MIDCAB vs Conventional Surgery

Abstract

To the EditorI would like to thank Dr. Murray for his comments on our article, “Temporary Coronary Artery Perfusion Catheter During Minimally Invasive Coronary Surgery.”As was stated in our original article (February 1998)1Coulson A Bakhshay S Quarnstrom J et al.Temporary coronary artery perfusion catheter during minimally invasive coronary surgery..Chest. 1998; 113: 514-520Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, the main focus of our study was on the use of a temporary catheter to prevent ischemic problems during off-pump minimally invasive direct coronary artery bypass (MIDCAB) surgery. This was presented as an alternative to the preconditioning technique. The catheter has continued to be very effective in this regard, and there continues to be no evidence of trauma to the coronary artery caused by the catheter.The surgeries presented to illustrate the use of the catheter were incidentally our first MIDCAB patients and were operated on before we had a stabilizing platform. A distinction must be made on MIDCAB surgical outcomes before and after the introduction of the stabilizing platform. When performing MIDCAB surgery in 1996, there was a considerable amount of movement of the target coronary artery during anastomosis, which made the procedure technically demanding. Since 1997, we have used the Estech platform (Estech; Danville, CA) and the US Surgical Platform (United States Surgical Corporation; Norwalk, CT). As a result, the anastomosis is technically much easier to perform, and our patency rates are now 95%.Dr. Murray has chosen to focus his attention on two of our first 20 patients who subsequently had a blocked left internal mammary graft. Both these patients were smokers who had diabetes and had previous angioplasty attempts. Patient 11, in addition, had a history of alcoholism and hypertension and had previous coronary bypass surgery. Using the Parsonnet system2 his preoperative evaluation produced a score of 14, which would have, in turn, put him at quite high risk for regular coronary bypass surgery on the order of 13%. I think MIDCAB surgery is a reasonable option for this type of patient. It is probably not reasonable to dismiss contemporary MIDCAB surgery on the basis of these two outcomes, particularly since the patients were operated on before the stabilizing platform was available.I have to take issue with Dr. Murray on another key point. Avoidance of cardiopulmonary bypass is not a “short-term achievement.” Cardiopulmonary bypass is associated with a number of serious complications.3Edmunds HY Why cardiopulmonary bypass makes patients sick: strategies to control the blood-synthetic surface interfaces, in Advances in Cardiac Surgery VI. Mosby-Yearbook,, St. Louis:1995: 121-167Google Scholar These include fluid shifts in the body, depression of the patient's immune system, and postoperative bleeding from activation of the blood clotting system as it passes over the artificial surfaces in the heart-lung machine. Hypotension associated with heart-lung machine operation also may cause renal failure and ischemia of the brain. Going on bypass and manipulating the ascending aorta may cause devastating cerebral damage,4Robin AD McCauley RF Notkin H Long-term cognitive abnormalities associated with cardiopulmonary bypass (CPB) and the Babel effect..Chest. 1994; 106: 278-281Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 5Blauth CI Cosgrove DM Webb DW et al.Atheroembolism from the ascending aorta..An emerging problem in cardiac surgery. J Thorac Cardioavasc Surg. 1992; 103: 1104-1112PubMed Google Scholar, 6Roach GW Adverse cerebral outcomes after coronary bypass surgery..N Engl J Med. 1996; 335: 1857-1863Crossref PubMed Scopus (1659) Google Scholar and there has been increased concern by an informed public about strokes and neurological deficits associated with the heart-lung machine. A headline in the San Francisco Chronicle read, “Heart Bypass Surgery Can Harm Brain, Study Says: Twenty-Five Thousand a Year May Be Affected”.7Heart Bypass Surgery Can Harm Brain, Study Says: Twenty-five Thousand a Year May Be Affected..San Francisco Chronicle. December 19,1996: A, 3Google Scholar Thus, an increasing number of astute patients fully understand the ramifications of their choice to undergo MIDCAB surgery, possible stroke vs possible need for graft revision. A graft can be revised, whereas a stroke or renal failure from cardiopulmonary bypass and aortic manipulation cannot be corrected later.All cardiac surgeons are striving for the same end: the best results in coronary revascularization with the least number of complications. Since the advent of angioplasty, surgeons are presented with an increasingly difficult residual patient population. MIDCAB surgery provides an alternative to the use of cardiopulmonary bypass and aortic manipulation. It has come a long way in the last few years and can safely be predicted to have an increasing role in the future. Current enabling technology, including the temporary perfusion cannula and the stabilizing platform, make MIDCAB surgery increasingly easier to perform. If Dr. Murray is concerned about the preservation of the left internal mammary artery, I would recommend he consider the technique that has been published recently where the left internal mammary artery is left in situ and a radial artery graft is brought down to the coronary artery.8Coulson AS Bakhshay S Borges M Modification of minimally invasive coronary artery bypass surgery for high-risk patients..Surgical Rounds. 