Minimally invasive coronary artery bypass grafting: an experimental perspective.

Abstract

In their recent editorial “Minimally Invasive Coronary Bypass: A Dissenting Opinion,” Bonchek and Ullyot1 express concerns about ill-guided attempts to deviate from the conventional revascularization procedure that is “safe, effective, durable, reproducible, complete, versatile, and teachable.” In the present editorial, an experimental perspective on the search for less invasive surgical strategies is provided that will convey an opposite opinion. First, a brief reappraisal is warranted of the safety of coronary artery bypass graft surgery (CABG) during cardiac arrest supported by cardiopulmonary bypass (CPB). The great majority of CABG patients benefit greatly from coronary revascularization, but the surgical procedure is not without adverse effects. The Society of Thoracic Surgeons (STS) National Cardiac Surgery Database (January 1998) lists complications of 170 895 CABG-only operations, including 13 736 reoperations, performed in the United States in 1996. Operative mortality was 2.9% (2.5% in men, 4.0% in women). Operative mortality increases with age, from 1.1% at age 20 to 50 years to 7.2% at 81 to 90 years. In only 65.4% of procedures were no complications reported. Most complications are listed in the Table⇓. View this table: Table 1. Complications CABG-Only Patients in the United States, 1996 Another way to assess the clinical outcome of conventional CABG is to analyze hospital discharge data from health insurance records.2 Of 101 812 patients ≥65 years old operated on in January through October 1993 in the United States, 4.3% died in hospital. Of particular concern are patients (3.6%) who were discharged to a non–acute-care facility.3 Owing to complications, 10.2% were discharged late (>14 days) to home. Thus, 81.9% were discharged to home in ≤14 days. In the first 2 months after discharge to home, 0.7% died and 9.9% were readmitted for cardiovascular, respiratory, or cerebrovascular reasons. Although each of these numbers needs to be carefully interpreted in its …