Direct plasty or bypass? That is still a question

In a recent issue of the European Journal of Cardiothoracic Surgery, Krokovay et al. [1] reported mid- to long-term results for nine patients who underwent direct surgical coronary angioplasty with a patch for left ostial stenosis or obstruction due to various causes. The most common aetiology was a failure of coronary transfer after the arterial switch operation (ASO; n = 6). The authors are to be commended for the excellent mid- to long-term outcomes following anatomical (direct) reconstruction of proximal coronary artery obstructions. The best patch material for direct coronary angioplasty has not been determined, although many kinds of autologous materials such as the saphenous vein, azygos vein, pericardium and pulmonary arterial wall have been used, with at least some short- to mid-term success [2]. The authors favour the saphenous vein owing to their successful experience with a small number of patients (n = 4) [1]. There are two main options for surgical treatment of congenital or iatrogenic (coronary transfer failure) proximal coronary artery obstruction in children, which seem to be equally effective for early and mid- to long-term clinical outcomes [2–10]. One option is a surgical ostial angioplasty, which is often accompanied by coronary calibre patch enlargement, as reported in the present paper [1]. The other option is paediatric coronary artery bypass surgery using an internal thoracic artery (ITA) [2–4]. Both of these methods have advantages and disadvantages compared with each other. Having two reliable methods available is important in this complicated situation, particularly for post-ASO coronary obstruction, which results in critical myocardial ischaemia that can occur during as well as shortly or a longer time after the ASO. Paediatric coronary artery bypass surgery does not require complete dissection of the suture lines for ASO, which avoids prolonged aortic cross-clamp and excessive blood loss in critically ill neonates or infants. Partial retrograde coronary flow through a bypass is of little concern. However, a bypass graft may fail if stenosis is not critical (string phenomenon). Use of a surgical microscope will facilitate secure suturing for direct repair and bypass grafting in neonates and infants [3–6]. I agree with the authors’ conclusion that direct reconstruction can be the first option for surgical repair in this situation, leaving the option of performing a future bypass surgery with ITA grafts when stenosis recurs. However, both methods currently provide similar early and late survival and clinical outcomes for the early and late phases of coronary transfer failure [6–10]. I believe that an ITA bypass can be a simple, quick, and often first-choice alternative in critical situations. Appropriate guidelines for the selection of and indications for each method have not been developed [7]. We can work together to create a guideline based on the best available evidence. I thank the editorial board for the opportunity to provide comments on this important article.