib and associates have given us a fascinating snapshot of current surgical attitudes toward MICAB. Their conclusion is truly a request for standardization of techniques and outcomes in MICAB. A surgeon's traditional ethic has been to seek therapy for a patient that truly address the medical problem, is applied in a timely and skillful manner, and thus achieves an improved outcome, all in the setting of "the patient's best interest."
Minimally invasive coronary artery bypass is a new therapy with promise, but it is not considered (or marketed) as an experimental procedure. Minimally invasive direct coronary artery bypass, per se, is viewed as an expansion of common surgical technique, and the port-access systems were sanctioned by the Food and Drug Administration in November 1996. Yet any surgeon performing these procedures will admit they are different (even radically so) from traditional coronary artery bypass grafting, and the survey underscores the concerns about MICAB: 62 percent of those surveyed considered the anastomotic quality to be inferior; 65% were concerned with the long-term outcome and a potentially higher morbidity and mortality of MICAB; and 38% felt the principal driver of MICAB was economic, not patient benefit. Younger surgeons are more enthusiastic about MICAB (perhaps from their familiarity with endoscopic techniques learned in general surgery) and undoubtedly the "video generation" now in medical school will be even more facile with MICAB concepts and techniques. But we as a profession now must develop this field in a fashion grounded in the traditional medical ethic. If MICAB is predominantly performed and marketed as a tool of economic competition, then we will justifiably lose the trust and standing given to us by our patients. Minimally invasive coronary artery bypass is not an answer to previously untreatable problems. It is a potential advance on a reliable, highly effective, and safe operation. Minimally invasive direct coronary artery bypass and port access will develop and undoubtedly will sort out as being optimal for a given subset of patients. What is crucial now is data. If programs have significant MICAB experience, yet negative data, it is incumbent that you report those results. We must also develop multiinstitutional trials, adhering to defined standards, that track short and long-term outcomes, including angiographic follow-up. The questions are whether MICAB should be performed, how best to do it, and for whom; not whether the illusion of the procedure gives an institution a competitive edge.
