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Eur J Cardiothorac Surg 2001;20:895-896
© 2001 Elsevier Science NL
Letter to the Editor |
Department of Cardiac Surgery, University Hospital Grosshadern, Ludwig-Maximilian-University, Munich, Germany
Received 18 June 2001; accepted 19 June 2001.
Tel.: +49-89-7095-3461; fax: +49-89-7095-3465
e-mail: cdetter{at}hch.med.uni-muenchen.de
Key Words: Coronary artery bypass grafting • Beating heart • Minimally invasive • Ministernotomy • Minimally invasive direct coronary artery bypass • Off-pump coronary artery bypass
We would like to thank Dr Meharwal and Trehan for their constructive comments on our paper and congratulate the work performed and reported from their institute.
Minimally invasive strategies continue to evolve in cardiac surgery and are focused on minimizing the invasiveness of surgical procedures. The possible benefits include decreased patient morbidity, less blood loss, and shorter hospital stay by avoiding cardiopulmonary bypass (CPB) and the elimination of median sternotomy. The lower partial sternotomy or ministernotomy clearly offers an important cosmetic advantage when compared with a full sternotomy because of a shorter skin incision. In addition, the small incision claims to preserve the stability of the superior thoracic aperture by not splitting the proximal part of the sternum, thus reducing the invasiveness.
However, the potential benefit of a ministernotomy compared with a full sternotomy approach is not well established with regard to the postoperative recovery of the patients. Bauer et al. could not show a beneficial effect of a ministernotomy after coronary artery bypass surgery with regard to postoperative pulmonary function, one of the best quantifiable parameters of postoperative recovery [1]. Laussen et al. were also unable to demonstrate shortened recovery or reduced hospital stay with a ministernotomy approach versus full sternotomy in children for atrial septal defect (ASD) repair [2]. In contrary, Luo et al. showed that the small incision reduced the postoperative drainage, decreased the hospital stay, and provided a superior cosmetic result [3]. There are two prospective, randomized studies comparing ministernotomy and full sternotomy for aortic valve replacement (AVR). Although the study from Aris has failed to show the theoretical advantages of ministernotomy over median sternotomy for AVR [4], Mächler concluded that there is a reduced trauma from the incision and duration of ventilation, decreased blood loss and postoperative pain, and a cosmetically attractive result [5].
Nevertheless, we share the opinion by Dr Meharwal and Trehan that the ministernotomy has some theoretical advantages to full sternotomy while not increasing the risk of operation.
Furthermore, ministernotomy has some advantages compared with a minithoracotomy approach (minimally invasive direct coronary artery bypass (MIDCAB) procedure). First, there is no need for double-lumen endotracheal intubation with right single-lung ventilation. Thus, severe chronic obstructive pulmonary disease (COPD) is not a contraindication for a ministernotomy approach, making this technique also possible for these patients. Second, internal mammary artery (IMA) harvest is easier to perform and no additional instruments and retractors are required. Third, the ministernotomy approach can be easily extended to a full sternotomy without having an extra incision and the patient can rapidly be put on CPB if necessary. Fourth, complete visualization of the left anterior descending artery (LAD) and the right coronary artery (RCA) is achieved, making this approach also applicable for unfavorable coronary anatomy and multivessel revascularization.
As randomized trials are lacking, we have just started a prospective, randomized study comparing the ministernotomy and minithoracotomy approaches for single vessel revascularization.
References
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