| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1999;67:57
© 1999 The Society of Thoracic Surgeons
a Department of Cardiovascular Surgery, Klinik für Herzchirurgie, Universität Leipzig, Herzzentrum Leipzig, Russenstrasse 19, 04289 Leipzig, Germany
Invited commentary
This report of the Port-Access International Registry (PAIR) sponsored by Heartport accumulates the data of 121 centers, including our own, using the port-access technique for coronary artery bypass grafting and mitral valve operation over a 1-year period. Up to now, this is the largest database reported with the Port-Access approach. The authors describe encouraging early results with this technology and are to be congratulated for their efforts in gathering these data.
However, the result and comment sections deserve careful reading. These data do not include the early experiences from April 1996 onward, with higher complication rates reported by some groups. Especially, the high incidence of aortic dissection that was associated with the use of this technique is worth mentioning and is not fully discussed in the report. Thus, the present report does not reflect the initial introduction of this technique; rather, it describes the conduct of the surgical procedures after the early learning curves and substantial technical improvements of the endoaortic balloon clamp.
It is of interest that the majority of centers (103 [85%]) that participated in the PAIR registry reported less than 25 cases, which may reflect a strong patient selection. Of the 1,063 patients included, the procedure was completed in only 1,004, yielding a conversion rate of 5.6% that is not further discussed. The focus of the registry is on morbidity and mortality only. Functional outcome (graft patency rates, freedom from angina, mitral valve function after repair) was not assessed, but these data would be very important for evaluating the technique and are necessary to put into a perspective for both conventional and beating heart surgical intervention.
The PAIR follow-up period is very short. Centers were able to choose either in-hospital or 30-day follow-up. This is scientifically inappropriate and makes the data not comparable to other large databases with clearly defined follow-up end points. Besides, it is well recognized that although often applied, 30-day morbidity and mortality rates do not reflect the true outcome after a surgical intervention. It is an interesting finding that not all the complications filed in the registry forms were analyzed in this report. All participating centers were asked to report also on vascular, pulmonary, respiratory, and infectious complications, none of which are mentioned in the report. Maybe there were none, but this is unlikely considering our own experience and that of other groups we know of. In particular, vascular complications from femoral cannulation have been uniformly reported in all reports on this technique.
Other complications have a remarkably low incidence. Myocardial infarction after port-access coronary artery bypass grafting, for example, has an incidence of 1%. However, only Q-wave infarctions were included, whereas other reports consider significant elevations in creatine kinase-MB fraction also diagnostic for perioperative myocardial infarction. In fact, on the PAIR data collection form, elevated creatine kinase-MB fractions had to be marked, but the results are not discussed in the present report. One has to agree that most of the patients had one-vessel disease with optimal target vessel diameters. Comparable results can be obtained with minimally invasive direct coronary artery bypass grafting.
Overall, the data presented seem to be a selection of some data that have been collected during the study, but not all available information is presented, which is acceptable for an oral presentation; however, this is inappropriate from a scientific point of view.
It is of course debatable whether the size of the incision or cardiopulmonary bypass contribute more to the invasiveness of cardiac operation. For single-vessel revascularization of the left anterior descending coronary artery the minimally invasive direct coronary artery bypass grafting approach (small incision, no cardiopulmonary bypass) is the least invasive approach currently available. Almost half (48%) of the patients undergoing coronary artery bypass grafting included in the PAIR data underwent single-vessel revascularization, presumably mainly of the left anterior descending coronary artery (target vessels are not identified in the present report). We think that given the excellent patency rates with the minimally invasive direct coronary artery bypass grafting approach it is no longer appropriate to expose these patients to cardiopulmonary bypass, except for future developments of totally endoscopic closed chest bypass procedures.
For mitral valve operation, the registry demonstrates favorable data, which seem to be comparable or better than current data with conventional operation. Our own recent series with a robot-assisted mitral valve solo operation using a simplified port-access technique demonstrated very good results for both the surgical technique and the functional outcome.
In summary, the data presented in the present report show favorable results but are not complete, and therefore the conclusions made by the authors have to be evaluated with care. The discussion should have also reflected early results and learning curves. Future publications on the ongoing PAIR registry should include all available data and should focus on functional results as well.
Related Article
Ann. Thorac. Surg. 1999 67: 51-58.
This article has been cited by other articles:
|
|
 |
|
  B. E. Muhs, A. C. Galloway, M. Lombino, M. Silberstein, E. A. Grossi, S. B. Colvin, P. Lamparello, G. Jacobowitz, M. A. Adelman, C. Rockman, et al. Arterial Injuries from Femoral Artery Cannulation with Port Access Cardiac Surgery Vascular and Endovascular Surgery, March 1, 2005; 39(2): 153 - 158. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
