Ann Thorac Surg 2007;84:72
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
Friedrich S. Eckstein, MD
Clinic for Cardiovascular Surgery, University Hospital Berne, Freiburgstrasse, Berne, CH-3010 Switzerland
(Email: friedrich.eckstein{at}insel.ch).
Tabata and colleagues [1] present the results of their study on surgery for the ascending aorta and proximal arch and compare these results following two different approaches. In both groups the results are excellent and reflect high professionalism due to a wide experience in aortic and limited access surgery.
Unfortunately the patients were not randomized; the operative access and choice of approach were chosen only by the attending surgeon. Whether or not upper hemisternotomy was performed by only one surgeon or whether it was a routine practice for all surgeons of the group is not described. Because of the variety of pathologies and operative procedures on the ascending aorta and aortic arch, it is not clear which criteria besides surgeon’s preference determined the upper hemisternotomy approach. The majority of procedures were elective and some were urgent, but there were no emergency operations included. Initially from 128 patients, the authors excluded 49 patients from the study that did not enter the matched group. Were the operative results of these patients comparable to the reported two groups? The authors do not describe drawbacks, intraoperative problems, or difficulties of the upper hemisternotomy approach (ie, myocardial protection or removal of air from the ventricle). They found no significant differences in the incidence of reoperation for bleeding, myocardial infarction, infection, stroke, and operating times, cardiopulmonary bypass times (CPB), aortic cross clamp times, and small differences in hospital stay and red blood cell transfusions in favor of the minimal access group. It is astonishing that in both groups (ie, in a total of 158 patients after complex operations) no (n = 0) renal insufficiency occurred despite mean CPB times of approximately 2.5 hours and deep hypothermic circulatory arrest in 22 patients. In a previously published article the group reported their results in minimally-invasive aortic root replacement and concluded that "the operation takes longer through the smaller incision and therefore requires more careful attention to myocardial protection" [2]. If hemisternotomy and conventional sternotomy now have similar aortic cross-clamp times, should it be considered routine practice in all patients?
If the small skin incision for upper hemisternotomy is the focus, it might be asked if this approach really meets the criteria for "minimal access surgery." For cosmetic reasons, an upper hemisternotomy with a relatively high skin incision is of questionable superiority to a full conventional sternotomy with slightly longer but lower skin incision, especially for women.
In conclusion, the authors show that upper hemisternotomy is feasible for aortic surgery with comparable outcomes with a conventional incision in an experienced surgical group. Despite excellent results it is questionable if this approach is really advantageous for the surgeon (with limited visibility, less comfort, and security) and the patients. It is also doubtful if centers with little experience in limited access surgery and limited experience in aortic surgery should start a similar program and obtain comparable results.
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References
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- Tabata M, Khalpey Z, Aranki SF, Couper GS, Cohn LH, Shekar PS. Minimal access surgery of ascending and proximal arch of the aorta: a 9-year experience Ann Thorac Surg 2007;84:67-72.[Abstract/Free Full Text]
- Byrne JG, Adams DH, Couper GS, Rizzo RJ, Cohn LH, Aranki SF. Minimally-invasive aortic root replacement Heart Surg Forum 1999;2:326-329.[Medline]
Related Article
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Minimal Access Surgery of Ascending and Proximal Arch of the Aorta: A 9-Year Experience
- Minoru Tabata, Zain Khalpey, Sary F. Aranki, Gregory S. Couper, Lawrence H. Cohn, and Prem S. Shekar
Ann. Thorac. Surg. 2007 84: 67-72.
[Abstract]
[Full Text]
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References