1998; 21: 126-138Google Scholar This may address some of his concerns.I think Dr. Murray is being just a little over critical when he describes our early results as “discouraging.” On the contrary, they were a record of the beginnings of our MIDCAB experience with an emphasis on the use of the coronary perfusion cannula before stabilizing platforms were available. Under these conditions, we had no operative mortality and a 90% graft patency. Of the two patients who had graft failure, patient 11 would have been a high risk for regular coronary bypass surgery. The patency rate we achieved also compares not unfavorably to published international experience.9Emery RW Techniques for minimally invasive direct coronary artery bypass (MIDCAB) surgery. Hanley & Belfus,, Philadelphia:1997Google Scholar In this textbook, Benetti reported 84% of his patients were angina-free; Subramanian reported a 91% patency rate at 36 h; Emery et al reported 92% patency at 6 weeks; and Calafiore reported 93.1% of his patients were asymptomatic at 8 months. To the EditorI would like to thank Dr. Murray for his comments on our article, “Temporary Coronary Artery Perfusion Catheter During Minimally Invasive Coronary Surgery.”As was stated in our original article (February 1998)1Coulson A Bakhshay S Quarnstrom J et al.Temporary coronary artery perfusion catheter during minimally invasive coronary surgery..Chest. 1998; 113: 514-520Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, the main focus of our study was on the use of a temporary catheter to prevent ischemic problems during off-pump minimally invasive direct coronary artery bypass (MIDCAB) surgery. This was presented as an alternative to the preconditioning technique. The catheter has continued to be very effective in this regard, and there continues to be no evidence of trauma to the coronary artery caused by the catheter.The surgeries presented to illustrate the use of the catheter were incidentally our first MIDCAB patients and were operated on before we had a stabilizing platform. A distinction must be made on MIDCAB surgical outcomes before and after the introduction of the stabilizing platform. When performing MIDCAB surgery in 1996, there was a considerable amount of movement of the target coronary artery during anastomosis, which made the procedure technically demanding. Since 1997, we have used the Estech platform (Estech; Danville, CA) and the US Surgical Platform (United States Surgical Corporation; Norwalk, CT). As a result, the anastomosis is technically much easier to perform, and our patency rates are now 95%.Dr. Murray has chosen to focus his attention on two of our first 20 patients who subsequently had a blocked left internal mammary graft. Both these patients were smokers who had diabetes and had previous angioplasty attempts. Patient 11, in addition, had a history of alcoholism and hypertension and had previous coronary bypass surgery. Using the Parsonnet system2 his preoperative evaluation produced a score of 14, which would have, in turn, put him at quite high risk for regular coronary bypass surgery on the order of 13%. I think MIDCAB surgery is a reasonable option for this type of patient. It is probably not reasonable to dismiss contemporary MIDCAB surgery on the basis of these two outcomes, particularly since the patients were operated on before the stabilizing platform was available.I have to take issue with Dr. Murray on another key point. Avoidance of cardiopulmonary bypass is not a “short-term achievement.” Cardiopulmonary bypass is associated with a number of serious complications.3Edmunds HY Why cardiopulmonary bypass makes patients sick: strategies to control the blood-synthetic surface interfaces, in Advances in Cardiac Surgery VI. Mosby-Yearbook,, St. Louis:1995: 121-167Google Scholar These include fluid shifts in the body, depression of the patient's immune system, and postoperative bleeding from activation of the blood clotting system as it passes over the artificial surfaces in the heart-lung machine. Hypotension associated with heart-lung machine operation also may cause renal failure and ischemia of the brain. Going on bypass and manipulating the ascending aorta may cause devastating cerebral damage,4Robin AD McCauley RF Notkin H Long-term cognitive abnormalities associated with cardiopulmonary bypass (CPB) and the Babel effect..Chest. 