CORRESPONDENCE

Implementation of New Technology for CABG in Low-Risk Patients: Could It Be Too Soon?To the Editor:

We read with interest and concern the case report from Doganand colleagues [1]. Although we are well aware and supportiveof the trend and of the principles towards a less invasiveapproach in coronary artery bypass graft (CABG) surgery, aswell as the growing role of computer enhancement in enablinga totally endoscopic technique, several issues in this report arecause for concern.

First, the exact place of hybrid revascularization (PTCA �minimally invasive direct coronary artery bypass) in the arma-mentarium of myocardial revascularization remains blurry, es-pecially in young patients with no significant comorbidities, asreported here (patient 1), and this strategy should still be viewedwith a healthy amount of skepticism.

Secondly, the use of 7-0 polypropylene suture with the largerneedle used for the anastomosis appear suboptimal for perfor-mance of internal thoracic artery to coronary anastomosis,especially for side-to-side anastomosis, as we believe that tech-nology should not modify the accepted surgical principles ofmicrovascular anastomosis.

Lastly and most importantly, the operative times and specifi-cally the ischemic times of 100 and 126 minutes (even withcardioplegic arrest) appear disproportionate compared with theclassical approach of full sternotomy and cardioplegic arrest orbeating heart surgery revascularization techniques currentlyavailable and carry, in our opinion, an unnecessarily high risk ofischemic injury to the myocardium. Another issue related to theHeartport system and the long cardiopulmonary bypass times isthe moderate reperfusion injury to the cannulated leg of the48-year-old patient that is part of the spectrum of vascular andgroin complications which would be easily avoided by use of themore accepted approaches. Taken altogether, these issues makeus question whether, even though “we have the technology,” weshould submit patients with straightforward coronary insuffi-ciency to risks out of proportion to classical approaches. We fullyagree with the closing statement of the authors that develop-ments in the computer system, instrumentation, and the Heart-port system are needed, and believe that such advances shouldbe implemented, studied, and tested before ethically exposingpatients with low surgical risks to complex procedures of ques-tionable benefits. The integrity of our profession is at stake aswell as our capacity to safely and rationally implement newtechnology in the clinical arena. Are we the only ones thinkingthat way?

Louis P. Perrault, MD, PhDYves Hebert, MD, FRCSCMichel Carrier, MD, FRCSC

Research Center and Department of SurgeryMontreal Heart InstituteUniversity of Montreal5000 Belanger St EastMontreal, Quebec H1T 1C8, Canadae-mail: lpperrau@icm.umontreal.ca.

Reference

1. Dogan S, Aybek T, Westphal K, Mierdl S, Moritz A, Wimmer-Greinecker G. Computer-enhanced totally endoscopic se-quential arterial coronary artery bypass. Ann Thorac Surg2001;72:610–1. 23

ReplyTo the Editor:

We appreciate the poignant discussion of Dr Perrault andcolleagues. Please allow us to express our point of view on thesesensitive issues.

We do not exactly understand the criticism regarding theindication of the procedure performed in patient 1. This had notbeen a planned hybrid revascularization. As we described pre-cisely in our report, a progression of the lesions in the leftanterior descending and the diagonal branch were observed inrecatheterization; this then led to the surgical procedure. At thedate of the first intervention (percutaneous transluminal coro-nary angioplasty of the right coronary artery), the lesions in theleft anterior descending and the diagonal branch were notconsidered advanced.

At least in Europe it is not dogma to use 8-0 polypropylenesuture for internal thoracic artery to coronary anastomosis.Many surgeons still use 7-0 sutures, which we definitely do notconsider suboptimal.

We agree that the ischemic times were long, though we do notreally see a high risk of ischemic injury to healthy myocardium.Patients with impaired left ventricular function would not beappropriate candidates for such a procedure.

We admit that the reperfusion injury of the cannulated leg isassociated with the Port Access technique. This complicationshould be seen in relation to the fact that this has been the onlyreperfusion injury in our total series of 152 Port Access cases todate.

We believe that this new technology has been implementedsafely into our clinical practice in an ethically warrantablemanner. To date, we have performed a variety of 62 totallyendoscopic cardiac procedures with good results. Among those,five totally endoscopic sequential bypass grafting procedureswere performed—the latest with an ischemic time of 46 minutes.Every innovation has its trade-offs at the beginning. If nobodytakes on these challenges, progress in medicine will not takeplace.

Selami Dogan, MDGerhard Wimmer-Greinecker, MD, PhD

Klinik fur Thorax- Herz- and GefaßchirurgieJohann Wolfgang Goethe–Universitat FrankfurtTheodor Stern Kai 760590 Frankfurt, Germanye-mail: s.dogan@em.uni-frankfurt.de.

Triangular Resection of Prolapsing Anterior MitralLeafletTo the Editor:

In a recent issue of The Annals, Fasol and Joubert-Hubner [1]reported a technique of a triangular resection of the anteriormitral leaflet (AML) to repair isolated segmental AML prolapse.This technique was initially introduced by Carpentier, but it waslater abandoned because of a high incidence of recurrent regur-gitation [2]. However, in 1995, Colvin’s group [3] again empha-sized the usefulness and reliability of this technique for treat-ment of prolapsing AML.

We employed this technique in 9 of 68 patients who under-went mitral valve repair for AML prolapse. During operation,

© 2002 by The Society of Thoracic Surgeons Ann Thorac Surg 2002;73:1020–823 • 0003-4975/02/$22.00Published by Elsevier Science Inc PII S0003-4975(01)03550-0