Lawrence I. Bonchek

Minimally Invasive Coronary Bypass A Dissenting Opinion

Minimally invasive techniques for coronary surgery are gaining increased attention, but not without debate. We recognize that in criticizing a new technique, it is necessary to have not only a firm opinion but also a willingness to be wrong; our purpose is to stimulate discussion and debate. Of course, it is difficult to argue against attempts to minimize the invasiveness of any procedure, but it is well to recall that the most obvious successes of minimally invasive surgery have involved technically simple operations, such as arthroscopy or cholecystectomy, which involve a minimum of precision and almost no sewing. The circumstances are different, however, when one attempts to apply the same theory and strategy to physiologically and technically complex cardiac operations. The remarkable success of conventional CABG is due to the application of a standardized operation in a wide variety of settings to large numbers of patients with advanced disease by a vast cadre of trained, experienced surgeons who can offer the public an operation that is safe, effective, durable, reproducible, complete, versatile, and teachable and that, over time, offers cost savings because of the low incidence of complications and repeat revascularizations. (Randomized studies such as the RITA trial,1 which compare CABG with angioplasty, show higher initial costs for surgery but convergence of costs within 2 to 3 years because of the infrequency of repeat revascularizations in the surgical cohort.) These excellent outcomes after surgery depend on a number of critical components: uncompromising selection of the best sites for coronary anastomoses; careful management of unexpected circumstances, such as intramyocardial vessels; use of properly chosen, optimum conduits of exact length; avoidance of trauma to conduits and native coronary vessels; provision of optimum conditions for microvascular anastomoses; and performance of complete, multivessel revascularization. These maneuvers require adequate exposure, which remains a basic …

Cox/maze procedure for atrial septal defect with atrial fibrillation: Management strategies

Atrial fibrillation is found at late follow-up in approximately half of all adults who have had correction of atrial septal defect, even if it was not present preoperatively. These patients are thus exposed to the risks of stroke and chronic drug therapy even after a successful operation. Simultaneous surgical correction of atrial septal defect and atrial fibrillation was accomplished in a 52-year-old man by means of the Cox/maze procedure. The small added risk and the substantial benefit of eliminating atrial fibrillation suggest that this approach is warranted in selected adults with atrial septal defect.

Maximal utilization of the left internal mammary artery for coronary bypass grafting

A technique is described for using the internal mammary artery to bypass the left anterior descending coronary artery and another adjacent coronary artery even when the alignment of the two vessels is not favorable for a conventional sequential graft. The distal end of the mammary artery is amputated and used to construct a Y graft to the anterior descending artery and to the secondary target vessel.

A simple and safe technique of left ventricular venting

Left ventricular venting has many physiologic and practical benefits. A venting technique is described that employs a simple, closed system which allows the perfusionist to monitor left ventricular distention. By monitoring the left ventricular volume the perfusionist can regulate the degree of negative pressure on the vent and thus reduce the chance of air entering the heart.

SOME THOUGHTS ON MINIMALLY INVASIVE CORONARY BYPASS

With the advent of minimally invasive and off-pump coronary artery bypass grafting (CABG), cardiac surgery has reached a “strategic inflexion point” at which alternate pathways offer both dangers and opportunities that may lead to increased success or dismal failure. Since the price of a cardiac surgeon’s misjudgment is ultimately paid by the patient, at critical junctures it is vital to maintain our profession’s tradition of vigorous discussion and debate about new technologies. Most of my comments will be about off-pump coronary artery bypass (OPCAB) because avoidance of the pump seems a worthwhile goal. In contrast, with current technology, the complexity and risk of port-access coronary bypass with the pump seem to outweigh the benefit of merely avoiding a sternotomy. This view may change as we improve port-access techniques but I know from personal experience that sternotomy incisions are not so bad. Furthermore, portaccess CABG is done in relatively few centers compared with off-pump CABG.

Postoperative Fibrous Cardiac Constriction

Two patients with postoperative fibrous cardiac constriction are described. Unlike postoperative pericardial or epicardial constriction, the fibrous constricting layer in these patients envelopes the vein bypass grafts and is separate from the pericardium, which is not involved. Surgical management of these patients is difficult and hazardous; a strategy is outlined.

952-27 Truly Simultaneous Surgery for Carotid and Coronary Disease

Management of coexisting carotid and coronary disease has always aroused debate. Now, even more patients undergoing coronary bypass (CABG) will require consideration of carotid endarterectomy (CE). since randomized trials show that prophylactic CE benefits even certain asymptomatic patients with severe carotid stenoses. We propose a management plan and a unique operative strategy of truly simultaneous surgery. All CABG patients with carotid bruits or cerebral symptoms undergo carotid doppler studies, then MRI or conventional angiography if appropriate. Severe stenoses are corrected during CABG as follows: cardiopulmonary bypass is begun and the left ventricle is vented. The carotid artery is exposed during systemic cooling to 23–25°C. (Lower temperatures may be used if deemed necessary — e.g. deficient communicating arteries etc.) CE is then performed without the time consuming distraction of a shunt, since profound hypothermia provides cerebral protection. Ventricular fibrillation is inevitable at these low temperatures and is ignored. After CE, systemic rewarming is begun while the cardiac procedure is performed with myocardial protection according to the surgeons preference. The neck is closed after protamine is given. Since January 1993, 29 patients have had combined CABG and CE by this protocol with no strokes and no deaths. This approach offers substantial advantages in outcome, efficiency, patient convenience, and cost, and we strongly recommend its wider use.