1994; 106: 278-281Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 5Blauth CI Cosgrove DM Webb DW et al.Atheroembolism from the ascending aorta..An emerging problem in cardiac surgery. J Thorac Cardioavasc Surg. 1992; 103: 1104-1112PubMed Google Scholar, 6Roach GW Adverse cerebral outcomes after coronary bypass surgery..N Engl J Med. 1996; 335: 1857-1863Crossref PubMed Scopus (1659) Google Scholar and there has been increased concern by an informed public about strokes and neurological deficits associated with the heart-lung machine. A headline in the San Francisco Chronicle read, “Heart Bypass Surgery Can Harm Brain, Study Says: Twenty-Five Thousand a Year May Be Affected”.7Heart Bypass Surgery Can Harm Brain, Study Says: Twenty-five Thousand a Year May Be Affected..San Francisco Chronicle. December 19,1996: A, 3Google Scholar Thus, an increasing number of astute patients fully understand the ramifications of their choice to undergo MIDCAB surgery, possible stroke vs possible need for graft revision. A graft can be revised, whereas a stroke or renal failure from cardiopulmonary bypass and aortic manipulation cannot be corrected later.All cardiac surgeons are striving for the same end: the best results in coronary revascularization with the least number of complications. Since the advent of angioplasty, surgeons are presented with an increasingly difficult residual patient population. MIDCAB surgery provides an alternative to the use of cardiopulmonary bypass and aortic manipulation. It has come a long way in the last few years and can safely be predicted to have an increasing role in the future. Current enabling technology, including the temporary perfusion cannula and the stabilizing platform, make MIDCAB surgery increasingly easier to perform. If Dr. Murray is concerned about the preservation of the left internal mammary artery, I would recommend he consider the technique that has been published recently where the left internal mammary artery is left in situ and a radial artery graft is brought down to the coronary artery.8Coulson AS Bakhshay S Borges M Modification of minimally invasive coronary artery bypass surgery for high-risk patients..Surgical Rounds. 1998; 21: 126-138Google Scholar This may address some of his concerns.I think Dr. Murray is being just a little over critical when he describes our early results as “discouraging.” On the contrary, they were a record of the beginnings of our MIDCAB experience with an emphasis on the use of the coronary perfusion cannula before stabilizing platforms were available. Under these conditions, we had no operative mortality and a 90% graft patency. Of the two patients who had graft failure, patient 11 would have been a high risk for regular coronary bypass surgery. The patency rate we achieved also compares not unfavorably to published international experience.9Emery RW Techniques for minimally invasive direct coronary artery bypass (MIDCAB) surgery. Hanley & Belfus,, Philadelphia:1997Google Scholar In this textbook, Benetti reported 84% of his patients were angina-free; Subramanian reported a 91% patency rate at 36 h; Emery et al reported 92% patency at 6 weeks; and Calafiore reported 93.1% of his patients were asymptomatic at 8 months. I would like to thank Dr. Murray for his comments on our article, “Temporary Coronary Artery Perfusion Catheter During Minimally Invasive Coronary Surgery.” As was stated in our original article (February 1998)1Coulson A Bakhshay S Quarnstrom J et al.Temporary coronary artery perfusion catheter during minimally invasive coronary surgery..Chest. 1998; 113: 514-520Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, the main focus of our study was on the use of a temporary catheter to prevent ischemic problems during off-pump minimally invasive direct coronary artery bypass (MIDCAB) surgery. This was presented as an alternative to the preconditioning technique. The catheter has continued to be very effective in this regard, and there continues to be no evidence of trauma to the coronary artery caused by the catheter. The surgeries presented to illustrate the use of the catheter were incidentally our first MIDCAB patients and were operated on before we had a stabilizing platform. A distinction must be made on MIDCAB surgical outcomes before and after the introduction of the stabilizing platform. When performing MIDCAB surgery in 1996, there was a considerable amount of movement of the target coronary artery during anastomosis, which made the procedure technically demanding. Since 1997, we have used the Estech platform (Estech; Danville, CA) and the US Surgical Platform (United States Surgical Corporation; Norwalk, CT). As a result, the anastomosis is technically much easier to perform, and our patency rates are now 95%. Dr. Murray has chosen to focus his attention on two of our first 20 patients who subsequently had a blocked left internal mammary graft. Both these patients were smokers who had diabetes and had previous angioplasty attempts. Patient 11, in addition, had a history of alcoholism and hypertension and had previous coronary bypass surgery. Using the Parsonnet system2 his preoperative evaluation produced a score of 14, which would have, in turn, put him at quite high risk for regular coronary bypass surgery on the order of 13%. I think MIDCAB surgery is a reasonable