Introduction

Article Outline

• Off-Pump Coronary Bypass
• The Fontan Procedure
• Pancoast Tumors
• Reference
• Copyright

The controversy of off-pump versus on-pump coronary bypass continues several years after its inception. Dr. Sundt, in the cardiac surgery section, has lined up two outstanding surgeons in off-pump coronary bypass surgery, and it is interesting to compare and contrast their techniques. Alternative techniques for the Fontan procedure continue to be of interest; Dr. Jonas has expertly guided two outstanding groups to describe their alternative methods for this complex congenital procedure. Finally, Dr. Mentzer has put together two very controversial approaches to the Pancoast tumor, a very difficult tumor for general thoracic surgeons.

Again, the point/counterpoint approach is helpful to understand the alternatively successful techniques in treating complex cardiothoracic problems.

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Off-Pump Coronary Bypass 

Off-pump coronary bypass has become an essential element in our armamentarium. Although most coronary bypass procedures today are still performed with the heart–lung machine and aortic cross-clamp, many surgeons feel that better outcomes can be obtained off-pump. Regardless of one’s position on this argument, it is clear that unique circumstances exist in which the ability to perform a revascularization without the use of the pump can be a tremendous advantage. For example, these techniques can be safe alternatives to more complex, high-risk procedures in the presence of a calcified or atherosclerotic ascending aorta. Often times in a redo setting, off-pump coronary revascularization is also a simpler option. Controversy continues over the impact of off-pump surgery on cognitive changes; however, we seem to have a pretty clear consensus that the risk of renal function is less when we avoid the pump. With the increasing number of patients suffering diabetic complications, including chronic renal failure, off-pump surgery is a technique that should be in every cardiac surgeon’s toolbox.

We are fortunate to have two outstanding descriptions of off-pump surgery in this issue. The authors have shared many clinical pearls, which should enhance the practice of beginners and experienced surgeons alike. John Puskas, a pioneer in off-pump surgery, has beautifully described his approach and generously shared the lessons he learned in perfecting his technique. His outstanding results are well recognized throughout the cardiac surgical community. Dr. Joseph Sabik then elucidates the Cleveland Clinic approach, including harvest of multiple arterial conduits to achieve complete arterial revascularization without the use of the heart-lung machine. His exposition provides a useful complement to that of Dr. Puskas.

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The Fontan Procedure 

The congenital section addresses the ongoing controversy regarding the optimal method for performing the Fontan procedure. Carin van Doorn and Marc de Leval illustrate the lateral tunnel technique popularized by Marc de Leval in the late 1980s as the so-called “total cavopulmonary connection.” Concern regarding potential for injury to the sinus node with resulting bradyarrhythmias or tachyarrythmias consequent to atrial wall exposed to high pressure led Marcelletti to reintroduce an extracardiac conduit method for the Fontan procedure. Scott Bradley illustrates this alternative method that is currently in vogue despite the fact that, as with any procedure involving a conduit, it does not incorporate growth potential. We thank all authors for clear and concise presentations.

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Pancoast Tumors 

Superior sulcus tumors of the lung, also referred to as Pancoast tumors, are technically challenging lung cancers involving the apex of the chest. Since Shaw and colleagues’ original report,¹ two surgical approaches to the resection of these tumors have evolved. The posterolateral thoracotomy (Paulson–Shaw) approach provides excellent exposure to the ipsilateral hemithorax. The posterior approach can be used effectively with bulky tumors and tumors involving the vertebral bodies. An alternative is the anterior transclavicular (Dartevelle) approach. The anterior approach provides excellent exposure to tumors with cervical extension or subclavian vessel involvement. The pros and cons of these approaches are illustrated in this issue.

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Reference 

1. Shaw RR , Paulson DL , Kee JL . Treatment of the superior sulcus tumor by irradiation followed by resection . Ann Surg . 1961;154:29–40
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