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Reply to the Invited Commentary

I thank the Editor for giving me the opportunity to reply to the Invited Comment . This is not usual and therefore deserves a sincere acknowledgment. This exchange may ignite if not a discussion, then at least some critical and interesting thoughts among the readers of the journal. I am also thankful for the thorough Invited Comment, which in part reflects my own thoughts and my own back-and-forths when contemplating the future of coronary surgery.

Cardiac surgery in general, and coronary surgery in particular, is facing a challenge from the treatment options offered by invasive cardiologists. We are witnessing, mostly to our surprise, how the wish to avoid open surgery prevails over the quality and longevity of the obtained results. How can and should we react? Besides educating patients and family doctors to look at the long-term results, proactively we can only do one thing: evolve. We must evolve without sacrificing the quality of our results. This can be done in many ways; however, the common denominator must be reduced invasiveness. Ideally, not only reduced incisional but also reduced biological invasiveness. It is beyond the scope of this text to elaborate extensively on this broad topic. As regards to coronary surgery: in my eyes the only reasonable and realistic way to achieve high-quality, minimally invasive coronary surgery is through the semiautomatic creation of reliable and geometrically symmetrical distal anastomoses. Reliable distal anastomotic devices permit distant approaches to the coronary arteries as required by minithoracotomy procedures or in closed-chest scenarios, such as in robotic surgery. It helps to recall why minimally invasive coronary surgery pursued 10–12 years ago failed: because of the anastomotic quality. This is where distal anastomotic devices could become a game changer. The quality of the results achieved by the C-Port product family is comparable with our standards [1]; certainly these were selected patients; however, all of them were referred regularly for CABG surgery. At this year's STS meeting, US surgeons demonstrated good results with the use of these devices in a robotic setup for 3-vessel disease. We are still at the beginning. At the present stage of development there will be many patients whose coronary arteries and anatomy are not suitable for those devices, and we will also encounter technical difficulties. It is illusory to expect automated devices with an incorporated stent extractor, endartherectomizer, patch creator, coronary reconstructor and anastomotic creator. All these interventions will be reserved for traditional surgery and for experienced surgeons. However, we should not hide behind these rather exceptional technical procedures. If we ignore developments such as distal anastomotic devices, if we don't explore them, if we don't come up with ideas, then we will not create the fertile environment for research and development in which start-up companies and the industry in general will be willing to invest. And we will end up resembling excellent saddle-makers manufacturing the best saddles in the world, but in which only a few people are interested because the majority of customers are buying and riding in cars instead of on horses. General surgeons have succeeded in this (for many colleagues) painful transition. Staplers and automatic anastomoses have allowed laparoscopic surgery to be performed, and this has become the standard of care despite the higher price of the equipment. It is up to us to regain the momentum, change our mindset, become proactive and repropose a modern surgical treatment for coronary artery disease.

References

• 1 Matschke K E, Gummert J F, Demertzis S et al. The Cardiac C-Port System: clinical and angiographic evaluation of a new device for automated, compliant distal anastomoses in coronary artery bypass grafting surgery – a multicenter prospective clinical trial.  J Thorac Cardiovasc Surg. 2005;  130 1645-1652