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Ann Thorac Surg 2000;70:819
© 2000 The Society of Thoracic Surgeons
Discussion
DR ALAA Y. AFIFI (Gulfport, MS): I enjoyed your paper very much. This is certainly a difficult group of patients to take care of, and, as you clearly outlined, with a significant perioperative morbidity and mortality. Some of the literature more recently has looked at this, and many authors think that because of the significance of poor patency in this group of patients, a larger number of surgeons have been using more arterial conduits versus the standard single mammary artery and reverse saphenous vein grafts. So it is kind of a two-part question.
One, have you changed more recently, using more arterial conduits rather than the standard mammary to the left anterior descending artery, and two, do you have any concerns in terms of hemodynamics or a steal phenomenon from the internal mammary artery bypass graft for patients that may have ipsilateral arteriovenous fistulas or arteriovenous shunts?
DR KRATZ: Those are good questions, and, no, we have not honestly moved toward advanced arterial revascularization in this group of patients. I think it is reasonable to talk about using the right internal mammary artery, although our relief of angina was really pretty good in our group of patients. We obviously have also not used the radial arteries, leaving those for dialysis access in this group of patients, and, no, no shunts or problems with the internal mammary arteries that we have noticed or recognized.
DR JOSEPH M. CRAVER (Atlanta, GA): I enjoyed Dr Franga’s presentation and Dr Kratz’s and their colleagues’ work. We are in agreement that you can do it, but there is an increased morbidity and mortality. I want to ask Dr Kratz particularly, has the off-pump coronary artery bypass grafting technology had a role in your thinking about people with chronic renal disease, not only for those who are on dialysis, but also those who are carrying a creatinine of 3 to 4, who, if you put them on the pump, they are going to be on dialysis postoperatively? We have been aggressively moving toward doing those patients off-pump if we at all possibly can, not only to reduce, which we have already seen, a significant early death rate and significant morbidity operation, but also for avoidance of needing dialysis after the operation. Dr Kratz, what has been your experience so far with that?
DR KRATZ: Doctor Craver, we have done the last two or three that I can recall off-pump, and I cannot honestly say today whether I know who the off-pump coronary artery bypass grafting technique is for and who it is not for. It certainly sounds like a good rationale, and that is what we have done for the last few patients and they have gone well.
Related Article
Ann. Thorac. Surg. 2000 70: 813-818.
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