option for this type of patient. It is probably not reasonable to dismiss contemporary MIDCAB surgery on the basis of these two outcomes, particularly since the patients were operated on before the stabilizing platform was available. I have to take issue with Dr. Murray on another key point. Avoidance of cardiopulmonary bypass is not a “short-term achievement.” Cardiopulmonary bypass is associated with a number of serious complications.3Edmunds HY Why cardiopulmonary bypass makes patients sick: strategies to control the blood-synthetic surface interfaces, in Advances in Cardiac Surgery VI. Mosby-Yearbook,, St. Louis:1995: 121-167Google Scholar These include fluid shifts in the body, depression of the patient's immune system, and postoperative bleeding from activation of the blood clotting system as it passes over the artificial surfaces in the heart-lung machine. Hypotension associated with heart-lung machine operation also may cause renal failure and ischemia of the brain. Going on bypass and manipulating the ascending aorta may cause devastating cerebral damage,4Robin AD McCauley RF Notkin H Long-term cognitive abnormalities associated with cardiopulmonary bypass (CPB) and the Babel effect..Chest. 1994; 106: 278-281Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 5Blauth CI Cosgrove DM Webb DW et al.Atheroembolism from the ascending aorta..An emerging problem in cardiac surgery. J Thorac Cardioavasc Surg. 1992; 103: 1104-1112PubMed Google Scholar, 6Roach GW Adverse cerebral outcomes after coronary bypass surgery..N Engl J Med. 1996; 335: 1857-1863Crossref PubMed Scopus (1659) Google Scholar and there has been increased concern by an informed public about strokes and neurological deficits associated with the heart-lung machine. A headline in the San Francisco Chronicle read, “Heart Bypass Surgery Can Harm Brain, Study Says: Twenty-Five Thousand a Year May Be Affected”.7Heart Bypass Surgery Can Harm Brain, Study Says: Twenty-five Thousand a Year May Be Affected..San Francisco Chronicle. December 19,1996: A, 3Google Scholar Thus, an increasing number of astute patients fully understand the ramifications of their choice to undergo MIDCAB surgery, possible stroke vs possible need for graft revision. A graft can be revised, whereas a stroke or renal failure from cardiopulmonary bypass and aortic manipulation cannot be corrected later. All cardiac surgeons are striving for the same end: the best results in coronary revascularization with the least number of complications. Since the advent of angioplasty, surgeons are presented with an increasingly difficult residual patient population. MIDCAB surgery provides an alternative to the use of cardiopulmonary bypass and aortic manipulation. It has come a long way in the last few years and can safely be predicted to have an increasing role in the future. Current enabling technology, including the temporary perfusion cannula and the stabilizing platform, make MIDCAB surgery increasingly easier to perform. If Dr. Murray is concerned about the preservation of the left internal mammary artery, I would recommend he consider the technique that has been published recently where the left internal mammary artery is left in situ and a radial artery graft is brought down to the coronary artery.8Coulson AS Bakhshay S Borges M Modification of minimally invasive coronary artery bypass surgery for high-risk patients..Surgical Rounds. 1998; 21: 126-138Google Scholar This may address some of his concerns. I think Dr. Murray is being just a little over critical when he describes our early results as “discouraging.” On the contrary, they were a record of the beginnings of our MIDCAB experience with an emphasis on the use of the coronary perfusion cannula before stabilizing platforms were available. Under these conditions, we had no operative mortality and a 90% graft patency. Of the two patients who had graft failure, patient 11 would have been a high risk for regular coronary bypass surgery. The patency rate we achieved also compares not unfavorably to published international experience.9Emery RW Techniques for minimally invasive direct coronary artery bypass (MIDCAB) surgery. Hanley & Belfus,, Philadelphia:1997Google Scholar In this textbook, Benetti reported 84% of his patients were angina-free; Subramanian reported a 91% patency rate at 36 h; Emery et al reported 92% patency at 6 weeks; and Calafiore reported 93.1% of his patients were asymptomatic at 8 months. MIDCAB vs Conventional Surgery: Is It Worth the Risk?CHESTVol. 114Issue 3PreviewThe article by Coulson and colleagues (February 1998)1 provides very discouraging results for minimally invasive direct coronary artery bypass (MIDCAB) surgery. The conclusion that their intraluminal coronary artery cannula has proved efficacious is overshadowed by the technically poor results of their left internal mammary artery (LIMA) bypass grafts. They reported a 40% complication rate for LIMA in their 10 elective cases, only 13 months after MIDCAB surgery. Half of these problems were occlusion of the LIMA with subsequent loss of the graft. Full-Text PDF