Con: beating-heart surgery for coronary revascularization: is it the most important development since the introduction of the heart-lung machine?

Contrary to what the media tend to suggest, beating-heart coronary artery bypass grafting (BHCABG) is not a new technique. It has been performed since the advent of coronary revascularization but, until recently, was largely abandoned in favor of cardiopulmonary bypass (CPB) and cardioplegic techniques. However, with the introduction of minimally invasive coronary surgery and mechanical methods for target-artery stabilization, interest in BHCABG has been renewed. In carefully selected cases, this approach has the advantages of simplicity, avoidance of the inflammatory response caused by CPB, and a decreased need for blood transfusion. Nevertheless, BHCABG may be technically difficult in some patients, and it involves a steep learning curve. Potential risks include incomplete revascularization, ischemia during temporary target-artery occlusion, and suboptimal anastomoses. Because of the need for special equipment, BHCABG can be expensive and time consuming. It may benefit older or sicker patients who are poor candidates for CPB, especially those with left anterior descending or right coronary artery lesions, but it should be used with discretion and not be considered for all coronary patients.