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To the Editor: The article by Drs Prêtre and Turina1 succinctly reviews trials examining the benefits of percutaneous transluminal coronary angioplasty (PTCA) vs coronary artery bypass graft (CABG) surgery and newer percutaneous transluminal coronary interventions (PTCIs) such as intracoronary stenting, and minimally invasive coronary surgery. The least invasive surgical approach to revascularize diseased coronary arteries uses off-pump techniques on the beating heart. Although data suggest that elimination of the heart-lung machine reduces morbidity and mortality,2 we disagree with the authors that complete revascularization using these techniques is achieved in some patients with 3-vessel disease.1 The main obstacle to complete revascularization of the beating heart has been difficulty in exposing coronary targets on the lateral and inferior wall of the heart without hemodynamic alterations.2 In our experience, the strategy of using the single-suture technique to place traction on the pericardium in a fashion that creates ectopia cordis has proven safe and effective in accomplishing off-pump grafting of all coronary territories, including those located in topographically difficult areas.2 Success in achieving complete revascularization using beating-heart techniques are clearly related to the operative experience of the surgeon.3 In our experience, complete revascularization can be achieved in more than 89% of patients who are referred for surgical revascularization.2
As pointed out by Prêtre and Turina, off-pump surgery can also be combined with PTCA in a hybrid approach. Another hybrid strategy combines PTCI and robotic surgical revascularization.3 Since patency of the left anterior descending (LAD) artery is a major determinant of survival and the best revascularization strategy for LAD stenosis is CABG surgery using the left internal mammary artery (LIMA), a hybrid strategy using robotic technology can minimize the surgical trauma associated with the minimally invasive direct CABG procedure.3 - 4 Following harvest, the LIMA is anastomosed to the LAD using endoscopic techniques with robotic instruments.5 Following this procedure, PTCI can be used to revascularize other coronary territories. This strategy ensures that a safe PTCI can be performed on a coronary system protected by a graft to the LAD. Furthermore, patency of the coronary anastomosis can be assessed immediately after surgery. This promises to be a viable field of study for coronary revascularization in the next decade.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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