Heart, Lung and Circulation 2000; 9: 46

Dear Sir,

Drs Alvarez, Cooke, Shardey and Goldstein are to becongratulated on their excellent results of primary coro-nary artery bypass surgery on a large contemporarygroup of patients.1 This does indeed provide a gold stan-dard and is reflective of the excellent surgery available inAustralia today to patients with coronary disease. How-ever, the authors are critical of newer developments incoronary artery surgery and challenge that these newtechniques meet these standards by controlled ran-domised direct comparison before being deemed ethical.The fact is that despite the enormous numbers of coro-nary interventional procedures and their evolutionthroughout the world over the last 30 years, there are rel-atively few successful attempts to do this, and even theseare often flawed (e.g. the BARI trial).

It is inevitable that all new techniques involve a learn-ing curve just as has occurred with the development ofconventional coronary bypass surgery bringing to itspresent level. The advent of mechanical cardiac stabilisa-tion has now allowed the next step in the evolution ofcoronary surgery by allowing surgical revascularisationto be performed without cardiopulmonary bypass. Thispromises distinct advantages by being less invasive,often avoiding manipulation of the ascending aorta andsometimes allowing access through smaller incisions.

These new techniques need to be embraced by cardiacsurgeons and not rejected. They need investigation,development, refinement and critical evaluation and, yesof course, there is a learning curve, just as there is inevery other facet of our work. In our experience and inthat of others,2,3 the patency of LIMA to LAD with off-pump surgery is highly acceptable and comparable toon-pump studies.

Off-pump surgery is unlikely to completely replaceconventional coronary artery bypass surgery; however, itis an additional technique which will have definiteadvantages for many patients and particularly for thoseat high risk for conventional surgery (e.g. the atheroma-tous ascending aorta). It is important that surgeonsdevelop expertise in the technique at least in its simplestform (single coronary anastomosis) and have it as part oftheir surgical armamentarium.

I wonder whether a stroke produced by dislodgementof a plaque by an aortic cannula during a 15 minutepump run for a LIMA to LAD anastomosis would raise,as the authors state, ‘serious ethical–legal issues’, whenthe same procedure could be done off pump withouttouching the aorta. As the author wisely points out, pri-mum non nocere (first do no harm).

References

1. Alvarez JM, Cooke JC, Shardey GC, Goldstein J.Orthodox coronary artery bypass surgery: The goldstandard in surgical coronary artery diseaseintervention. Asia Pacific Heart J. 1999; 8: 148–53.

2. Calafiore AM, Vitolla G, Mzei V et al. The LASToperation: Techniques and results before and afterthe stabilization era. Ann. Thorac. Surg. 1998; 66:998–1001.

3. Mack MJ, Osborne JA, Shennib H. Arterial graftpatency in coronary artery bypass grafting: What dowe really know? Ann. Thorac. Surg. 1998; 66: 1055–9.

Michael GardnerSpring HillQueensland

Letter to the Editor