J Thorac Cardiovasc Surg 2004;128:799-800
© 2004 The American Association for Thoracic Surgery
The difference is meaningful: Anatomic coronary-coronary bypass or physiologic coronary-coronary bypass?
Mathias H. Aazami, MD
Cardiac Surgery Department, Paris, France
To the Editor:
It was with great interest that I read the communication of Ne
i
and colleagues.1 The authors have renewed interest in coronary-coronary bypass (CCB) grafting by highlighting its complementary technical issues, especially in the setting of multiple left anterior descending artery (LAD) stenosis, which might require a synchronous multisided revascularization. The authors have advanced the presumed physiologic advantages related to CCB, aiming thereby to promote their current surgical alternative. However, the current case points out the vigilance that should be paid in distinguishing anatomic CCB from physiologic CCB.
The physiologic advantage of CCB has been highlighted by Biglioli and associates.2 However, these authors have imputed this physiologic advantage directly to the diastolic coronary flow rather than to its systolic fraction. Biglioli and associates used the initial portion of the right coronary artery as a donor site for the saphenous graft proximal anastomosis providing the LAD. From a physiologic point of view, Biglioli and associates' procedure results in a functional interdependency between the right and left coronary systems, whereas its concrete functional consequences are unknown.
Nottin and coworkers3 later introduced the use of an arterial conduit mainly in a right-right CCB fashion. Although Nottin and coworkers had never argued about the physiologic aspects of CCB (just in view of arterial conduit sparing), their approach seems to be more physiologic, avoiding the creation of functional imbrications between the right and left coronary systems. The common point of the two aforementioned techniques is nevertheless that the proximal anastomosis takes off from a purely coronary physiology, which is partly caused by the coronary prompting effect of the sinus of Valsalva.4,5
On the contrary, the inflow of the CCB that is proposed by the authors takes off from the midportion of the LAD. Because the mid-LAD is subserved itself by the in situ left internal thoracic artery, the authors' CCB is governed by an aorta-coronary physiology rather than by the coronary physiology.
Consequently and in a physiologic point of view, the CCB proposed by the authors is just an indirect prolongation of in situ left internal thoracic artery aorta-coronary bypass, which I suggest to call an anatomic CCB.. This latter procedure should not carry the expected flow advantages of an authentic physiologic CCB, such as the procedure of Nottin and coworkers.3
In conclusion, I would congratulate Dr Nei's team for their innovation and especially their interest in CCB grafting and its physiologic features.
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References
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- Nei DG, Kneevi AM,
irkovi MV, Ne
kovi V
, Vukovi PM, Nekovi AN. The dilemma of skeletonized internal thoracic artery sequential bypass versus proximal pedicled in situ internal thoracic artery plus coronary-coronary free internal thoracic artery bypass for multiple lesions of the left anterior descending coronary artery. J Thorac Cardiovasc Surg.2004;127:1810-1812.[Free Full Text]
- Biglioli P, Alamanni F, Antona C, Sala A, Susini G. Coronary-coronary bypass: theoretical basis and techniques. J Cardiovasc Surg (Torino).1987;28:333-335.[Medline]
- Nottin R, Grinda JM, Anidjar S, Folliguet T, Detroux M. Coronary-coronary bypass graft: an arterial conduit-sparing procedure. J Thorac Cardiovasc Surg.1996;112:1223-1230.[Abstract/Free Full Text]
- Nishida H, Grooters RK, Endo M, Koyanagi H, Merkley DF, Thieman KC, et al. Flow study of coronary-coronary bypass grafting. Cardiovasc Surg.1993;1:296-299.[Medline]
- Yacoub MH, Cohn LH. Novel approaches to cardiac valve repair: from structure to function: part I. Circulation.2004;109:942-950.[Free Full Text]
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References