Paul WM Fedak, MD

Myocardial revascularization is a scarce resource where demand exceeds supply. Waiting lists for these procedures are increasingly lengthy and the growing elderly population with advanced coronary artery disease (CAD) challenges physicians to consider the appropriateness of our contemporary revascularization procedures. Despite the current period of accelerating resource demands, resource allocation decisions regarding myocardial revascularization should not be made on the basis of age alone. Available evidence suggests that definitive revascularization strategies significantly benefit appropriately selected elderly patients but have been underused. Guidelines in the management of the elderly patient with CAD will help to ensure that resources are rationed fairly and that interventions are directed at prolonging life with an improved state of health. The ultimate goal of revascularization in CAD is to optimize symptom-free survival at a reasonable cost and with minimal morbidity.

Michele Kohli, BSc

Cardiopulmonary bypass (CPB) machines, which oxygenate and pump blood, allow surgeons to stop the heart during cardiac surgery. Complicated surgeries are technically easier to perform on a non-beating heart. However, CPB can damage blood cells and increase the risk of complications including damage to the lung, excessive bleeding, low output syndrome, renal failure and perioperative myocardial infarction.¹ Also, bringing the patient on and off the CPB pump increases the overall operating time, which in turn increases the risk of complications. The other major causes of morbidity and mortality in cardiac surgery include the sternotomy and manipulation of the aorta.^2,3,4 In a recent survey of cardiac surgeons at a forum in Montreal, 81% identified CPB as the most common cause of complication, while 19% cited sternotomy.⁵

Recently, work in minimally invasive abdominal and general thoracic techniques has provoked interest in utilizing these techniques for cardiac surgery.⁴ Also, surgeons in South America such as Benetti and Buffolo reported that coronary artery bypasses performed on a beating heart, had mortality rates similar to conventional procedures with CPB. ^3,4

In the past few years, interest in a variety of techniques that eliminate use of CPB, sternotomy and aortic manipulation has grown.