Cardiothoracic Surgeons Get to Grips with "Keyhole" Operations

Cardiothoracic Surgeons Get to Grips with "Keyhole" Operations

by David W. Sharp

WHAT'S HOT IN MEDICINE...

Rank	Paper	Citations This Period Jul- Aug 97	Rank Last Period May- Jun 97
1	R.V. Considine, et al., "Serum immunoreactive-leptin concentrations in normal-weight and obese humans," New Engl. J. Med., 334(5):292-5, 1 February 1996. [Thomas Jefferson U., Philadelphia, PA; Eli Lilly Res. Labs., Indianapolis, IN] *TV695	46	1
2	J. Shepherd, et al., "Prevention of coronary heart disease with prava-statin in men with hypercholesterolemia," New Engl. J. Med., 333(20):1301-7, 16 November 1995. [U. Glasgow, U.K.; Royal Infirm., Glasgow, U.K.; Dumfries & Galloway Dist. Gen. Hosp., Dumfries, U.K.] *TE365	44	2
3	J.W. Mellors, et al., "Prognosis in HIV-1 infection predicted by the quantity of virus in plasma," Science, 272(5265):1167-70, 24 May 1996. [U. Pittsburgh, PA; Chiron Corp., Emeryville, CA] *UM889	43	4
4	F.M. Sacks, et al., "The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels," New Engl. J. Med., 335(14):1001-9, 3 October 1996. [8 U.S. andCanadian institutions] *VL459	26	5
5	A.M. Calafiore, et al., "Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonarybypass," Ann. Thoracic Surg., 61(6):1658-63, June 1996. [U. G. D'Annunzio, Chieti, Italy] *UN412	25	†
6	M. Yoshiba, H. Okamoto, S. Mishiro, "Detection of the GBV-C hepatitis virus genome in serum from patients with fulminant hepatitis of unknown aetiology," The Lancet, 346(8983):1131-2, 28 October 1995. [Toshiba Gen. Hosp., Tokyo, Japan; Showa U., Yokohama, Japan; Jichi Med. Sch., Tochigi, Japan] *TB549	22	3
7	D.C. Rees, M. Cox, J.B. Clegg, "World distribution of factor V Leiden," The Lancet, 346(8983):1133-4, 28 October 1995. [John Radcliffe Hosp., Oxford, U.K.] *TB549	22	†
8	B.M. Psaty, et al., "The risk of myocardial infarction associated with antihypertensive drug therapies," JAMA-J. Amer. Med. Assn., 274(8):620-5, 23/30 August 1995. [5 U.S. institutions] *RP702	21	†
9	K. Masuko, et al., "Infection with hepatitis GB virus C in patients on maintenance hemodialysis," New Engl. J. Med., 334(23):1485-90,6 June 1996. [6 Japanese institutions] *UN799	21	†
10	D. Whitby, et al., "Detection of Kaposi sarcoma associated herpesvirus in peripheral blood of HIV-infected individuals and progression to Kaposi's sarcoma," The Lancet, 346(8978):799-802, 23 September 1995. [University Coll. London, U.K.] *RW258	19	†

SOURCE: ISI's Hot Papers Database. Read the full legend.

Just over two years ago a letter for publication arrived at our editorial office of The Lancet in London, and I well remember the surprise it caused among the editorial team, none of whom would have ever done a coronary-artery bypass procedure. We were probably being naive, but the notion that you could do coronary-artery grafting without cardiopulmonary bypass (i.e., while the heart was beating), and via a smallish incision rather than the crude sternum-splitting route, seemed almost miraculous.

That letter, by R.D. Stanbridge and colleagues, was published in September, 1995 (The Lancet, 346[8978]:837, 1995). Four months later, at a meeting in Orlando, Florida, Antonio M. Calafiore's group in Chieti, Italy, presented their experience with 155 cases, a series that had started in November, 1994. As the discussion following this paper (#5) shows, several groups had in fact tried this approach or something similar, and the true pioneer seems to be Valavanur A. Subramanian of Lenox Hill Hospital, New York City.

The surgeons here are not displaying superb technique for its own sake. Cardiopulmonary bypass itself has problems, and the traditional sternotomy route leaves a very sore patient. The Chieti group had their patients out of intensive care in four hours or so (range 1-23) and, with the one death and seven reoperations excluded, the postoperative stay averaged just 53 hours. 77% of patients were discharged from hospital on the second day. Those are extraordinary figures. At follow-up, to six months, 92% of patients were "alive and free of symptoms without a cardiac event."

A criticism of some minimal access or minimally invasive surgical procedures (the lay term is "keyhole," but clinicians, rightly, resist that word, and it is certainly inappropriate here) is that they may be adopted too widely and too quickly without full evaluation or complete training. Subramanian was concerned about this, and focused on the need to immobilize the coronary artery. His group was looking at two ideas, neither, of course, involving bypass—namely, a mechanical stabilization platform and pharmacological maneuvers to stop the heart very briefly.

We are going to hear more of this procedure. What will it be called? The traditional operation of coronary artery bypass grafting is known as CABG (pronounced "cabbage"). This procedure grafts a left internal mammary artery (LIMA) via a left anterior small thoracotomy (LAST) but only by implication does LIMA-LAST carry the flavor of a bypass-free operation.

Hepatitis GB Virus C

Farther down the list, two papers report investigations of the hepatitis agent known as hepatitis GB virus C (GBV-C). This agent is one of a family of GB viruses, so named after being isolated in 1967 from a hepatitis patient whose initials were G.B. In paper #6, a trio of Japanese researchers investigated the possible role of GBV-C in cases of non-A-E hepatitis (that is, not caused by the known viruses A through E). Examining serum from six patients afflicted with fulminant hepatitis of unknown viral origin, the team found evidence of the GBV-C virus genome in three of the cases. They conclude that this agent appears to be important in the etiology of non-A-E hepatitis. In a more recent study (#9), another Japanese team notes an increased risk of GBV-C infection to patients on maintenance hemodialysis.

Mr David W. Sharp, M.A. (Cambridge),
is a Deputy Editor of The Lancet, London, U.K.