New technology for surgical coronary revascularization.

In the past decade, the face of surgical coronary revascularization has been changed by a number of advances, most notably the development of minimally invasive techniques, including minimally invasive direct coronary artery bypass (MIDCAB), off-pump coronary artery bypass (OPCAB), and totally endoscopic, robot-assisted coronary artery bypass grafting (TECAB). Initial attempts to perform cardiac operations through small incisions were hindered by the absence of appropriate accessory technology, such as visualization systems, anastomotic devices, stabilizers, and alternative methods of vascular cannulation and cardiopulmonary bypass. With the development of these technologies, surgeons have been increasingly able to perform complex cardiac procedures, including coronary artery bypass grafting (CABG), mitral and aortic valve replacement, and atrial septal defect closure, through smaller-than-traditional incisions. Nonetheless, in many cases, the extent to which incision size has been reduced by these minimally invasive approaches has been matched by a corresponding increase in technical difficulty and operative time—and a potentially decreased safety margin—owing to the constraints imposed by limited or incomplete cardiac exposure. The emerging field of cell-based therapy represents an attractive alternative to surgical bypass. Spurred on by rapid advances in our understanding of vascular biology and positive results from studies of smalland large-animal models, a number of clinical trials have been conducted exploring the use of multiple cell types, either as sole or adjunctive therapy at the time of open heart surgery. Although significant myogenesis remains elusive, substantial progress with angiogenic cell therapy warrants discussion in the context of surgical revascularization. It is likely that the future will bring a convergence of several new technologies, as the way that we treat coronary vascular occlusive disease continues to evolve.