Commentary: Endoscopic Coronary Arterial Bypass: Strike A Balance

Abstract

See Article page 21.

Recent interest in minimal incisional cardiac surgery (MICS) has prompted the development of endoscope-assisted cardiac procedures designed to minimize surgical wounds [1]. The primary advantages of MICS include reduced pain and faster postoperative rehabilitation [2]. These benefits are expected to contribute to shorten hospital stays [3]. The use of an endoscope offers additional advantages, such as enhanced illumination and magnification, which improve visualization of the surgical field. Further technical advancements are anticipated in the near future. Therefore, pioneers in MICS are eager to promote the benefits of this procedure.

Despite the enthusiasm for MICS, its broader adoption unfortunately remains limited. This technique, which involves handling long instruments through small openings, requires a longer learning curve and higher level of technical skills compared with the conventional open cardiac surgeries [4,5]. Hence, MICS for mitral valve (MV) surgery is still reportedly performed in less than 25% of total MV surgeries from 2014 to 2018 depending on the STS database [6]. In my personal experience, endoscopic MV surgery accounts for less than 10% of cases, despite over 80% of isolated MV surgeries being performed by minimal thoracotomy (Fig. 1) [7]. Additionally, the rising costs of equipment and education pose significant challenges, particularly in the setting of undervalued surgical fees.

Fig. 1.

Wan Kee Kim, MD performing endoscopic mitral valve surgery (provided by the author).

In the Journal, the authors reviewed 100 cases of endoscopic-assisted off-pump coronary arterial bypass grafting (CABG) from May 2022 to March 2024 [8]. The study population consists of young patients (average age, 65 years old) with low risk (Euroscore II=1.0). Notably, 95% of patients were in sinus rhythm, and 78% had a good ejection fraction. The proportion of patients requiring inferior side anastomoses (e.g., posterior descending artery) was relatively small at 14% compared to other publications on CABG [9]. In all patients, endoscopic-assisted graft harvesting was performed, and coronary anastomoses were completed via extended thoracotomy. An average of 2.3 anastomoses were made per patient. Eleven patients underwent hybrid revascularization. There was one conversion to sternotomy. The median operation time was 3.3 hours, and the in-hospital mortality rate was 1%. The authors are to be congratulated for their wonderful outcome and their diligent efforts to minimize surgical pain for patients. The inclusion criteria were well-designed to yield an excellent result for this complex procedure.

Nevertheless, the present study does have certain limitations that warrant mention. First, the inclusion of 11 patients who underwent hybrid procedures could potentially increase the heterogeneity of the cohort, given their significantly different characteristics compared to those undergoing multiple anastomoses. Second, there is a concern regarding the generalizability of the findings. The mean procedural time of 3 hours without statistical significance of the Pearson correlation coefficient (Fig. 5 of [8]) suggests that most of the surgeries in this study were predominantly performed by experienced hands. In addition, the inferior side anastomosis through a small opening is not easily reproducible for an average beginning surgeon.

Technical advancements have dramatically evolved, especially in the biomedical field, facilitating smaller incisions for medical procedures. Recently, tests have been conducted on endovascular treatments that utilize circulating micro-magnetic robots [10]. However, open surgical treatment continues to hold a significant role in contemporary medical practice. A key takeaway from the study is that a less incisional approach does not necessarily equate to less invasive surgery. It is crucial to verify the effectiveness and reproducibility of these procedures. Moreover, careful evaluation of the benefits, weighed against potential risks, is essential when performing MICS.

Funding Statement

Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.