Ann Thorac Surg 2000;70:83
© 2000 The Society of Thoracic Surgeons
Invited commentary
Invited commentary
Patrick M. McCarthy, MDa
a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, One Clinic Center, 9500 Euclid Ave, F-25, Cleveland, OH 44195-5066, USA
e-mail: mccartp{at}ccf.org
Any cardiac surgeon who has performed a left internal mammary artery (IMA) to left anterior descending (LAD) anastomosis on a beating heart through an anterior minithoracotomy knows in his soul that the patency rates will not be as high as for conventional surgery. Many have commented that what has been described from the podium as a simple and easy operation, was exaggerated and misleading. Wiklund and colleagues are to be congratulated for publishing a negative result, and demonstrating with a small number of patients that the emperor has no clothes. In their series, 9 of 24 patients with minithoracotomy (37.5%) had significant stenosis or occlusion of the anastomosis or graft, versus 3 of 26 patients (11.5%) who had surgery through a sternotomy, also with the anastomosis performed on a beating heart (p = 0.03; personal communication, Eugene Blackstone, Cleveland, OH).
As the authors point out, it is true that an early stenosis may show improvement when studied with later angiograms. However, it is a striking difference and one would expect that with a larger series of patients and longer follow-up, the late results would be worse than surgeons and patients expect from bypass operation. Furthermore, they could not show any significant improvement of the minithoracotomy over median sternotomy regarding the alleged benefits including reduced pain or length of hospital stay.
The study is limited because this was a small group of patients, a nonrandomized trial, and ideal patients underwent operation (not reflective of many of our patients). However, their findings support our intuition: the minithoracotomy operation is more difficult, more dangerous for the patient, and does not demonstrate major clinical benefits. On the other hand, new stabilizers to facilitate off-pump coronary artery bypass through a median sternotomy have made tremendous advances and now allow many patients to undergo bypass operations safely. Therefore early clinical experiences with off- pump operation were not a dead end. A generation of cardiac surgeons perfected coronary artery bypass operation until it became safe and effective, especially the most important left IMA to LAD anastomosis. The next generation of cardiac surgeons have to be extremely careful not to jeopardize these excellent results and the reputation of our craft.
Related Article
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Early outcome and graft patency in mammary artery grafting of left anterior descending artery with sternotomy or anterior minithoracotomy
- Lars Wiklund, Mats Johansson, Mogens Bugge, L.O. Göran Rådberg, Gunnar Brandup-Wognsen, and Eva Berglin
Ann. Thorac. Surg. 2000 70: 79-83.
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